Consent for Psychotropic Medication Connecticut’s Model for Children and Youth in Foster Care Lesley Siegel, MD Chief of Psychiatry CT Dept. of Children and Families

CT Department of Children and Families (DCF): A Multi-Mandate Agency Abuse/Neglect Mental Health Juvenile Justice Foster Care/Adoption

State-Wide Advisory Committee began in 1999 Psychotropic Medication Advisory Committee (PMAC) meets monthly Members include private and public APRNs, Child Psychiatrists, Pharmacists, Pediatricians, Medicaid Agency Representatives, Parents Initially set-up by former DCF Chief of Psychiatry, Dr. Pat Leebens Reviews “Best Practice” for evaluation and treatment of foster care children and youth, including all aspects of evidence-informed care

CT adapts Illinois Model Former Chief of Psychiatry, Dr. Pat Leebens, worked with Dr. Mike Naylor (from U of Illinois) on AACAP Practice Standards for Prescribing in Foster Care Population Used Illinois state/university partnership when proposing CT informed consent model and new legislation Given small size of state and multi-mandate child welfare agency, decision made to develop unit within DCF for consultations/consent instead of partnership with a university

Connecticut Law passed 2004 Sec. 17a-21a. Guidelines for use and management of psychotropic medications. Database established. The Department of Children and Families shall, within available resources and with the assistance of The University of Connecticut Health Center, (1) establish guidelines for the use and management of psychotropic medications with children and youths in the care of the Department of Children and Families, and (2) establish and maintain a database to track the use of psychotropic medications with children and youths committed to the care of the Department of Children and Families.       (P.A. 04-238, S. 2; P.A. 06-196, S. 112.)

Centralized Medication Consent Unit (CMCU) Chief of Psychiatry Child Psychiatrist(s) Advanced Practice Nurse(s) Support Staff

Stakeholders in Informed Consent Youth Worker Foster Family PCP CMCU

CT Guidelines for Consent/Assent Guardian Consent Required under age 18 Patient Assent: Required by age 14; Best practice age 9 and over

Shared Decision-Making Shared decision-making is a description of the process that should be happening regarding psychotropic medication prescribing and has been associated with better outcomes due to increased youth and other stakeholder involvement and compliance. Components include agreement with what is being prescribed, knowledge about side effects and necessary monitoring, and alternatives to medication. Similar principles to team decision making which child welfare staff in CT and many other states are currently being trained on.

Prescriber completes 465 and emails or faxes it to CMCU Consent Procedure Prescriber completes 465 and emails or faxes it to CMCU CMCU Child Psychiatrist or APRN reviews information, checks SACWIS (electronic data base) for past prescribing info **If after review request is considered appropriate, consent is given and emailed/faxed to provider CMCU enters information in SACWIS and emails worker, regional nurse, and regional clinical manager of details Prescription filled

Consent Decisions Based On: Legal Status Verified Form relatively complete Baseline Monitoring Done Meds fit Diagnosis

Consent Decisions, cont. Med on Approved List Dosing appropriate Number of psych meds overall Generally only one antipsychotic

Other factors informing decision: Past psychiatric history available in LINK(SACWIS) Child’s setting (PRNs and more than one change at once might be approved for hospitals) History with prescriber Other ongoing treatment, especially trauma-informed modalities Over-arching goal of least number of meds long-term

Consent Process Practice Changes 2007-2010 More likely to give consent if within core guidelines (approved med at approved dose) 2011/2012 More dialogue with prescribers More discussion of trauma-informed treatment approaches Consents “modified” by CMCU increased from 5% to 29% Consent Process Practice Changes

Quarterly Consent Data

CMCU Website Readily available on CT DCF home page and user-friendly, with frequent updates. Link to the website on all CMCU members’ electronic signatures. Information about meds, prescribing doses, monitoring protocols, risk in pregnancy, links to NIMH and NYU information on all psychotropic medications, handbook written for families and DCF workers by PMAC, etc.

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Pros and Cons of Centralized Process Pros: Standardized system; quick turn-around; providers are happy; Medical team enters note directly in LINK; Medical team aware of need for medical information prior to starting med; doses; monitoring. Centralized unit can review past psychotropic med history easily as available in LINK notes since CMCU began in 2007.

Pros and Cons, cont. Cons: Area office CPS staff feel disconnected from process; may have information from the foster family or the child/adolescent that is different from what the prescriber is told; may feel they don’t have the authority or access to question the APRN/Physician. Also, area office staff may feel they can’t alter or undo the official CMCU consent. Children/Youth may feel they don’t have a voice in the process, may feel they have no choice about taking prescribed medication.

“Crisis of Credibility” Training developed to address “crisis of credibility” between CPS workers and prescribers; includes Diane Sawyer’s 20/20 segment with foster children describing their experiences on psychotropic medication. Purpose is to increase collaboration so that CPS workers don’t feel prescribers just “over-medicate” foster kids and prescribers don’t feel that child welfare is “black hole” of information (i.e. multiple requirements to produce documents with no information given out).

Analyze data by race/ethnicity Next Steps Complete psychotropic med training for all case workers Develop training in Spanish Train Foster Families Link trauma treatment data with medication data Analyze data by race/ethnicity

Consent data 2011 23

Examples: Consent Process 15 year old adolescent girl newly admitted to a psych hospital 8 year old boy in a foster home 17 ½ year old boy in a residential treatment setting Girl- urgency; on BCP? Side effects very important (wt gain/polycystic ovaries with depakote); good time to stop meds which haven’t been effective Boy- explain in developmentally appropriate terms; provider tells foster parents she’ll call and tell them to fill script when consent received 17- will he need help with decision making when he turns 18?

DCF Chief of Psychiatry, State of Connecticut Questions? Lesley Siegel, MD DCF Chief of Psychiatry, State of Connecticut Lesley.Siegel@ct.gov 860-560-5020 (w); 203-530-0351(c) www.ct.gov/dcf/