Psychotropic Medication in Foster Care Trainer's Guide

PsychotropicMedicationinFosterCare

Version1.0|April2017

Trainer’sGuide

Trainer’sGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017

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TableofContentsTableofContents.................................................................................................................................2

BackgroundandContext......................................................................................................................3

TipsforTrainingThisCurriculum..........................................................................................................6

Agenda.................................................................................................................................................8

LearningObjectives..............................................................................................................................9

LessonPlan........................................................................................................................................10

Segment1:WelcomeandIntroductions............................................................................................12

Segment2:LawsandRegulations......................................................................................................15

Segment3:CourtForms....................................................................................................................20

Segment4:Trauma...........................................................................................................................26

Segment5:AccessingMentalHealthServices.....................................................................................31

Segment6:PsychotropicMedication..................................................................................................37

Segment7:UsingtheCaliforniaGuidelinesDocuments.....................................................................49

Segment8:SummaryandEvaluation.................................................................................................56

Trainer’sGuide|PsychotropicMedicationinFosterCare|Version1.0|April2017 3

BackgroundandContextTheuseofpsychotropicmedicationamongchildrenandyouthintheUnitedStateshasincreasedsignificantlyoverthelasttwodecades,particularlyforchildrenandyouthinfostercare(Longhofer,Floersch,&Okpych,2011;Raghavan,Lama,Kohl,&Hamilton,2010).Raghavanandcolleagues(2005)estimatethat13%ofallchildrenandyouthinthechildwelfaresystemnationwidereceivepsychotropicmedicationscomparedto4%ofchildrenandyouthinthegeneralpopulation.In2014theSanJoseMercuryNewsfoundthatfrom2004to2014,nearly1outof4adolescentsintheCaliforniafostercaresystemreceivedpsychotropicmedications—3.5timestherateforalladolescentsnationwide.Ofchildrenandyouthincarewhowereprescribedpsychotropicmedications,60%receivedthestrongestclass—antipsychotics.Whatisparticularlyconcerningistheprescriptionofmultiplemedications(i.e.,polypharmacy).Thenewspaperstudyalsofoundthatin2013,12.2%ofchildrenandyouthincarewhowereprescribedmedicationswereprescribedmorethanonemedicationatatime.

Mackieandcolleagues(2011)listanumberoffactors,whichmayormaynotberelatedtoclinicalneed,thatexplainwhythispopulationofchildrenandyoutharedisproportionatelyprescribedpsychotropicmedications,including:higherratesoftraumavictimizationandmentalhealthdisordersfoundinthispopulation;traumacausedbybeingremovedfromfamilyoforiginandmultipleplacementchangesthereafter;andthecomplexemotionalandbehavioralsymptomsthataccompanyalltheseunderlyingcircumstances;lackofclearoversightandmonitoringguidelinesandprotocols;anincreaseinmedicationprescriptionsinoutpatientsettings;andinadequateaccesstoMedicaidservices.Researchrepeatedlyfindsthatchildrenandyouthinthefostercaresystemarediagnosedwithmentalhealthdisordersmoreoftenthanchildrennotinfostercareandarethereforemorelikelytobeprescribedpsychotropicmedications(Longhofer,Floersch,&Okpych,2011;Sheldon,Berwick,&Hyde,2011).Themostcommondiagnosesamongchildrenandyouthinfostercareareconductdisorder/oppositionaldefiantdisorder,depression,attentiondeficit/hyperactivitydisorder,andposttraumaticstressdisorder.Commonlyprescribedmedicationsforchildrenandyouthinfostercareincludeantipsychoticstotreatschizophrenia,bipolardisorder,andautismwithirritability;stimulantstotreatsymptomsofattentiondeficithyperactivitydisorder;antidepressantstotreatmajordepressionandobsessivecompulsivedisorder;andmoodstabilizersforaggressivebehaviorandunspecifiedemotionalproblems.


Inresponsetothisdata,Californiahastakenstepstobuilduponpreviouslegislationandexpandanddevelopnewguidelinesthatcontinuetopromotethebasicprinciplesofsafety,permanency,andwellbeing,withtheaddedgoalofreducingshort-andlong-termharmcausedbyinappropriateprescriptionsanduseofpsychotropicmedications.AspartoftheFosterCareQualityImprovementProject,TheCaliforniaDepartmentofHealthCareServices(DHCS)andtheCDSSreleasedtheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare,2015.Thenewguidelinescreateasharedunderstandingofoversightandmonitoringofpsychotropicmedicationpracticesforbothchildwelfareservicesandmentalhealthservices.Theguidelinessetexpectationsforphysicians,socialworkers,maturechildrenandyouth,parents,caregivers,Tribalmembers,andallotherpsychotropicmedicationstakeholderstocollaborateinstrengtheningtheoversightandmonitoringofpsychotropicmedications("Californiaguidelines,"2015).All-CountyInformationNoticeNo.1-05-14providesdetailsaboutsharingrequiredinformationwithcaregiverstofacilitatetheirinvolvementinprovidingcareforchildrenandyouth.SenateBill238,signedintolawbyGovernorBrownonOctober6thof2015stipulatesthatcertainprofessionalsandotherswhoworkwithchildrenandyouthinfostercareshouldbeprovidedtrainingaboutimportanttopicsrelatedtotheadministrationofpsychotropicmedicationtothosechildrenandyouth.Specifically,trainingaboutpsychotropicmedicationandtraumaasrelatedtochildrenandyouthinfostercareistobeprovidedtogrouphomeadministrators,fosterparents,childwelfaresocialworkers,probationofficers,publichealthnurses,dependencycourtjudgesandattorneys,courtappointedcounselandspecialadvocatesalongwithinformationaboutbehavioralhealthandsubstanceuse.Severalmediasourcesandotherstudieshaverecentlyrevealedthattherateofpsychotropicmedicationprescriptionsforchildrenandyouthinfostercareishigherthanthegeneralpopulation.Analarmingnumberofchildrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneously.Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.Psychotropicmedicationsareonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere. Atthetimeofthiswriting,theCaliforniaDepartmentofSocialServicesisengagedinthedevelopmentoftheCaliforniaChildWelfareCorePracticeModel,whichsubsumesthePathwaystoMentalHealthServicesCorePracticeModelwithinalargerpracticeframeworkthatintegratesthechildwelfaresystemwithotherchild-andfamily-servingsystemsinthepublicsectorandtheirpartners.Inturn,theCaliforniaChildWelfareCorePracticeModelispartofatripartite“SharedApproachtoCalifornia’sChildren,Youth,andFamilies”withthepublicsystemsofbehavioralhealthandjuvenilejustice,whicharealsoinprocessofdevelopingpracticemodelsfortheirrespectivefieldsofpractice.An“Integrated


StatewideTrainingPlan”iscurrentlyunderwaywhichwillreflectthepracticeandservicedeliveryenvironmentsofthechildwelfare,behavioralhealth,andjuvenilejusticesystemsunderthe“SharedApproach.”ThiscurriculumiscongruentwiththedevelopingCaliforniaChildWelfareCorePracticeModelandwiththeforthcoming“IntegratedStatewideTrainingPlan.”TheCorePracticeModel(CPM)setsthefoundationforacommonpracticeframeworkthatintegratesbehavioralhealthscreenings,referrals,serviceplanning,servicedelivery,andoverallcoordinationandcasemanagementamongallthoseinvolvedinworkingwithchildrenwhoreceiveservicesfromchildwelfareandbehavioralhealthsystemsinthepublicsector.Theeffectiveengagementoffamiliesinthereferralandtreatmentprocessfortheirchildrenisintegraltothismission.TheCPMdescribesstandardsandexpectationsforpracticebehaviorsbychildwelfareandbehavioralhealthstaffthatensuresandsupportsmeaningfulparticipationbyfamiliesinthecareandtreatmentoftheirchildren.ChildandfamilyteamingisaservicerequirementforchildrenwhoqualifyforIntensiveCareCoordination,andwillsoonbethestandardthroughoutchildwelfare.Forchildrenandyouthwithidentifiedmentalhealthissues,childandfamilyteamingisstronglyrecommended.Childrenandyouthforwhompsychotropicmedicationisbeingrequestedfromthecourtwilllikelyfallintooneofthesecategories.AudienceTheintendedaudienceforthePsychotropicMedicationinFosterCareclassroomtrainingislinestafffromchildwelfare,juvenilejustice,andchildren'sbehavioralhealthagenciesthroughoutCalifornia,aswellaspublichealthnurses,caregivers,youth,andcommunitypartnerswhohaveaninterestinlearningaboutpsychotropicmedicationandhowitcanbeusedtoservethementalhealthneedsofchildrenandyouthinthechildwelfaresystem.


TipsforTrainingThisCurriculumDuration:OneDay(9:00am-4:00pm,anhourlunchbreak,two15-minutebreaks)Thiscurriculumprovides:

• Anoverviewoftheuses,benefits,andrisksofpsychotropicmedication;• Informationabouttraumaandhowitcaninformcareandtreatmentdecisions;• Guidanceforprofessionalstotomakeandmonitortreatmentdecisions;and• HowtolocateandusetheformsandinformationalmaterialsintheApplicationforPsychotropic

MedicationprocessintheCourts(JV-220Process).ThetrainershouldbefamiliarwiththeCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCarethemostrecentversionofwhichcanbefoundhere:http://www.dhcs.ca.gov/provgovpart/pharmacy/Documents/QIP_Guidelines.pdfThisGuidelinesdocumentoutlines:

• Basicprinciplesandvalues,• Expectationsregardingthedevelopmentandmonitoringoftreatmentplans(emotionaland

behavioralhealthcare,psychosocialservicesandnon-pharmacologicaltreatments),• Principlesforinformedconsenttomedication,and• Principlesgoverningmedicationsafety.

Mostimportantly,itisdesignedtobeusedasanadvocacytooltohelpguideprescribersandotherswhoareworkingwithchildrenandyouthinfostercare.ItisonewayformembersofatreatmentteamtoreferencethestandardsofpracticeandexpectationsoftheCaliforniaDepartmentsofSocialServicesandHealthCareServicesregardingtheuseofpsychotropicmedicationwithchildrenandyouthinfostercare.Itisintentionallycreatedsothatprofessionalscanrefereachothertoitforguidanceinmakingtheseimportanttreatmentdecisions.

