Guidelines for Psychotropic Medication Use in Children and Adolescents

Guidelines for Psychotropic Medication Use in Children and Adolescents

DCF Psychotropic Medication Advisory Committee

Department of Children and Families

State of Connecticut

June, 2005

Guidelines for Use of Psychotropic Medications

with Children and Adolescents

Department of Children and Families

State of Connecticut

Table of Contents

Letter to Practitioners …………………………………………………………………………. i

Acknowledgements ……………………………………………………………………………. ii

Dedication …………………………………………………………………………………………. iii

DCF Psychotropic Medication Advisory Committee …………………………………..iv

Committee Membership ……………………………..……………………………….v

Chapter One: Introduction

Chapter Two: Psychiatric Assessment of Children and Adolescents

Psychiatric Assessment of Children & Adolescents in DCF Care ………

Guidelines for Psychotropic Treatment ……………………………

Chapter Three: Informed Consent and Medication Permission Process

Permission Process at DCF Facilities (Riverview, High Meadows, CT Children’s Place, CT Juvenile Training School) …………………………….

Permission for DCF-Committed Youth in Community Treatments

Chapter Four: DCF Psychotropic Medication Formulary & Oversight

Formulary: Alphabetical List of Medications

DCF Psychotropic Medication Protocol

Non-Formulary Medication Request Process and Form

Adverse Drug Reactions Reporting Process

Chapter Five: References and Resources

Helpful Psychotropic Medication References and Websites

Safe Prescription-Writing Practices

Dear Fellow Practitioner:

Thank you for your commitment and dedication in caring for children under the care of the Department of Children and Families (DCF). We understand that you will face special challenges in treating these children and their families.

Over the past three years the DCF Psychotropic Medication Advisory Committee has been meeting. The Committee is comprised of professionals from multiple disciplines in the DCF system and from the community, as well as family advocates, chaired by the DCF Director of Psychiatry, Patricia K. Leebens, MD. As well as reviewing the psychiatric and mental health treatment needs of children in the DCF system, we have been working to refine and standardize the processes related to the use of psychotropic medications in DCF- involved children. Using multiple resources we have formulated guidelines to improve and systematize children’s treatment with psychotropic medications. Additionally, these guidelines will aid DCF personnel who work diligently to advocate for children under their care. While these are not meant to dictate standards of care in your practice, they should provide a consistent approval process for the use of psychotropic medications as well as serve to improve the overall level of care for DCF children.

These new guidelines will doubtless stimulate many thoughts and questions, which we welcome and encourage. Although they will be in effect for the next calendar year, the guidelines are not intended to be fixed and will be regularly reviewed. Enclosed is a feedback sheet for any comments and suggestions.

Once again we thank you for your dedicated work with children in the care of the Department of Children and Families, and we look forward to working collaboratively with you in the future.

Respectfully,

Patricia K. Leebens, MD

DCF Director of Psychiatry

For the Members of the DCF Psychotropic Medication Advisory Committee

Acknowledgements

The DCF Psychotropic Medication Advisory Committee would like to thank those individuals and institutions that have provided invaluable support and assistance in accomplishing our work. These include, but are not limited to: Darlene Dunbar, MSW, DCF Commissioner; Kristine D. Ragaglia, JD, former DCF Commissioner; Peter Mendelson, PhD, DCF Bureau Chief of Behavioral Health, Medicine, and Education; Louis Ando, PhD, DCF Bureau Chief of Quality Management; Victoria Niman, MD, DCF Medical Director; Riverview Hospital for Children and Youth; Marianne Scully; Stacy Lambert; Tina Morin; P & T Consulting; Clifford Beers Child Guidance Clinic, New Haven; TheChildren’s Home of Cromwell; Family and Children’s Aid, Danbury; The Institute of Living/Hartford Hospital; Connecticut Children’s Medical Center; Klingberg Family Centers, Inc.; The Village for Families & Children, Hartford; Wheeler Clinic, Plainville; St. Francis Care Behavioral Health, Hartford; The Hospital of St. Raphael, New Haven; University of Connecticut Department of Psychiatry; the CT Departments of Social Services and the Department of Mental Retardation; family members of our family advocates; and numerous individuals within the Department of Children and Families.

Dedication

We dedicate these guidelines to the many children and families throughout the state who are served by the Department of Children and Families.

