1. 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

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

3. 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

4. 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

5. 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 , S. 2; P.A , S. 112.)

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

7. Stakeholders in
Informed Consent
Youth
Worker
Foster Family
PCP
CMCU

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

9. 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.

10. Prescriber completes 465 and emails or faxes it to CMCU
Consent Procedure
Prescriber completes 465 and s 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 ed/faxed to provider
CMCU enters information in SACWIS and s worker, regional nurse, and regional clinical manager of details
Prescription filled

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

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

14. 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

15. Consent Process Practice Changes
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

16. Quarterly Consent Data

17. 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.

18. 18

19. 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.

20. 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.

21. “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).

22. 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

23. Consent data 2011 23

24. 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?

25. DCF Chief of Psychiatry, State of Connecticut
Questions?
Lesley Siegel, MD
DCF Chief of Psychiatry, State of Connecticut
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