Further,thetrainershouldknowandunderstandCalifornia’sPathwaystoMentalHealthpracticemodel.Themostrecentversionofwhichmaybefoundhere:http://www.dhcs.ca.gov/Documents/KACorePracticeModelGuideFINAL3-1-13.pdfAswellastheCaliforniachildwelfarecorepracticemodel(CPM).Themostrecentversionofwhichcanbefoundhere:http://calswec.berkeley.edu/california-child-welfare-core-practice-model-0ThetrainershouldbefamiliarwithandsupportiveoftheFosterCareYouth’sMentalHealthBillofRightswhichcanbefoundhere:http://www.fosteryouthhelp.ca.gov/PDFs/FosterYouthBillOfRights.pdf

AlamedaCountyTransition-AgeYouthandshareddecisionmakingtoolswhichcanbefoundhere:http://www.acbhcs.org/MedDir/decision_tools.htm


Practiceandlocalrulesofcourtvaryacrosscounties.Knowingthespecificsofthecountyorcountiesforwhichyouareprovidingtrainingwillhelpthetraininggosmoothly.Trainersshouldbefamiliarwithcountyprotocols,procedures,forms,andtoolsrelatedtotheprovisionofbehavioralhealthservicesforchildreninfostercare,andcourtauthorizationprotocolswheretheyaretraining.Ifparticipantsarefromseveralcountiesbesuretoallowinformationandfeedbackfromthegroupaboutthesevariations.AdditionalResources

• CalSWEChostsatoolkitforthechildwelfare/mentalhealthlearningcollaborativethathasanarrayoftrainingandimplementationresourcesregardingthedeliveryofbehavioralhealthservicestochildreninfostercare.Thetoolkitalsoprovidescontactinformationforpartneringorganizationsthatprovidetrainingandtechnicalassistance.ThetoolkitwasdesignedforusebyCaliforniacountiesandregions,andisalsoaccessiblebythepublic:http://calswec.berkeley.edu/toolkits/child-welfare-mental-health-learning-collaborative-katie.Withinthistoolkit,thetrainermayhaveparticularinterestintheresourcesfoundinthewebpagesfor“TeamingTools”and“EngagementTools.”

• TheChildren’sBureaupublishedMakingHealthyChoices:AGuideonPsychotropicMedicationsforYouthinFosterCarein2012https://www.childwelfare.gov/pubs/makinghealthychoices/andthecompanionguideforcaregiversandcaseworkerscalledSupportingYouthinFosterCareinMakingHealthyChoices:AGuideforCaregiversandCaseworkersonTrauma,Treatment,andPsychotropicMedicationin2015https://www.childwelfare.gov/pubs/mhc-caregivers.Theyarebothvaluableresourcesonthetopicsmostrelevanttothistraining.

• SubstanceAbuseandMentalHealthServicesAdministration’sConceptofTraumaandGuidanceforaTrauma-InformedApproach,July2014http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf

• AmericanAcademyofPediatrics’HelpingFosterandAdoptiveFamiliesCopewithTraumahttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf

• TheNationalChildTraumaticStressNetwork’stoolkitswww.NCTSN.org

• TheCaliforniaInstituteforBehavioralHealthSolutions(CIBHS)offerstrainingresourcesthatsupportKatieA.implementation,includingwebinarsforpreparingyouth,parents,andprofessionalsforparticipationintheChildandFamilyTeam(CFT)andteammeetings:http://www.cibhs.org/katie-implementation-technical-assistance-and-training

Thiscurriculumisdevelopedwithpublicfundsandintendedforpublicuse.Useofcurriculumcontentshouldbecitedas:CaliforniaSocialWorkEducationCenter.(Ed.).(2017).PsychotropicMedicationinFosterCare.Berkeley,CA:CaliforniaSocialWorkEducationCenter.

Forquestionsregardingthecurriculum,contactShayK.O’Brien,[email protected].


AgendaSegment1 WelcomeandIntroductions 9:00–9:15am

Segment2 LawsandRegulations 9:15–9:45am

Segment3 CourtProcessandForms 9:45–11:00am

BREAK 11:00–11:15am

Segment4 Trauma 11:15–11:45pm

Segment5 AccessingServices 11:45–12:30pm

LUNCH 12:30-1:30pm

Segment6 PsychotropicMedication 1:30-2:30pm

BREAK 2:30-2:45pm

Segment7 UsingtheCaliforniaGuidelines 2:45-3:45pm

Segment7 Wrap-UpandEvaluations 3:45-4:00pm


LearningObjectives

Knowledge

K1:TraineeswillbeabletonameatleastthreekeypointsinthelawsandregulationsthatgovernadministrationofpsychotropicmedicationstochildrenandyouthinfostercareinCalifornia.

K2:Traineeswillbeabletonameatleastoneofthebasicprinciplesoftrauma-informedcareastheyrelatetouseofpsychotropicmedicationinfostercare.

K3:Traineeswillbeabletonameatleasttwocommonbehavioralhealthdiagnosesandtherelatedtreatmentoptions(bothpsychosocialandmedical)forchildren,youth,andyoungadultsinfostercare.

K4:Traineeswillbeabletodescribewhatdotoifsideeffectsarenoticedorreportedbyachild,youth,oryoungadultinfostercarewhoistakingprescribedpsychotropicmedication.

K5:Traineeswillbeabletolocateandutilizethecorrectstaterequiredforms(JV-217throughJV-224)whenamedicalproviderisstartingorcontinuingapsychotropicmedicationforachildoryouthinfostercare.

K6:Traineeswillbeabletodescribethenotificationprocessesusedinrequestingandmonitoringadministrationofpsychotropicmedications.

Skills

S1:Usingsampleplans,traineeswillutilizetheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCareandthetoolsinitsappendicestoevaluateandmodifytreatmentplansthatincludepsychotropicmedicationdecisions.

a. PrescribingStandardsbyAgeGroup,b. ParametersforUseofPsychotropicMedicationforChildrenandAdolescents,c. ChallengesinDiagnosisandPrescribingPsychotropicMedication,andd. Algorithm/DecisionTreeforPrescribingPsychotropicMedication.

S2:Usingavignette,traineeswillbeabletoidentify:• Therelevantpartiesanddocumentationtobeincludedinthecourtprocess,• Thoseparties’rightsandobligations,and• Thetimelineforcourtrequests,decisions,andnotifications.

Values

V1:Traineeswillvaluebuildingonchildandfamilyresilienceandstrengthsinbothformalandinformalservicesusedtoamelioratethenegativeeffectsof

• abuseand/orneglect;• emotional,cognitive,and/orbehavioraldysregulations;and• potentialmentalillness.

V2:Traineeswillvalueensuringthatthevoicesofchildren,youth,andyoungadultsareincorporatedintotreatmentplansandmedicationdecisions.

V3:Traineeswillvalueworkingwithamulti-disciplinaryteamtounderstandandmanagetheuseofpsychotropicmedicationbychildren,youth,andyoungadultsinfostercare.


LessonPlan

Segment MethodologyandLearningObjectives

Segment1

15minutes

9:00-9:15am

WelcomeandOrientation

Introductionsandreviewoflearningobjectives.

Groupagreements.

Segment2

30minutes

9:15-9:45am

LawsandRegulations

Reviewofapplicablelaw,regulations,policy,andprocedureswithafocusonrecentchanges.Videoclips.

LOs:K1

Segment3

75minutes

9:45-11:00am

CourtProcessandForms

Locatingandaccuratelycompletingtheappropriateform(s)forcourtapprovalof,monitoringof,and/orinputabouttheadministrationofpsychotropicmedication(s)toachildoryouthinfostercare.

Whoisinvolved,whentheyneedtobeinvolved,andtheirrightsandobligations.

Timelinefordecisionsandnotificationsandcourtapprovalprocessflow.

Applicationactivities:Matchinggame.Reviewofforms.

LOs:K5,K6,S1,S2,V1,V2,V3

BREAK11:00-11:15am

Segment4

30minutes

11:15-11:45

Trauma

Overviewoftrauma.Presentationofthebasicprinciplesoftrauma-informedcarerelatedtotheadministrationandmonitoringofpsychotropicmedicationinfostercaresettings.Challengesandbenefits.

Trauma-informedandstrengths-basedviewofsymptomsandbehaviorscommonlyincludedinmental/behavioralhealthdiagnosesincludingsubstanceusedisorder.

Applicationactivity:Sharingpracticeexperience.

LOs:K2,V1,V2


Segment MethodologyandLearningObjectives

Segment5

45minutes

11:45-12:30

AccessingServices

QuickoverviewofMental/BehavioralHealthServicesavailabletofosteryouthandhowtoaccessthem.

Choosingbestwaystotreatsymptomsandaddressbehaviors:a. utilizingformalandinformalinterventions,b. ensuringtrauma-informedandculturallyappropriateapproaches,andc. combiningpsychotropicmedicationsandnon-pharmaceutical

therapies.

Applicationactivity:Planningtowardquality,diverse,trauma-informedservices.

LO’s:K2,K3,V1,V2,V3

12:30-1:30pm

LUNCH

Segment6

60minutes

1:30-2:30

PsychotropicMedications

ReviewtheFosterYouthMentalHealthBillofRights.

Overviewofcommonbehavioralhealthdiagnosesandthemedicationsthatmaybeprescribedtotreatthem.Howtofindreliableandcurrentinformationaboutmedicationsideeffectsandadversereactions.

Howtoassistfosteryouthwithself-administration,trackingsideeffects,andothermonitoringissues.

Applicationactivity:Roleplayconversationsaboutevaluatingprescriptions,sideeffects,andsafetyplanning.

LOs:K3,K4,S1,S2,V1,V2,V3

BREAK2:30-2:45pm

Segment7

60minutes

2:45-3:45pm

UsingtheCaliforniaGuidelines

OverviewoftheGuidelinescontent.

Howthatcontentcanbeusedwithinateamtohelpmonitor,assess,andmodifytreatmentplansthatcontainpsychotropicmedication.

UsingtheGuidelinesandcourtprocesstoadvocateforbestinterestofthechild.

Applicationactivities:HowtousetheGuidelines.IncorporatingtheGuidelinesintoregularpractice.

LO’s:K3,K5,S1,V3

15minutes

3:45-4:00pm

Wrap-UpandEvaluations

Activities:Debrief/QuestionsandCourseEvaluations


Segment1:WelcomeandIntroductions

SegmentTime: 15minutes

Materials: LearningObjectivesFlipchartforGroupAgreements

Slides: 1–5

DescriptionofSegment:Facilitateintroductions,groupagreements,andreviewoflearningobjectives.