DCF Psychotropic Medication Advisory Committee

(updated June, 2005)

Alton Allen, MD DCF Child/Adolescent Psychiatrist, Riverview Hospital

Naida Arcenas, APRN DCF Program Review and Evaluation Unit

David Aresco, RPh Pharmacist, P & T Consulting

CB Benway, APRN, Village for Children & Families, Hartford

Patty Cables, APRN Nurse Practioner, Wheeler Clinic

*Jagan Chilikamara, MD Child/Adolescent Psychiatrist, Hospital of St. Raphael

Mary Ann D’Addario, RN DCF Director of Nursing

Joseph Flanagan, MD DCF Pediatrician, CT Juvenile Training School

Danile Greene, RN, DCF Area Resource Group Nurse, Manchester

Christine Hart, MD DCF Pediatrician, High Meadows

Brian Keyes, MD Child/Adolescent Psychiatrist, Children’s Home of Cromwell

Irvin Jennings, MD Child/Adolescent Psychiatrist, Family & Children’s Aid

*Lisa Karabelnik, MD Child/Adolescent Psychiatrist, Institute of Living (IOL)

Gema Guanco, MD DCF Psychiatrist, Connecticut Children’s Place

Naveen Hassam, APRN DCF Area Resource Group Nurse Practitioner, Danbury

Milind Kale, MD Child/Adolescent Psychiatrist, CJTS & CT Children’s Place

Patricia Leebens, MD Child/Adolescent Psychiatrist, DCF Director of Psychiatry

Mathew LeMaster, APRN, Community Health Resources

*Karina Lewis, BA DCF Policy Writer, Bureau of Quality Management

Chris Malinowski, APRN Nurse Clinical Specialist, Riverview Hosptial

Adele Martel, MD, PhD Child/Adol Psychiatrist, Klingberg Family Center & IOL

*Lynn Mangini, MD Child/Adoles Psychiatrist, Village for Families & Children

Beth Muller, APRN, University of Connecticut and Wheeler Clinic

*Morgan Meltz, Parent and patient advocate

Joan Narad, MD DCF Child/Adolescent Psychiatrist, Riverview Hospital

Patricia Cables, APRN Nurse Practitioner, Wheeler Clinic

John Pitegoff, MD DCF Pediatrician, Connecticut Children’s Place

*Lind Remmele, LCSW DCF Mental Health Program Director

*Edward Rabe, MD, PhD Child/Adolescent Psychiatrist, St. Francis Beh. Health

Charles Rich, MD, Child/Adolescent Psychiatrist, Private Practice, Middletown

*Billie Robinson-Gore, APRN DCF Area Resource Nurse Practitioner

Donald Shevchuk, JD, DCF Prinicipal Attorney

Blyse Soby, RN DCF Area Resource Group Nurse, Manchester

Tracy Steinbach, Parent and patient advocate

Madga Teruel, MEd, DCF Policy Writer, Bureau of Quality Management

Aurele Wilson Kamm , APRN DCF Department of Psychiatry

Amy Veivia, PharmD, Clinical Pharmcist, Pelton’s Inc., Consulting Division

Pieter Joost van Wattum, MD, Child/Adolescent Psychiatrist, Clifford Beers

*members who have rotated off of the committee

Chapter One: Introduction

Psychiatric Assessment and Treatment

of Children and Adolescents

in the Care of the

Department of Children and Families

The children and adolescents in the care of the Department of Children and Families (DCF) offer special challenges to the practitioner. Not only may they present with complex diagnostic issues (i.e. higher than normal rates of psychiatric and medical illness, co-morbid medical and psychiatric disorders, and psychiatric illness exacerbated by the effects of trauma, neglect, and/or abuse), but also reliable and comprehensive medical history on the child may not be available to help clarify these complex issues. The child may have had multiple caretakers, disruptions and trauma caused by the foster care system itself, and may currently be in transition from one home setting to another.

These many moves may also mean multiple past medical, educational, or psychiatric treaters----each with a different view of the child. A child’s own difficulties----serious medical problems, substance use/abuse, AWOL history, self-abuse, and non-compliance with treatment----may influence medication options as well. The child’s living arrangement (foster home with multiple children, group home, shelter, residential treatment center, hospital) may influence the kind of medication and the medication schedule appropriate for a child in that circumstance.

Despite these many challenges, the practitioner working with DCF children will experience satisfaction and rewards not always seen in routine medical practice. This is important work. The treatment of pediatric mental illness, both pharmacologically and non-pharmacologically, is a high priority. The best possible treatment with the least possible risk is the goal. These guidelines were developed as a step to achieving that goal.

Over the past several years, there has been a marked increase in the use of psychotropic medications in children and adolescents. This may be related to the availability of agents with fewer side effects and with more specific indications as well as the longer term experience of use of psychotropic agents in adults. In addition, clinical evidence that psychopharmacological treatment can improve the disturbances in mood, cognition, and behavior that are associated with mental illness in children and adolescents has been building.

There are concerning new issues, however, related to this new trend. Many of the agents that are now typically being used have yet to gain Food and Drug Administration (FDA) approval for pediatric use. Also, the use of polypharmacy has been on the rise in the treatment of children and adolescents. These guidelines, based on clinical evidence, clinical judgment, and research, represent a community standard in the use of psychotropic medications in children and adolescents under the care of the Department of Children and Families (DCF). The purpose of the following guidelines is to support practitioners who work with this complex, ever-changing, ever-moving population and to guide rational treatment of these patients.

