1. “Psychotropic medications and children: science, Law, and Policy” UC Hastings college of law symposium on children’s health, mental health & the law March 29, 2014 3/29/14Bill Grimm1

2. Federal Focus & ActionCourt Resolution & The JV220 ProcessState InitiativesPsychotropic Drug ConcernsStandard of CarePrioritizing Policies & ActionsImproving Prescribing Practices 3/29/14Bill Grimm2

3. Federal Focus and Action February 2006: Senate Finance Committee Testimony October 2008: Federal Fostering Connections to Success and Increasing Adoptions Act September 2011: Child and Family Services Improvement and Innovation Act November 2011: Joint Letter from ACF, CMS, SAMHSA, HHS December 2011: GAO Report Foster Children April 2012: Children’s Bureau Information Memorandum August 2012: ACF Because Minds Matter Conference December 2012: GAO Report Children’s Mental Health August 2013: HHS Office of the Inspector General Investigation March 2013: The President’s Budget - $750 million 3/29/14Bill Grimm3

4. Federal Focus and Action “I think putting me on all these stupid meds was the most idiotic thing I have ever experienced in foster care and was the worst thing someone could do to foster kids. I was upset about my situation, not bipolar or ADHD.” Testimony of Ke’onte Cooke, 12 year old former foster child, before Congress, December 1, 2011 3/29/14 Bill Grimm 4

5. Court Resolution & The JV220 Process National Council of Juvenile & Family Court Judges Resolution Whereas, Judges in child welfare and juvenile justice cases are responsible for overseeing the safety and well-being of children under court jurisdiction; Whereas, the NCJFCJ believes that this oversight responsibility extends to children prescribed psychotropic medications, including ensuring that medications are safe and appropriate… 3/29/14Bill Grimm5

6. Court Resolution & The JV220 Process JV-220 Process Statute enacted in 1999 Intended to reduce use of psychotropic drugs Is the Court Review & Authorization Process effective? 3/29/14 Bill Grimm 6

7. 3/29/14Bill Grimm7 COURT RESOLUTION & THE JV220 PROCESS

8. Percentage of Children Authorized Psychotropic Medications By Placement Type Apr-Jun 2013 3/29/14Bill Grimm8 COURT RESOLUTION & THE JV220 PROCESS

9. 3/29/14Bill Grimm9

10. State Initiatives September 2010: AB 12 Passed August 2012: Because Minds Matter Conference October 2012: Quality Improvement Project Charter Kick-off January 2012: “Monthly” Workgroup Calls Clinical Workgroup Data and Technology Workgroup Youth, Family and Education Workgroup August 2013: Draft Action Plan Circulated September 2013-February 2014: State Process Suspended February 26 th, 2014: Invitation Only Meeting March 26 th, 2014: Meeting to Kick-off Workgroups 10/21/13Anna Johnson10

11. Psychotropic Drug Concerns Too Many Too Much Too Soon Too Long No Monitoring (Mis- Over- Inaccurate) Diagnoses No Risk/Benefit Profiles Untested Off-label No Alternatives Adverse Effects Powerful Opposition Untrained Caregivers Lack of educational resources 3/29/14Bill Grimm11

12. Too Many Children in care medicated Children on multiple medications Inaccurate diagnoses 3/29/14Bill Grimm12 ABC News Investigation Psychotropic Drug Concerns

13. Too Much Above maximum dosages Adult dosages for children 3/29/14Bill Grimm13 Gabriel Myers Story Psychotropic Drug Concerns

14. Too Soon Very young ages Too early in placement Before other interventions 3/29/14Bill Grimm14 Tiffany's Story Psychotropic Drug Concerns

15. Too Long No set monitoring No timeline to taper off Authorization for indefinite amount of time 3/29/14Bill Grimm15 Tristen's Story Psychotropic Drug Concerns

16. Standard of Care Policy Sources: Appropriate Use of Psychotropics  American Academy of Child & Adolescent Psychiatry (AACAP)  Child Welfare League of America (CWLA)  HEDIS  American Academy of Pediatrics (AAP)  State Legislation  Medicaid Medical Directors Learning Network (MMDLN) 3/29/14Bill Grimm16

17. Prioritizing Policies & Actions Special Populations  Very young children  Child-bearing age youth  Youth transitioning from care  Group home youth 3/29/14Bill Grimm17

18. 3/29/14Bill Grimm18 Prioritizing Policies & Actions Antipsychotics  Limited FDA approval  Off-label prescription  Adverse Effects  Disruptive Behavior Diagnoses

19. 3/29/14Bill Grimm19 Maximum Dosing  LA Parameters  Connecticut Guidelines Prioritizing Policies & Actions

20. 3/29/14Bill Grimm20 Prioritizing Policies & Actions Polypharmacy

21. 3/29/14Bill Grimm21 Prioritizing Policies & Actions Gaps in Medications

22. Improving Prescribing Practices Consultation & Second Review  California  Child Psychiatrists  Public Health Nurses  Pharmacists  Minnesota  Washington 3/29/14Bill Grimm22

23. Improving Prescribing Practices Prior Authorizations/TARS  CA 2006 TAR for antipsychotic prescriptions for children under six  Prescriptions fell from 5686 to 4200 3/29/14Bill Grimm23

24. Improving Prescribing Practices Monitoring Requirements & Baseline Metabolic Testing  AK requires baseline lab testing and 9 month follow ups  NJ has a detailed monitoring protocol by drug class 3/29/14Bill Grimm24

25. Improving Prescribing Practices Outlying Prescriber Identification  Many states use Medicaid pharmaceutical data to identify inappropriate prescribing patterns 3/29/14Bill Grimm25

26. Improving Prescribing Practices Academic Detailing  Prescriber education and outreach  Safe Rx Amendment Act of 2008 established an academic detailing program in Washington, D.C. 3/29/14Bill Grimm26

27. Discussion and Questions 3/29/14Bill Grimm27