BeforetheSegment

p Activity1A:Ifpossible,beforetrainingbegins,useplacecardstoarrangetheseatingsothatsocialworkersandotherprofessionalsaresittingtogether,andmixupfolksfromdifferentcounties.

p Activity1C:Prepareyourchartpadinadvanceforthegrouptodeveloptheirownagreements.Bepreparedtofillingapsiftherearestandardsyouneedeveryonetoagreeto(confidentiality,silentphones,etc.).Somesuggestedstandardstogetstartedorfillinarelistedbelow.

DuringtheSegment

p Activity1A:Welcome

Slide1Coursename,Slide2BeginsSegment1Welcometheparticipantstothetraining,introduceyourself,andreviewanyhousekeepingmaterials(parking,bathrooms,cellphones).

p Activity1B:IntroductionsSlide3—IntroductionsandGroupAgreementsFacilitateparticipantintroductions.Introductionsshouldbesimpleself-introductionsthatinclude:

• Participant’sname• Thedepartment,unit,ordivisionwhereparticipantworks• Theirrolerelatedtopsychotropicmedicationinfoster

care.

Considerinvitingparticipantstostatetheirpreferredgenderpronouns*

p Activity1C:GroupAgreementsFacilitategroupagreements.Askthegrouptoprovidesomeguidelinesforinteractionandconductduringthetraining.Somesuggestedagreementsarelistedbelow.Thisactivityprovidesamodelforparticipantsfortheworktheydowithchildandfamilyteams,whichisaconnectionthatyoucannoteforthegroup.

SuggestedGroupAgreements

• Respecteachother’sperspectivesandexperience.

PsychotropicMedicationandFosterCareinCalifornia

WelcomeandOrientation

Segment1

3

Introductions

•Name•Department•Role

GroupAgreements


• Mindfullyparticipatebykeepingtheenvironmentcollegialandproductive.

• Ifanissuearises,addresstheinstructorontheside,one-on-one,ratherthaninfrontofthewholegroup.

• Avoidinterrupting,ridiculing,ortalkingovereachother.• Considerprivacyandconfidentialityconcernscarefullybefore

youdiscussanycaseoruseacurrentorformercaseasanexample.

p Activity1D:Overview

Slide4—Whythistraining?SenateBill238,signedintolawbyGovernorBrownonOctober6thof2015stipulatesthatcertainprofessionalslistedhereandotherswhoworkwithchildrenandyouthinfostercareshouldbeprovidedtrainingonimportanttopicsrelatedtotheadministrationofpsychotropicmedicationtothosechildrenandyouth.Specifically,trainingabout• psychotropicmedication(uses,benefits,risks)• trauma• mental/behavioralhealthservices• substanceabuse• asrelatedtochildrenandyouthinfostercareistobeprovidedto• grouphomeadministrators• fosterparents• childwelfaresocialworkers• probationofficers• dependencycourtjudgesandattorneys• courtappointedcounselandspecialadvocates.

p Activity1E:LearningObjectivesSlide5—LearningObjectivesQuicklyreviewthelearningobjectiveslocatedonthenextpageandonpage8intheTraineeBinders.Goaroundtheroomandhaveparticipantsreadtheobjectivesonebyoneoutloudtothegroup.

*Youmayconsideraskingthegrouptomakeothersawareoftheirpreferredgenderpronounwhentheyintroducethemselves.Thisisgoodpracticewhetherornotthereappearstobeany“question”becausegender-identityisn’talwaysperfectlyinterpretable.Thispracticehelpstocreateaninclusiveenvironment,andwillhelpavoidmis-genderinganyparticipants.Italsomodelsanapproachthatparticipantscanuseininteractionswithyouth.

5

Whythistraining?

SenateBill238requirestrainingbeprovidedto:• Grouphomeadministrators• Fosterparents• Childwelfaresocialworkersorprobationofficers• Dependencycourtjudges• CourtappointedcounselandCASA• Publichealthnurses• Othersupportpeople

Aboutthesetopics:• Psychotropicmedication• Trauma• Mental/Behavioralhealthandsubstanceuse

5

LearningObjectives

ü Knowledge

ü Skills

ü Values


LEARNINGOBJECTIVES(onpage8ofthetraineebinder)

KnowledgeK1 Traineeswillbeabletonameatleastthreekeypointsinthelawsandregulationsthatgovern

administrationofpsychotropicmedicationstochildren,youth,andyoungadultsinfostercareinCalifornia.

K2 Traineeswillbeabletonameatleastoneofthebasicprinciplesofperson-centeredandtrauma-informedcareastheyrelatetouseofpsychotropicmedicationinfostercare.

K3 Traineeswillbeabletonameatleasttwocommonbehavioralhealthdiagnosesandtherelatedtreatmentoptions(bothpsychosocialandmedical)forchildren,youth,andyoungadultsinfostercare.

K4 Traineeswillbeabletodescribewhatdotoifsideeffectsarenoticedorreportedbyachild,youth,oryoungadultinfostercarewhoistakingprescribedpsychotropicmedication.

K5 Traineeswillbeabletolocateandutilizethecorrectstaterequiredform(s)whenamedicalproviderisstartingorcontinuingapsychotropicmedicationforachild,youth,oryoungadultinfostercare.

K6 Traineeswillbeabletodescribethenotificationprocessesusedinrequestingandmonitoringadministrationofpsychotropicmedications.

SkillsS1 Usingsampleplans,traineeswillutilizetheCaliforniaGuidelinesfortheUseofPsychotropicMedication

withChildrenandYouthinFosterCareandthetoolsinitsappendicestoevaluateandmodifytreatmentplansthatincludepsychotropicmedicationdecisions.

• PrescribingStandardsbyAgeGroup,• ParametersforUseofPsychotropicMedicationforChildrenandAdolescents,• ChallengesinDiagnosisandPrescribingPsychotropicMedication,and• Algorithm/DecisionTreeforPrescribingPsychotropicMedication.

S2 Usingavignette,traineeswillbeabletoidentify:• Therelevantpartiesanddocumentationtobeincludedinthecourtprocess,• Thoseparties’rightsandobligations,and• Thetimelineforcourtrequests,decisions,andnotifications.

ValuesV1 Traineeswillvaluebuildingonchildandfamilyresilienceandstrengthsinbothformalandinformal

servicesusedtoamelioratethenegativeeffectsof1. abuseand/orneglect;2. emotional,cognitive,and/orbehavioraldysregulations;and3. potentialmentalillness.

V2 Traineeswillvalueensuringthatthevoicesofchildren,youth,andyoungadultsareincorporatedintotreatmentplansandmedicationdecisions.

V3 Traineeswillvalueworkingwithamulti-disciplinaryteamtounderstandandmanagetheuseofpsychotropicmedicationbychildren,youth,andyoungadultsinfostercare.


Segment2:LawsandRegulationsSegmentTime: 30minutes

Materials: Internetconnectiontoshowvideos

Slides: 6-13

DescriptionofSegment:Lecture:Providebackgroundofpsychotropicmedicationandintroducethethreenewlawsandthenewregulationstheyputinplace.Watch:VideoclipsofStateAuditor’sReportandFosterYouthTestimony

Note:Keepcarefultrackoftimeinthissegment.Questionsthatmightariseherewilllikelybecoveredinlatersections,soit’sgoodtokeepmoving.Considerassigningatimekeepertoalertyou.

DuringtheSegment

Slide6beginsSegment2

p Activity2A:Lecture—BriefintroductiontodefinitionandbackgroundSlide7—DefinitionofPsychotropicMedication

FromtheWelfareandInstitutionsCode,psychotropicmedicationsaredefinedas

“Thosemedicationsprescribedtoaffectthecentralnervoussystemtotreatpsychiatricdisordersorillnesses.Theymayinclude,butarenotlimitedto,anxiolyticagents,antidepressants,moodstabilizers,antipsychoticmedications,anti-Parkinsonagents,hypnotics,medicationsfordementia,andpsychostimulants.”

TheCaliforniaDepartmentofSocialServicesandtheDepartmentofHealthCareServicesusethissamedefinitionintheirGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCaredocument,whichwewilluselaterintheday.

Slide8—BigPicture

Problemsthathavebeenraisedbyresearchstudies,governmentreportsandthemediacoverageinclude:over-medication,off-labelmedication,multipleprescriptionsinsufficientmonitoring,andveryyoungpatients.

Researchandmediasourcesrevealthattherateofpsychotropicmedicationprescriptionsinfostercareishigherthanthegeneralpopulation,childrenhavebeenprescribedmultiplepotentclassesofdrugstobetakensimultaneouslyandwithoutascheduletoevaluateeffectiveness(inotherwords,permanently).Thiscoverageandothermovementstoimprovementalhealthservicesinfostercareproducedseveralreformlaws.

LawsandRegulations

Segment2

7

Section1:PsychotropicMedication

“Thosemedicationsprescribedtoaffectthecentralnervoussystemtotreatpsychiatricdisordersorillnesses.Theymayinclude,butarenotlimitedto,anxiolyticagents,antidepressants,moodstabilizers,antipsychoticmedications,anti-Parkinsonagents,hypnotics,medicationsfordementia,andpsychostimulants.”

7

8

BigPicture

• Researchstudies,governmentreports,andmediacoverage• Inputfromchildren,families,andtheirrepresentativesabouttreatmentdecisions• Reformsencourageuseoftrauma-informedlensandteamingwithfamily• Psychotropicmedicationsareonepossibletooltobecarefullyconsidered• Supportservices

8


Federallawrequiresstatesfigureouthowtheywilladdresstheseissues.AdministrationofChildrenandFamiliesissuedIM-12-03.Inthebinder.Input:Theselawsmakeexplicitthatchildrenandyouthinfostercare,alongwiththeirfamiliesandrepresentatives,mustbeallowedtoprovideinputintowhetherornotpsychotropicmedicationispartoftheirtreatmentplan.Refusalandprotection:Theselawsalsoemphasizethechild’srighttorefusemedicationandtheirrightnottobepenalizedordisciplinedforthatrefusal.Trauma:Ratherthanworkingfromtheassumptionthatsymptomsandbehaviorsarenecessarilyindicativeofmentalillness,thesereformsencouragetheuseofatrauma-informedlenstoviewthechild’senvironmentandexperiencesaspossiblesourcesofbehaviororsymptomsandtoexploreabroadrangeoftreatmentoptions.Broadarrayofservices:Psychotropicmedicationsareonetoolamongmanythatmaybeusedtoaddressbehavioralhealthconcerns.Theymustbeconsideredverycarefullyasthelong-termeffectsofthesemedicationsondevelopingbrainsisunknownandpotentialsideeffectscanbesevere.Goalistogetappropriate,quality,accessiblemental/behavioralhealthservicestochildrenandyouthincare.

p Activity2B:VideoclipsSlide9—Expertvideos

ShowtheshortvideoclipfromStateAuditor.• StateAuditor’sReportis4:16minuteslong—Takeafew

momentsafterthisvideotoreviewthekeypointsandanswerquestions.Thefollowingvideosareemotional,solettheparticipantsknowthattheywillbehearingstrongtestimonyfromformerfosteryouthwhohadnegativeexperiences.