Chapter Two: Psychiatric Assessment

The baseline assessment of a child or adolescent prior to initiating psychopharmacological treatment is complex. It must involve the evaluation of a myriad of biological, psychological, and social variables. The actual purpose of the assessment is multifaceted and includes: 1) the establishment of a therapeutic relationship with the patient and parent/guardian; 2) the establishment of a working diagnosis and formulation; 3) the identification of target symptoms;and, 4) the development of a comprehensive treatment plan.

It is important to note that in children and adolescents comorbid medical and psychiatric disorders are often present. In those cases, the identification of target symptoms is most critical. When pharmacologic intervention is identified as part of the treatment plan, considerations such as diagnostic medical evaluations, drug-drug interactions, polypharmacy, treatment compliance, informed consent, and the safe storage and administration of medications become key.

The administration of psychotropic medication should involve appropriate education of the patient and caretaker, an adequate trial and careful monitoring by the prescribing practitioner along with other treatment providers. An adequate trial refers to an appropriate dose of the medication being given over a reasonable period of time needed to obtain benefit. Adequate treatment must be offered in order to clearly determine therapeutic efficacy; however, the practitioner must be ever-mindful of possible adverse reactions which might necessitate a careful discontinuation of the medication. Regular and frequent follow-up with the patient and guardian is important in enhancing compliance, providing ongoing psycho-education about side effects and medical monitoring, monitoring therapeutic effects of the medication , and assessing effectiveness of the medication intervention. Please see DCF Psychotropic Mediation Protocol enclosed.

The assessment of a medication trial is facilitated by the initial identification of target symptoms and the regular evaluation of those target symptoms. Secondly, the consideration of intercurrent life events, particularly in children and adolescents, is also essential in assessing the benefits of medication. The start of school, a change in living situation, physical illness, parental functioning, issues of loss, a birthday, etc., can all impact functioning and can confound the evaluation of a medication trial. Thirdly, compliance may need to be investigated through pharmacy records or medication administration records in order to clearly assess efficacy of a medication trial. Once an informed decision is made about a particular medication, changes in the treatment plan may be necessary including changes in medication regimen, adjustment in non-pharmacologic treatment strategies, and re-evaluation of the diagnosis.

In children and adolescents, re-evaluation of the working diagnosis is useful not only when there is a lack of treatment response but in other situations as well. By nature, children and adolescents are developing and changing during their treatment. Longitudinal information may become available revealing temporal patterns of functioning that may alter diagnosis. And, at times, the successful treatment of one disorder may then expose an underlying comorbid disorder that requires treatment. Ultimately, the resolution of a disorder or the ineffectiveness of a medication requires the medically supervised discontinuation of medications. Because withdrawal or discontinuation effects may arise and confound the clinical picture, close monitoring is vital to sort out the illness from medication effects. Polypharmacy can be avoided or minimized if these issues are considered.

Guidelines for Psychotropic Medication Treatment of Children and Adolescents

BASELINE ASSESSMENT AND INTERVENTION

A. Establish a working diagnosis

1. Review of history, past files and records, as available

• Medical history, including medication history, and review of systems
• Psychosocial history, including caregiver information
• Developmental history
• Family history
• Substance abuse history
• Trauma, abuse, neglect
• Foster Care placement history

1. Review reasons for seeking treatment.

1. Clinical assessment and evaluations, as appropriate (i.e., physical exam, lab tests, diagnostic scans or tests such as EKG, EEG, MRI Scan, psychological or educational testing)

1. Identify target behaviors needing intervention

B. Define appropriate interventions

1. Address any untreated medical conditions (e.g., constipation, headaches, UTI, GERD, allergies, toxic conditions)

1. Consider behavior management and parent guidance strategies

Continue. . .

1. Consider therapy (e.g. cognitive-behavioral, insight-oriented, supportive, group, substance abuse 12-step)

1. Consider family support services (e.g. mentors, parent aide, extended day treatments, after school programs)

1. Consider complementary approaches and alternative treatments (i.e., nutritional supplements, sensorimotor programs)

1. Medications as part of comprehensive treatment

• Review history of past medication trials, if available
• Evaluate appropriateness and need for medications
• Obtain baseline studies and workup as indicated (please see DCF Psychotropic Medication Protocol)

• Evaluate drug-drug, food-drug interactions
• Establish a dosing schedule which makes pharmacologic sense and which enhances compliance, taking into account the patient’s past history and current living setting (aim for the lowest effective dose)

• Monitor drug responses, particularly in regard to targeted symptoms, drug reactions and side effects
• Perform follow up studies as needed (please see DCF Psychotropic Medication Protocol)

STATUS REVIEW

A. Review diagnostic assessment.

B. Review overall treatment plan for effectiveness.

C. Plan changes in treatment regimen as needed.

Continue. . . . .

FOLLOW UP CARE

1. Discontinue ineffective therapeutic interventions and medication to avoid polypharmacy.
2. Establish termination schedule and process for therapeutic work.
3. Establish withdrawal schedule for medications and monitor for withdrawal symptoms or syndrome.
4. Ensure continuity of care with appropriate and timely follow up, including necessary releases of information to transfer medical records as needed.

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