Besuretointroducetheformerfosteryouthbytheirnames(TishaOrtizisfirstandShanequaArrington).Thesefolksaretheexpertsinthistopic,andtheyrepresentthe“why”behindtheentiretraining.

• Tisha’stestimonyis4:10• Shanequa’stestimonyis2:28

p Activity2C:Lecture—Overviewofnewlaws(Slides10-13)

Slide10—SenateBill238

Courtauthorizationprocess:

• Onlyajuvenilecourtjudicialofficercanordertheadministrationofpsychotropicmedicationstoachildoryouthinfostercare(exceptrarecaseswe’llcoverlater)

• Thatofficermayonlydosobaseduponarequestfromaphysician.

9

ExpertVideos

StateAuditor’sReporthttps://youtu.be/8XLA5stjYgY

TishaOrtiz’stestimonyaboutSB1174https://youtu.be/bEEO83wMb5Q

Shanequa Arrington’stestimonyaboutSB1291https://www.youtube.com/watch?v=wWXP8tjxNw4

10

SB238:PsychotropicMedication

Providesforthefollowing:• Courtauthorizationtoadministermedication• Caregiverreceivesacopyofthecourtorder• Childandteamprovideinputaboutmedicationdecisions• Publichealthnurseparticipation• Dataandinformationsharing• Trainingrequirements

10


• Thatphysicianwillprovidereasonsfortherequestandadescriptionofthechild’sdiagnosisandsymptoms.

• Thecourtwillreceiveinformationaboutthechild’soverallmentalhealthassessmentandtreatmentplan,andtheprocessforperiodicoversightandevaluationtobefacilitatedbythesocialworker,publichealthnurseorothercountystaff.

• Caregiverreceivesnoticewithintwodaysofcourt’sdecision

ChildandFamilyInputProvidesopportunityforthechildandhisorherfamilyandcaregiver,court-appointedspecialadvocate,thechild’stribe,orotherstoprovideinputonthemedicationsbeingrequested,andrequiresthatthechild’scaregiverreceiveacopyofanyresultingcourtorder.

PublicHealthNursesSB238clarifiesthepublichealthnursingprograminchildwelfarewiththepurposeofpromotingandenhancingthephysical,mental,dental,anddevelopmentalwell-beingofchildreninthechildwelfaresystem.PHNswillcollectanddocumentmedicalrecords,assistwithreferrals,andparticipateinmedicalcareplanningandcoordination.WEWILLTALKMOREABOUTTHISTHROUGHOUTTHEDAY.

MonthlyStateDataRequirestheCaliforniaDepartmentofSocialServicestoissueamonthlyreportwhenredflagsarepresent.Forexample,• whenmultiplemedicationsareprescribedforthesamechild,or• whenunusuallyhighdosesareindicated,or• whenprescriptionsareforchildrenwhoare5yearsoldoryounger.Countiesaresubsequentlyrequiredtosharerelevantinformationwithappropriatejuvenilecourt,attorneys,countydepartmentofbehavioralhealthandCASAs.Countydata-sharingagreementsdiffer,sonoteveryonereceivesthesamereports.

MandatesthistrainingSB238alsorequirestrainingabouttheauthorization,uses,risks,andbenefitsofpsychotropicmedicationaswellastrainingonself-administration,oversight,andmonitoringofthosemedications.Thistrainingrequirementalsoincludesinformationabouttrauma,substanceusedisorderandmentalhealthtreatments.That’sthistrainingwe’reinrightnow.


Slide11—SenateBill319

NOTE:ThislawandtheissuessurroundingtherolesandresponsibilitiesofPHNscanbecontroversialand/orconfusing.IftherearePHNsattendingyourclass,taketimetoacknowledgetheirconcernsandreassurethemthatwewillbecoveringthisinmoredepthlaterintheday.ClarifythatthespecificpracticesandprotocolsforPHNactivitieswillvaryaccordingtocountydecisions,sosomespecificquestionsandconcernsareoutsidethescopeofthistrainingasitisdesignedprimarilyforchildwelfareworkers.Encouragethemtotalktoeachotherandtheircountyadministrationforclarificationandsupport.SenateBill319addressestheroleofFosterCarePublicHealthNurses.ItdoesnotfundamentallyCHANGEtheirrole,itjustoutlinesactivitiesspecifictopsychotropicmedicationoversight.PHNsareto:

o monitoruseofpsychotropicmedicationbychildrenandyouthinfostercare,

o documentinitialandfollow-uphealthscreenings,o collecthealthinformationtodetermineappropriatereferral,o helpchildrenandfamiliesconnectwiththeservicesthey

need,o assistwithtreatmentplanning,o assessprogresstowardtreatmentgoals,ando advocatetoensurethatthehealthneedsofthechildare

metandthatthechildandfamilycanmakeinformeddecisionsabouttheirownmedicaltreatmentandhealthcaregoals.

Makesuretolistentotheconcernsofnurseshere.Wewillgooversomeoptionsforhowtheseactivitiesmightoccurintheafternoonsectionofthistraining,anditwillbeimportanttocovertheirspecificconcernsandquestionsasmuchaspossible.RefertoACL16-48fordetails.Also,inthefuture,theremaybeaclassonthistopicespeciallydesignedfornurses.Anotherfutureoptionisthatitwillbeco-taughtbysocialworker/childwelfareworkerandanurse..Slide12—SenateBill484ThislawappliesprimarilytoGroupHomes.Runawayandemergencysheltersareexemptedfromtherequirementsofthisbill.Grouphomesarerequiredtousepsychotropicmedicationinaccordancewiththewrittendirectionsoftheprescribingphysicianasauthorizedbythejuvenilecourt.GroupHomesaretomaintainspecificinformationinthechild’srecords

• Acopyofthecourtorderthatauthorizestheadministrationofprescribedmedicationand

• Aseparatelogforeachmedicationthatincludes:ü thenameofthemedication,ü thedateofprescription,

11

SB319:FosterCarePublicHealthNurses

PHN’sroleisclarifiedto• Monitorandoverseepsychotropicmedication• Documenthealthscreenings• Makereferralsandlinkages• Playkeyroleinplanningandassessment• AdvocateforhealthneedsofthechildSB319allowssharingofhealthinformationbetweenspecificpartiesfortheexpresspurposeofaccessinghealthcareandmedicalservices.

11

12

SB484:GroupHomes

• Methodologyforidentifyingandinspectingfacilitieswithconcerningmedicationusage• Allowsforinformationsharingaboutinspections• AnnualreporttobepostedonCDSSwebsite• Requiresmaintenanceofcourtrecordsandmedicationlogs• Newperformancestandardsandoutcomemeasures

12


ü thequantityofmedicineandthenumberofrefills,ü dosageanddirections,andü thedateandtimewhenthechildtookeachdose.

Thestatewillidentifygrouphomesthatwarrantadditionalreviewandconductvisitsatleastonceayeartoidentifiedfacilities.GrouphomeswhohavehadavisitorreportwillbeallowedtosubmitimprovementplanstoCDSSwithin30daysofthatvisit.SB484authorizesCDSStoshareinformationaboutthesevisitswithcountyplacingagencies,socialworkersandprobationofficers,thecourtanddependencycouncilortheMedicalBoardofCalifornia.Grouphomeswillberequiredtoadheretonewperformancestandardsandoutcomemeasures.Slide13—LegislativeUpdatesSenateBills

• 1174—prescriber-oversightbillallowingMedicalBoardofCaliforniatoexamineprescriptionpatterns

• 1291—improvestransparencyandtrackingofmentalhealthservicesforchildrenandyouthinfostercare

InformationaboutnewCalifornialawsconcerninghealthcanbefoundhere:http://www.dhcs.ca.gov/formsandpubs/laws/Pages/LawsandRegulations.aspxNote:TraineeBindercontainsthecompletetextofeachoftheselawsshouldanyparticipantswanttoknowmore.

13

LegislativeUpdates

SenateBills• 1174—prescriber-oversightbillallowingMedicalBoardofCaliforniatoexamineprescriptionpatterns• 1291—improvestransparencyandtrackingofmentalhealthservicesforchildrenandyouthinfostercare


Segment3:CourtForms


Materials:PacketsofblankcourtformsandJV-220HandoutsFlipchartsheets(7foreachteam)CopiedandcutsetsofStepcardsandFormcardsArolloftapeperteam

Slides: 14-33DescriptionofSegmentTrainerfacilitatesanoverviewoftheformsusedintheJV-220process,andguidesthegroupthroughtwoskill-buildingactivitiesforusingtheseforms.

BeforetheSegment

Createsevenflipchartpagesforeachgroupbywriting“Step1”through“Step7”andWhatForm(s)?halfwaydowneachpageasshownbelow.HangeachsetonadifferentwallinnumericalorderStep1-7.Itisprobablyeasiestifthisisdonebeforethetrainingbegins.

ThroughStep7

CopyandcuteachgroupasetofStepcardsandasetofFormscards(asincludedintheTrainerMaterialspacket).

DuringtheSegment

Slide14Introducesthissegmentp Activity3A:LectureontheCourtProcess

Slide15—CourtProcess

Theprocessofapplyingtothecourtforjudicialreviewofaplantoadministerpsychotropicmedicationtoachildoryouthinfostercare,andtheformsthatareusedinthatprocessaresometimesreferredtoasthe“JV-220Process.”ThenewprocessbecameeffectiveonJuly1st,2016.Itstrengthensthecontinuity,quality,andcoordinationofcare.• Continuityisimprovedbythesharingofmedicalandtreatment

historyacrossagencies,• qualityofcareisenhancedbyimprovedmonitoringandclear

expectations,and• coordinationiseasierbecausesocialworkersandpublichealthnurses

haveeasieraccesstonecessaryinformation.

CourtProcessandForms

Segment3

15

CourtProcess

•Continuity•Quality•Coordination

• JudicialReview• JV-220Forms

15

STEP1:WhatForm(s)?

STEP2:WhatForm(s)?

STEP3:WhatForm(s)?


MuchoftheworkdonebytheCFTorothertreatmentteamespecially1. thehealthhistory,2. pasttreatmentsdocumentationand3. risk/benefitanalysis,

willbeusefulforthecourtifpsychotropicmedicationisselectedaspartofthetreatmentplan.

Slide16—JudicialReview

Bylaw,achildwhoisawardordependentofjuvenilecourtorinfostercaremaynotreceivepsychotropicmedicationwithoutacourtorder.TheJudicialCouncilhascreatedaseriesofformsusedtorequestthisorderfromthecourt.Theymakeupthe“JV-220Process.”Thereareonlythreeexceptionstothismandate.

• Ifthechildoryouthlivesinanout-of-homefacilitythatisnotconsideredfostercare(e.g.juveniledetentionorvoluntaryplacement).

• Whenthereisapreviouscourtorderthatgivesthechild’sparentstheauthoritytoapproveorrefusethemedication.

• Inthecaseofanemergency.Adoctormayadministerpsychotropicmedicationtoachildiftheyposeaseriousrisktothemselvesorothers,topreventdeathorseriousharm,orifwaitingwouldcreatesignificantsuffering.Afteremergencyadministrationofmedication,thedoctorhasnomorethan2daystoseekcourtauthorizationthroughtheJV-220process.

Judicialreviewisinitiatedbythesocialworkerorprobationofficerwiththechild’sprescribingphysician.Theyworkincollaborationwiththechild,hisorhercourtandtribalrepresentatives,alongwithfamilymembersandcaregivers.PublicHealthNursesarekeymembersoftreatmentteamsforchildrenandyouthinfostercare.CivilCodesection56.103statesthatmedicalinformation,barringpsychotherapynotes,andotherrestrictedhealthinformationmaybesharedwithPublicHealthNursesorPHNs.CountieswillvaryintheapproachtheytaketoincorporatingtheroleofPHNsandthesedatasharingactivities.

Slide17—ExceptionsJudicialapprovalisrequiredexceptinthesecircumstances.

• Continuationofmedicinefrombeforetheywereinfostercare.• Parent/legalguardianremainstheonlypersonallowedto

consenttotreatment.• Emergency—rareandshort-term• Non-minordependentshavetheirownconsenttograntordeny,

theCourthasnoauthority

16

JudicialReview

• ApplicationforPsychotropicMedication• The“JV-220Process”• MandatedbylawunlessüOtherout-of-homefacilityü Previouscourtorderü Emergency

• Collaborationwiththechild,hisorhercourt,andTribalrepresentatives,family,andcaregivers• PublicHealthNurses

16

60

Exceptions

•Medicationiscontinuationofprescriptionbeingtakenbychildbeforetheyenterfostercare• Pre-disposition—parent/legalguardianconsentisrequired• Emergency• YouthwhoareNon-MinorDependents.Thesesyouthgranttheirownconsent(unlessemergencyornon-voluntaryhospitalization).


Slide18—RequiredFormsGiveaquickintrototheforms.Detailswillcomelater.JV-220isthebasicinformationformthatinitiatestherequesttoadministerpsychotropicdrugstoachildoryouthincare.JV-220(A)isanattachmenttotheJV-220andcontainsthephysician’sstatement.ItmustaccompanytheJV-220,unlesstherequestistocontinueanongoingtreatmentwithoutchangesandisrequestedbythesamedoctor.Inthatcase,JV-220(B)shouldbeattached.TheseJV-220formsarecommonlyreferredtoastheApplication.JV-221istheformthatshowstheCourtthatallpartieswitharighttoreceivenoticewereservedacopyoftheApplicationandattachments.Wewillcoverthesepartiesmorethoroughlyinafewmoments.JV-223istheOrderontheApplicationandistheformtheCourtusestoeithergrantordenytheApplication.JV-224istheCountyReportFormandisfiledwiththeCourtbythesocialworkerorprobationofficeratleast10calendardaysbeforeeachprogressreview.JV-217INFOisaGuidethatprovidesbriefdescriptionsofalltheformsrelatedtotheApplicationforPsychotropicMedication.ItissentalongwithnotificationsofapendingApplication.

Slide19—OptionalForms

Inadditiontotherequiredforms,therearesomethatthefamilyandtreatmentteammaydecidetouse.Itisimportanttonotethatwhiletheseformsarelistedas“optional,”thatdoesnotmeanthatseekingtheinputoftheseindividualsisoptional,justthattheuseofthesespecificformsisnotrequired.Involvedpartiesmaycommunicatetheirthoughtsandfeelingsusingothermeans,buttheirinputshouldalwaysbesought.

• TheJV-218formcanbeusedbythechildtoprovidetheirinputtotheCourtaboutthemedicationplan.

• JV-219isasimilarformthatmaybeusedbythecaregiver,CASA,orTribetoprovideastatementrelatedtotheApplication.

• JV-222formisfiledwhenoneofthespecifiedpartiesdoesnotagreethatthechildshouldtaketherecommendedmedication.

p Activity3B:MatchingGame—Slide20

NOTE:Thisslideisanimatedsothatyoucanrevealthecorrectanswerstothegameoncethegroupshavefinishedplaying.Thestepswillappearclockwiseasyouclickthrough.

1. Dividetheroomintoatleasttwogroups.Ifthegroupswillbelargerthan10persons,thenathirdgroupmightbeagoodidea.

2. Showthegroupsthesetofflipchartpagesyoucreatedandhungonthewallalready.EachgroupwillhaveasetofsevenflipchartpageswithStep1-7indicatedasdescribedabove.

61

RequiredForms

• JV-220 ApplicationforPsychotropicMedication• JV-220(A)Physician’sStatement• JV-220(B)Physician’sRequesttoContinueMedication• JV-221 ProofofNoticeofApplication• JV-223 OrderonApplicationforPsychotropicMedication• JV-224 CountyReportonPsychotropicMedication• JV-217INFOGuidetoPsychotropicMedicationForms

62

OptionalForms

• JV-218Child’sOpinionAbouttheMedication• JV-219StatementAboutMedicationPrescribed• JV-222InputonApplicationforPsychotropicMedication

Note:Itisnotoptionaltoseekinputfromthechildand/orfamily;itisoptionaltousethesespecificformstoprovideit.

20

JudicialProcessActivity1.Application

JV-220 2.Physician'sStatementJV-220 A

JV-220Bforrenewalofsameplanbysame

Prescriber

3.NotificationsAnnouncementofpendingApplication

BlankJV- 218,219,&222ProofofNotification

JV-221

4.Input/StatementsJV-218, JV-219,

JV-222Filedwithin 4 Court

DaysAndoptionalagainbeforeProgress

Reviews

5.Ruling/CourtOrderJV-223

Ifapproved,last2pagesofJV-220Aandmedication

informationsheetsFiledwithin7CourtDaysof

completeApplicationToCaregiverwithin2Court

Daysofruling

6.CountyReportJV-224

BlankJV-218&21910calendardaysbeforeeveryhearingorreview

7.ProgressReviewand/orStatusReviewAllrelevantformsand

information

20


3. Explainthattheywillbeputtingonesetofcards(helpfultodescribethesewithwhatevercoloryoucopiedtheStepcardsonto)intheproperorderfromStep1toStep7.Andthatthentheywillplacetheothersetofcards(again,whatevercoloryoucopiedthesecards,ideallyadifferentcolorthantheStepcards)willbeusedtomatchtheformswiththeappropriateStep.Forexample,”

4. Giveeachgroup• acopyofJV-217INFO,• theirsetofStepcards,• theirsetofFormcards,and• arolloftape.

5. Afterbothgroupshavefinished,clickthroughtheanimationtorevealtheanswers.Thisisthebig-pictureprocessoverview.Lettheparticipantsknowthatwewillbegoingintodetailabouteachofthesenext.

6. QUICKDEBRIEF:RemindtheparticipantsthattheJV-217INFOformisoftentheonlyinformationthatfamilies,caregivers,andotherfolksreceivetohelpthemnavigatethissystem.Isitenough?

CorrectAnswers:

STEP1:ApplicationForm(s):JV-220STEP2:Physician’sStatementForm(s):JV-220A(QuicklyexplainthatJV-220Bisonlyforsamemedicationplanwithsameprescriber)STEP3:NotificationsForm(s):JV-221,JV-217INFO,BlankJV-218,BlankJV-219,andBlankJV-222STEP4:InputandStatementsForm(s):JV-218,JV-219,andJV-222STEP5:Ruling/CourtOrderForm(s):JV-223STEP6:CountyReportForm(s):JV-224STEP7:ProgressReviewForm(s):JV-224(ongoingmonitoringandeval)BlankJV-218andBlank219providedbeforehand(sometimesthiswillcoincidewiththeCountyReport)p Activity3C:Lecture—ReviewofJudicialProcessForms.

Afterthegame,passoutthecopiesoftheactualblankformsandtheaccompanyingJV-220handouts.Showandreviewthedetailedslidesforeachform.Theyshouldcorrecttheirflipchartpagesandmovethingstotheproperplaceifmistakesweremadetovisuallyreinforcethroughouttheday.


JV-220ApplicationforPsychotropicMedication[Slide20]JV-220(A)Physician’sstatementandJV-220(B)Physician’sRequesttoContinueMedication[Slides21-25]JV-221ProofofNoticeofApplication[Slides26and27]JV-222InputonApplication[Slide28]JV-223OrderonApplication[Slide29]JV-224CountyReportonPsychotropicMedication[Slide30]Group7—JV-218Child’sOpinionabouttheMedicine[Slide31]Group8—JV-219StatementaboutMedicinePrescribed[Slide32]RequiredForms:

63

ApplicationforPsychotropicMedicationJV-220• Usuallycompletedbysocialworkerorprobationofficer• Functionslikeacoversheetfortheattachments• Providesthecourtwith:ü Basicinformationaboutthechildü Contactinformationforsocialworkerorprobationofficer

üMedicationandothertreatmenthistoryüWhowillbeprovidinginputandinwhatform

22

Physician’sStatement—JV-220(A)

Threeuses:1. aninitialrequesttoadministermedication2. arequesttostartadifferentmedicationor3. arequesttocontinuemedicationatdifferent

doseorfromdifferentPrescriber• Prescribingphysician’sinformation• Assessmentofchild’soverallmentalhealth• Descriptionofsymptoms,theirduration,andthetreatmentplan• Descriptionofchild’sresponsetocurrentmedicationifapplicable• SignedbythePrescriber(PhysicianorPsychiatrist)

22

65

Physician’sStatement—JV-220(A)(cont’d)

• Outlineofprevioustreatments:ü Listofpharmacologicalandnonpharmacological

treatmentsandthechild’sresponsetothemü Listofpreviousmedicationsandchild’sresponseü Descriptionofsymptomsnotimprovedbypast

treatments• Symptomsexpectedtoimprovewithrequestedmedication• DiagnosisfromDSM-5andrelevantmedicalhistory• Othertherapeuticservicesfornextsixmonths

66

Physician’sStatement—JV-220(A)(cont’d)

• Whetherornotthechildandcaregiverhavebeeninformedof:ü Recommendedmedicationü Anticipatedbenefitsü Possiblesideeffectsü Thatheorshemayopposetherequest

• Whetherthechild’sandcaregiver’sresponsestothisinformationwereagreeableornot

67

AttachmentstoPhysician’sStatement—JV-220(A)

• ListofmedicationcurrentlyadministeredüName,class,andtargetüDose,duration,andschedule

• Listofmedicationsthisorderwouldstop

• Mandatoryattachmentsü SignificantsideeffectsüWarnings/contraindicationsüDruginteractionsüWithdrawalsymptoms

68

Physician’sRequesttoContinueMedicationJV-220(B)

• ShorterversionofJV-220(A)• SamedoctorwhocompletedthemostrecentJV-220(A)• Samemedication• Samedosage,duration,andschedule

ProofofNoticeofApplication—JV-221

Parent/Guardian• Noticeofphysician’srequest• AnApplicationispending• Thenameofeachmedication• TheJV-217-INFOdocument• BlankJV-219(Statement)• BlankJV-222(Input)

Child’sAttorney/GAL• CopyofcompletedJV-220andJV-220(A)or(B)• CopyofJV-217-INFO• BlankJV-218forchild’sopinion• BlankJV-222forinput

Note:InconsistenciesexistbetweenthisformandCARulesofCourt5.640

Caregiver• SameasParent/Guardianexcept• Nomedicationinformation• NoJV-222(Input)

ProofofNoticeofApplication—JV-221

CASA• Noticeofphysician’srequest+pendingApplication• Nameofeachmedication

Child’sTribe• Noticeofrequest+pendingApplication• Nameofeachmedication• CopyofJV-217-INFO• BlankJV-219(Statement)• BlankJV-222(Input)

Note:InconsistenciesexistbetweenthisformandRulesofCourt

OtherAttorneys• Noticeofphysician’srequest• PendingApplication• Nameofeachmedication• CopyofJV-217-INFO• BlankJV-222forinput


OptionalForms:

JudicialProcessHandouts(locatedinHandoutFolder):AlltheBlankJVformsandthefollowinginfosheets:JV-220ApplicationforPsychotropicMedicationJV-220(A)Physician’sstatementandJV-220(B)Physician’sRequesttoContinueMedicationJV-221ProofofNoticeofApplication(IncludesnoteonJV-217-INFO)JV-223OrderonApplicationJV-224CountyReportonPsychotropicMedicationJV-218Child’sOpinionabouttheMedicineandJV-219StatementaboutMedicinePrescribedJV-222InputonApplication

71

OrderonApplicationforPsychotropicMedicationJV-223HearingsetwithinsevendaysCaregiverreceivesacopywithintwodays• ThedocumentsandformsthattheCourtconsidered• Noticerequirements• HearingDate/Time/Department• Application(pages5&6ofJV-220(A)attached)

ü Grantedü Grantedandmodifiedü Denied

• Resubmitwithmissinginformation• Progressreview

72

CountyReportonPsychotropicMedicationJV-224Completedbysocialworkerorprobationofficer:• Child’sinformation• Listofmedicationsanddosage• Caregiver’sobservationsabout:

ü Behavior/symptomchangeü Sideeffectsü Concerns

• Child’sobservationsaboutthesame• Datesofmedicationmanagementappointmentssincelasthearing• Datesandreasonsforotherappointments• AnyotherrelevantinformationFiledatleast10daysbeforethehearing

73

Child’sOpinionabouttheMedicineJV-218

Childcanusethisform,or:• Talktothejudgedirectly• Writealettertothejudge• Asktheirlawyer,socialworker,probationofficer,orCASAtotalktothejudgeforthem

Theformconsistsofashortquestionnaireaboutwhatthechildknowsaboutthemedicineandothertreatmentsandactivitiesandtheiropinionaboutthem. 74

StatementaboutMedicinePrescribedJV-219Caregiver,CASA,orIndianTribemayusethisformor:• Talktothejudgedirectly• Writealettertothejudge• Asktheattorneyofrecord,socialworker,probationofficer,orCASAtotellthejudgeforthem• TheCASAmayfileareportdirectlyTheformisaquestionnaireabout:• thechild’sbehavior• treatmentandfollow-upplans• descriptionsofcurrenttreatmentandcurrentmedicationifapplicable

70

InputonApplicationforPsychologicalMedicationJV-222

Thefiler’scontactinformationandoneofthreereasonsforfiling

1. OpposetheApplication2. Inputforthecourt(ifnotopposed)3. Attorneyneedsmoretimeand/ormore

information

• MustbefiledwiththeclerkoftheJuvenileCourtwithinfourdaysofreceivingnotice•Thecourtmayormaynotsetahearingduetooppositionorinput


Segment4:TraumaSegmentTime: 45minutes

Materials: DiscussionPrompts

Slides: 34-42

DescriptionofSegment:

Lecture:Traumaanditseffects,commonsymptoms/behaviorsthatmayresultfromtrauma,howtheserelatetofostercaresettinginparticular;howresilienceisprotective;andessentialelementsoftrauma-informedpractice.

Groupdiscussion:traumapracticeexperience,trauma-informedtoolsandservices,andadvocatingfortrauma-informedservicesintheirsmallgroups.

DuringtheSegment

p Slide34beginsSegment4:Trauma

p Activity4A:Lecture—TraumaasitrelatestoPsychotropicMedicationinFosterCare(Slides15-22)

Slide35—DefinitionofTrauma

SubstanceAbuseMentalHealthServicesAdministration’sdefinitionoftrauma:

“Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorthreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandphysical,social,emotional,orspiritualwell-being.”

Slide36—Thisdefinitionisspecialbecauseitincludes“setofcircumstances.”

Theinclusionof“setofcircumstances”incorporatestheexperienceofneglect,whichisthemostfrequentreasonthatchildrenandyouthareremovedfromtheirhomes.Therefore,thisdefinitionisimportantforworkwiththefostercarepopulation.Itdoesn’tcompletelyalignwiththediagnosticcriteriaforPTSD,sothisisanareathatrequiresattention.Thetrauma-informedapproachisofparticularimportancewhenwearediscussingmentalandbehavioralhealthinterventions.Often,thesignsandsymptomsoftraumacanresemblethoseofmentalillnessorbehaviordisorders.Thesesymptomsandbehaviorsmightthenbetreatedasamentalillnessorchemicalimbalanceand/orwithpsychotropicmedications,thuscausingmissedopportunitiestoaddressthetraumaaswellasincreasingthelikelihoodofaddingunduestressorevenre-traumatizingtheindividual.

Trauma

Segment4

15

Trauma

TheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)definition:

“Individualtraumaresultsfromanevent,seriesofevents,orsetofcircumstancesthatisexperiencedbyanindividualasphysicallyoremotionallyharmfulorthreateningandthathaslastingadverseeffectsontheindividual’sfunctioningandphysical,social,emotional,orspiritualwell-being.”

36

Trauma

•Traumacanresultfroma“setofcircumstances”notonlyfromspecificevent(s)—includesneglect•PosttraumaticStressDisorder(PTSD)diagnosisrequiresexposuretoaspecificeventorseriesofevents,somaynotcoverfosterchildrenandyouthwhohavehistoriesofneglect.•Trauma-informedcareandservicesareespeciallyimportantwhenassessingandtreatingmentalorbehavioralhealthconcerns.•Traumaandmental/behavioralhealthconcernscanoverlap• Signsandsymptomsaresimilar• Canco-existandbeinter-related

36


Slide37—ThethreeE’softrauma

Thisdefinitionhighlightsthethreecomponentsoftrauma:THEEVENTORCIRCUMSTANCE:Thesourceofpotentialtraumaisan

eventorcircumstancethatcausessignificantstress.Noteverychildexposedtostresswilldeveloptrauma.Examplesmayincludetheactualorextremethreatofphysicalorpsychologicalharmorsevere,life-threateningneglect.(abuse,caraccident,murder,disaster).Theseeventsandcircumstancesmayhappenasasingleoccurrenceorrepeatedlyovertime.Traumacanalsooccurwhenanindividualwitnessesextremethreatsorstressfulcircumstancesexperiencedbysomeonetheycareabout(domesticviolence,abuseandneglectofothers).

EXPERIENCE:Thesingularexperienceanindividualhasoftheseeventsorcircumstancesdetermineswhetheritisatraumaticevent.Aparticulareventmaybetraumaticforoneperson,butnotforanother(i.e.siblingsremovedfromthesameenvironmentofneglectmaynotalldeveloptraumaresponse).Feelingsofpowerlessness,humiliation,guilt,shame,betrayal,orsilencingoftenshapetheexperienceoftheevent.Howtheeventisexperiencedmaybelinkedtoarangeoffactorsincludingtheindividual’spersonality,culturalbeliefs,availabilityofsocialsupports,ordevelopmentalstageatthetimetheeventoreventsoccurred.

EFFECTS:Acriticalcomponentofdeterminingifanexperiencewastraumaticforanindividualisthepresenceoflong-lastingandadverseeffects.Theymayoccurimmediately,ornot.Sometimesadverseeffectsarenotnoticeduntilmuchlater,butarenonethelesscausedbythepreviousEventsandExperiences.Itmaytakemanyyearsforsymptomsoftraumaticexperiencestobecomeapparent.Itisnotuncommonforadolescencetobeatimewhenchildhoodtraumaisrevealedinphysiologicaland/orbehavioralsymptoms.Individualresponsesvarywidely,soitisimportanttocarefullyandcompassionatelyassesssymptomsandbehaviorsthroughatrauma-informedlensevenifnothingobviouslytraumatichashappenedrecentlyinthechild’slife.

Slide38—TraumaandFosterCare

Childrenandyouthcurrentlyorformerlyinfostercarehavelivedthroughatleastonecircumstancewhichcouldbetraumatic:• theywereremovedfromtheirhome.Theylostaccesstotheirfamily

foratleastsometime.• Theyalsoexperiencedthesignificantloss,abuseand/orneglectthat

leadtotheirremoval.

Fostercareservices,whicharedesignedtoprotectchildrenfromharm,canbetraumatizing,

17

TheThreeE’sofTrauma

•TheEventorseriesofevents,orcircumstance

•TheExperiencedeeplypersonalandindividualized

•TheEffectlong-lastingandadverse

38

TraumaandFosterCare

• Removal,loss,abuse,and/orneglect• Evensystemsdesignedtoprotectcantraumatize

• Similarsymptomsü Sleepproblemsü Toiletingproblemsü Angerandaggressivebehaviorsü Depressionü Difficultysustainingattention

• Negativeeffectsoftraumaareoftensimilartomentalhealthsymptomsandbehaviors

• Maybeimmediateordelayed

38


• removalfromhome,neighborhood,community• separationfromsiblings,pets,andfamiliarenvironment• changeinroutineandexpectations• chaotic/unreliable(i.e.turn-overinsocialworker,placements)

Therefore,itmakessensetoviewthispopulationthroughthelensofpotentialtraumaanditseffects.TheAmericanAcademyofPediatricsidentifiedsymptomslike• sleepproblems,• toiletingproblems,• angerandaggressivebehaviors,• depression,• ordifficultysustainingattentionaspossiblepresentationsfromchildrenwithahistoryofadverseandpotentiallytraumaticexperiences.

Thesebehaviorsmaybeadaptiveandprotectivewhenthechildisinthestressfulenvironment,butcanbemisunderstoodaspathologicwhentheyareremovedfromthatenvironment.Noteverydysregulationisindicativeofadisease.That’swhyitisimportanttocarefullyscreenforandevaluatetraumawhenassessingtheneedsofchildrenoryouthandtokeepinmindthatchildrenaredoingthebesttheycanwiththecircumstancesthey’vegot.

Allthesesymptomsresemblesymptomscommonlyassociatedwithmentalorbehavioralhealthconcernsordiagnoses.Traumaandmentalhealthoftenoverlap.Traumacanhavenegativeeffectsonachild’spsychologyand,conversely,mentalhealthissuescanincreasevulnerabilitytotrauma.Traumashouldbeconsideredatallpointsinmentalhealthandsubstanceuseservicesincludingprevention,treatment,andrecovery.Negativeeffectsoftraumacansometimesalsoleadtomisdiagnosisand/orinappropriatetreatment(forexample,prescriptionofmedicationintendedtotreatamentalillnessratherthantreatmentfortrauma).Asmentionedbefore,theeffectsoftraumamaybeimmediateordelayed,whichisonereasonwhyongoingassessmentissoimportant.

Slide39—TraumaandResilience

Unaddressedtraumasignificantlyincreasestheriskof• mentalhealthconcerns,• substanceusedisorders,and• chronicphysicaldiseases.

Thesepotentialoutcomescanbemitigatedbyresilience.Resilienceiscomprisedofthreeinteractiveinfluences:

• Individualdifferencesintemperamentandcognitiveabilities• Qualityofsocialrelationships—doesthechildhavepeersand

adultstheycantrustandwhocareaboutthem?

39

Trauma andResilience

Resiliencehasthreeinteractiveinfluences:• Personaltemperament• Qualitysocialrelationships

andlovingconnections• Supportiveenvironment

Strength-basedapproachcanimproveresilience.

GroupDiscussion:Anyexamplesofresilienceand/orstrength-basedworkhelpingtoaddresstrauma?

39


• Qualityofthebroaderenvironment,suchasschoolandneighborhood

Resiliencecanbenoticed,heightened,andcenteredbytheuseofastrengths-basedapproachtoworkwithchildrenandfamilies.Focusingontheassetsandtoolsthatindividualsalreadypossessratherthanperceiveddeficitscanempowerindividualsandminimizelabelsandstigmas.Identifyingandbuildingonthestrengthsoftheindividual,theirsupportnetwork,andtheirenvironmentincreasesresilienceandcanimprovetheprotectivefactorsindealingwithpastandpotentialfuturetraumaandhelptomitigatenegativeeffectsfromstress.

Slide40—NegativeEffectsofTrauma

Examplesofnegativeeffectsincludethelimitedordisruptedabilityto:• copewiththenormalstressesandstrainsofdailyliving,• formrelationshipsorbeabletotrustinorbenefitfromthem.• managecognitiveprocesses,suchasmemory,attention,

thinking;• regulatebehavior;and/or• controltheexpressionofemotions.

Thiscansometimeslooklike• anger,violence,self-harm,distrustfulness• hypervigilanceornumbness• avoidanceorhopelessness• nightmaresorflashbacks• useofalcoholorotherdrugs• neurobiologicalmake-upandongoinghealthandwell-beingmay

bepermanentlyaltered.Theseeffectscaneventuallywearapersondownphysically,mentally,emotionallyandspiritually—survivorsoftraumahavehighlightedtheimpactoftraumaonspiritualbeliefsandthecapacitytomakemeaningoftheirexperiences.

Slide41—TraumaandSubstanceUse

Interrelatedandrisksgobothdirections• Substanceuseasanattempttomanagetraumasymptoms• Traumaoccursasresultofsubstanceuseandmaybemorelikely

(youngpeopleusingsubstancesaremorelikelytoengageinriskybehaviorsandbenearpotentiallyabusiveordangerouspeople,mayberequiredtodoillegalthingstosupportaddiction,etc.)

• Similarpatternsanddysregulationinaddictionandtraumaticstress

40

NegativeEffectsofTrauma

•Stress•Relationships—pushingawayortesting•Reducedcognitivefunctioning•Behaviorregulation—violence,self-harm•Expressionandregulationofemotion—anger,distrust

•Violenceorself-harm•Hypervigilanceorfear•Numbnessandavoidance--hopelessness•Nightmaresorflashbacks•Alcoholordrugs•Chronicphysicalillness•Spiritualimpact

40

41

TraumaandSubstanceUse

Interrelatedandrisksgobothdirections• Substanceuseasanattempttomanagetraumasymptoms• Traumacanberesultofsubstanceuseandmaybemorelikely• Similarpatternsanddysregulationinaddictionandtraumaticstress

Lookforintegratedservices• Canbechallengingtolocate• Integrationandresource-sharingcanoccurontreatmentteam• Acknowledgingtraumaanditsrelationshipwithsubstanceusecanbeanempoweringaspectoftreatmentandrecovery

41


Prioritizeintegratedservices:• Canbechallengingtolocate,butareamandatedcomponentof

MediCalviaEPSDT(SeeMHSUDSInformationNotice16-063).• Integrationandresource-sharingcanoccurontreatmentteam.• Acknowledgingtraumaanditsrelationshipwithsubstanceuse

canbeanempoweringaspectoftreatmentandrecovery.• Someserviceswon’tacceptfolkswhoareusingintotheirmental

health,andPTSDissometimesanexclusioncriterionforsubstanceusetreatment.

• Treatmentteamswithprofessionalsfrombothareascanhelpmakesuretheservicesarecomplimentary.

Self-medicatingtheory—substanceuseasacopingstrategyfortraumaYouthengageinriskybehaviorsasaresultofuseandexperienceatraumaticeventand/ormaybelessabletocopewithatraumaticeventduetosubstanceusethantheirnon-usingpeers.

Slide42—Trauma-InformedToolsandServices

• Awarenessthatsymptomscanbecopingmechanismsoradaptiveresponses,isanimportantpartofprovidingtrauma-informedcare.

• Carefulassessmentandtrauma-informedservicesarecrucialtoeffectivetreatment

• Thelongertraumaticstressgoesuntreated,thegreatertheriskofdevelopingmaladaptiveandpotentialdangerouscopingmechanisms

p Activity4B:SmallGroupDiscussionandReportOut(Slide42)Givethetraineesafewminutestodiscusstrauma-informedpracticeintheircountyoragency.Questionsareonpage19oftheirbinders.

Usethesediscussionpromptswiththeentiregroup:

1.Whataresomeexamplesofachild’sresilienceinthefaceoftraumaoratimewhenastrengths-basedapproachwasusedsuccessfully?

Oneexamplefromthepilot—ayoungadultinagrouphomewasactingoutatbedtime.Aftersomecarefulquestioning,herevealedthathedidn’twanttodo“lightsout”becauseheisafraidofthedarkduetotraumaticevents.So,thegrouphomeallowedhimtosleepwiththelightonratherthancontinuingdisciplinaryaction.

2.Doesanyoneinyourgroupuseformaltraumaassessmentsorothertrauma-specifictools?Whatabouttrauma-informedserviceproviders?

Ifso,howaretheyused?Whatarethesuccessesandchallengesofhavingthisinformation/approach?

Ifnot,doyouthinkitwouldbeusefultohavethesetools?Howwouldyouusethem?Howcanyougettheminyourcounty/agency?

42

Trauma-InformedToolsandServices

• Symptomscanbecopingmechanismsoradaptiveresponses.•Ongoingassessmentandtrauma-informedservicesarecrucialtoeffectivetreatment.• Thelongertraumaticstressgoesuntreated,thegreatertheriskofdevelopingmaladaptiveandpotentialdangerousresponses.

Smallgroupdiscussion—• Examplesofworkingwithtraumainfostercare.• Useoftrauma-informedtoolsorservices.Successes&challenges.• Ideas/nextstepforincorporatingmoreT-I.Getspecific.

42


Segment5:AccessingMentalHealthServices


Materials: Flipchartandmarkers

Slides: 43-51

DescriptionofSegment:Lecture:Quickoverviewofmental/behavioralhealthcareservicesprovidedbyCountyMentalHealthPlansandMedi-CalManagedCarePlansandtherightsofchildren,youth,andfamilieswithinthoseplans.Activity:Brainstormingforbestmental/behavioralhealthcareservices.

BeforetheSegment

Flipchartreadytocapturebrainstormedideas.

DuringtheSegment

p Activity5A:LectureSlide43beginsSegment5

Slide44—Person-CenteredApproachBecausetraumaandstrengthsaresouniquetoeachindividual,assessmentandtreatmentplanningrequiretheuseofaPerson-CenteredApproach.Thisapproachcanbedefinedas:

“ahighlyindividualizedcomprehensiveapproachtoassessmentandservicesthatisfoundedonanunderstandingoftheperson’shistory,strengths,needs,andvisionofhisorherownrecoveryandincludesattentiontoissuesofculture,spirituality,trauma,andotherfactors.”

Forchildrenandyouthinfostercare,somefactorstoobservearegriefandloss,sexualorientation,genderidentityandexpression,andanythingelsethatthechildoryouthtellsyouisimportant.Thisapproachsharestheplanning,development,andmonitoringofserviceswiththepersonforwhomtheservicesareintended.

Slide45and46—AccessingServices

EPSDT:AllchildrenandyouthinfostercareareeligibleforEarlyandPeriodicScreening,Diagnosis,andTreatment(EPSDT).ComprehensivefederalbenefitpackagewithinMedicaidspecificallyforchildrenuptoage21.Itincludes• medical,• dental,• substanceusetreatment,and• mental/behavioralhealthcareservices.

AllchildreninvolvedwiththefostercaresystemareeligiblefortheseMedicaidbenefits(Medi-CalinCalifornia).

AccessingMentalHealthServices

Segment5

44

Person-CenteredApproach

“Ahighlyindividualizedcomprehensiveapproachtoassessmentandservicesthatisfoundedonanunderstandingoftheperson’shistory,strengths,needs,andvisionofhisorherownrecoveryandincludesattentiontoissuesofculture,spirituality,trauma,andotherfactors.”

¾InstituteofMedicine(CrossingtheQualityChasm,2001)

Sharedplanning,development,andmonitoringcare.

44

45

AccessingServices

Early&PeriodicScreening,Diagnosis,&Treatment•FederallymandatedserviceforMedi-Caleligiblechildrenandyouthuptoage21•CoversALLnecessarytreatmenteveniftheserviceisnotcoveredunderthestateplanSpecialtyMentalHealthServices•Covereddiagnosis•Conditionnotresponsivetophysicalhealthcare•NecessarytocorrectoramelioratementalillnessandconditionsdiscoveredinscreeningbyMCP

45


Emphasizespreventionandearlyintervention,andrequiresthatchildrenreceivecomprehensiveexaminationstoidentifyandaddresstreatmentneeds.

Slide46—AccessingServices(con’t)SMHS:ChildrenandyouthwhomeetmedicalnecessitycriteriaareeligibletoreceiveSpecialtyMentalHealthServices(SMHS).AccordingtotheMentalHealthandSubstanceUseDisorderServices(MHSUDS)InformationNotice16-061,inordertoreceiveSMHS,childrenandyouthmustmeetthefollowingcriteria:1. Haveacovereddiagnosis(listedintheTraineeBinder)2. Haveaconditionthatwouldnotberesponsivetophysicalhealth

carebasedtreatment;and3. Theservicesarenecessarytocorrectorameliorateamentalillness

andconditiondiscoveredbyascreeningconductedbytheManagedCarePlan,theChildHealthandDisabilityPreventionProgram,oranyqualifiedprovideroperatingwithinthescopeofhisorherpractice,asdefinedbystatelawregardlessofwhetherornotthatproviderisaMedi-Calprovider.

SpecialtyMentalHealthServicesunderMedi-CalareprovidedthroughthecountyMentalHealthPlans(MHPs)MHPsmayprovideservicesdirectlyand/orthroughanetworkofproviders.Everycountyhasatoll-freenumbertocontacttheirMHP--listisonpages25-27intheTraineeBindersOthermentalhealthservicesinMedi-Cal--

• TherapeuticBehavioralServices/Coach• IntensiveCareCoordination• IntensiveHome-BasedServices• TherapeuticFosterCare

(TheMHSUDSInformationMemosNo.16-061andNo.16-063areintheTraineeBinder)Slide47—InitialMentalHealthScreeningFlowChart(alsoonpage23ofthetraineebinder)

ThefollowingflowchartoutlinesthebasicprocessofbehavioralhealthscreeningandassessmentaccordingtotheCorePracticeModelScreeningdeterminesemergencyornot(childwelfare)EmergencyreferstoMHwhothendetermines5150statusandeitherarrangesassessment/hospitalizationormeetswithCFTtostabilizeandsafetyplan.Non-emergencygoestoCFTtodeterminenextsteps.Screeninghappensatleastatintakeandannually,butcouldbemoreoftenifneeded.

46

AccessingServices

• SpecialtyMentalHealthServicesunderMedi-CalareprovidedthroughthecountyMentalHealthPlans(MHPs)

• MHPsmayprovideservicesdirectlyand/orthroughanetworkofproviders

• Everycountyhasatoll-freenumbertocontacttheirMHP--listisinyourbinders

• OthermentalhealthservicesinMedi-Cal--ü TherapeuticBehavioralServices/Coachü IntensiveCareCoordinationü IntensiveHome-BasedServicesü TherapeuticFosterCare

46

ChildWelfareConductsScreening

Intake+Annually

EmergencyNeeds

CWreferstoDept.ofMentalHealthforWIC5150evaluation

YesDMHnotifies

legalguardianandarranges

assessment

NoMentalHealthmeetswithChildandFamilyTeamtostabilizeandsafetyplan

Non-EmergencyNeeds

ChildandFamilyTeamdeterminesbestassessment.

ANYqualified MediCalmentalhealthclinician

canassess.Then,countyMHPorMediCal ManagedCarearrangefor/provide

services.

NoCurrentBehavioral Health

Needs

CorePracticeModelBehavioralHealthScreeningFlow

47


Slide48—Beneficiaries’RightsAllcountymentalhealthplansmusthaveatoll-freenumber(listedbelow).Beneficiarieshavearighttoreceive:1. Ahandbookthatoutlineshowtofileagrievanceand/oranappeal

andwhatservicesareavailabletothem,and2. Anelectronicversionofaproviderdirectorywithcontact

information.

Ifnecessaryservicesaredenied,terminated,reduced,ordelayedanappealmaybefiled.Contactyourcounty’sMHPortheHealthConsumerAllianceat888.804.3536orwww.healthconsumer.org.

Slide49—InformalMentalHealthServices

InformalMentalHealthServicesareactivitiesdeliberatelyintroducedtopromotehealingandalleviatesymptoms,andtoprovidethechildoryouthopportunitiesfor:

• positivepeerinteraction,• self-discipline,• toleranceforfrustration,• enhancedself-esteem,• masteryofskills,• beingpartofsomethinglargerthantheirowncurrent

circumstance.

Theycanalsoprovideasupportiveadultwhomaybecomeamemberofthetreatmentteamorcanofferinsighttotheteam,likeacoachoraninstructor.Someinformalmentalhealthservicesthattheteammaychoosetoincludeinachild’streatmentplanarethefollowing:

• Exerciseorparticipationinorganizedorinformalsports,• Musicaltraininglikemusiclessons,choir,orband• Artorwritingclassesorindividualartisticexpression.• Participatingincommunitytheaterproductionsordrama

activitiesatschool• Interactingwithanimalscanbeverytherapeutic,ascan

volunteeringtohelpothers.• Meditation,changesindietandcookingorparticipatingin

foodpreparationandgardeningcanallhelpchildrenmanagestressandfeelconnected.

Involvementintheseactivitiesshouldnotbethreatenedorremovedaspartofdisciplinaryactionsastheyareimportanttothechild’sresilienceandwell-being.Usecreativityandtheuniqueneedsanddesiresofeachindividualwhendevelopingthisportionofthetreatmentplan.Developingideasfor

48

Beneficiaries’Rights

• ChildrenwhoareassessedforservicesunderEPSDT,shouldreceiveaNoticeofActioninformingthemoftheresults.

• Ifservicesaredenied,terminated,reduced,ordelayedanappealmaybefiled.

• Familieshavearighttoreceive:ü Ahandbookthatoutlineshowtofilea

grievanceandanappealandwhatservicesareavailable

ü Aproviderdirectoryinelectronicform

48

49

InformalMentalHealthServices

• Exerciseandteamsports• Musicaltraining• Joiningacluboractivity• Artandwriting• Dramaanddance• Workingwithanimals• Volunteeringtohelpothers• Meditation• Healthyeating/cooking• Gardening

49


managingstressandenjoyingactivitiesispartoftreatment,sothechildoryouth’sengagementisvital.

Slide50—FormalMental/BehavioralHealthInterventions

Dependingupontheneedsofthechildandtheavailabilityofservicesinthecommunity,thetreatmentteammightconsiderthefollowing:

• MedicationSupportServices;• oneofthemanytypesoftherapy,suchasindividual,

family,orgrouptherapy;• medicalcasemanagement,• therapeuticbehavioralservices;• wraparoundservices;• intensivedaytreatment;or• residentialcare.

Alldecisionsshouldprioritizetheneedsofthechildabovewhatismerelyconvenient.Aclearlinetothegoalsofthetreatmentplanshouldbeevidentinanyinterventionselected.

Activity5B:HowtoselectservicesHaveparticipantsturntopage28intheirbinders.ThereisaMental/BehavioralHealthServiceBrainstormingForm.Thisisjustabrainstormingtool,notanofficialpieceofpaperwork.Instructions:Havetheparticipantsfilloutthisformascompletelyastheycanjustoffthetopoftheirheads.Writedownanyoneoranyservicesthattheythinkmightbeusefulforachildoryouthinneedofmentalorbehavioralhealthcare.Reportout—Askthelargegrouptodiscussthesetogetherusingthefollowingprompts:

• Whatresonated?• Wasthisuseful?(Theymightthinkaboutkeepingitupdatedor

addingelementstoresourcedirectoriestheyalreadyuse.)• Whataresomewayswecanincreasethequalityanddiversityof

careinourareas?• Didanyonecomeupwithnextstepsiftherearen’tanygood

serviceoptions?Suggestionstostart:CallyourCountyMHPContactandaskAskotherfolksinyourdepartmentBesureyoursupervisorknowsabouttheservicegapKeeptalkingaboutthegapuntilthereisaplantofillit

Thereisanotherform,similartothisone,inthehandoutfolderthatcanbeusedtobrainstormaboutoneparticularcase.Itisdesignedtohelpidentifystrengthsandresourcesinthechild,family,andtreatmentteamtobuildon.

50

FormalMentalHealthInterventions

• MedicationSupportServices• Therapy—behavioral/cognitive/relational• Counseling—individual/family/group• Medicalcasemanagement• Therapeuticbehavioralservices• Wrap-aroundservices• Intensivedaytreatmentservices• Residentialcare• Psychotropicmedication

50


Mental/Behavioral Health Services Brainstorming Form County or Agency:

Role in Mental/Behavioral Health for foster children:

County MHP Provider’s Name and Contact Info: Other Useful Partners’ Names and Contact Info: Agency strengths and resources:

Strengths and resources outside the agency:

What gaps/needs are left after considering these strengths and resources?


What informal treatment options are available to children and youth served by your agency?

Are these options culturally sensitive? Safe for potentially traumatized children? Diverse?

What informal treatment options do you wish you had access to for your children and youth?

What formal treatment options are available to children and youth served by your agency?

Are these options culturally sensitive? Trauma-informed? Diverse?

What formal treatment options do you wish you had access to for your children and youth?

What can you do to increase the quality and diversity of treatment options? Who can you ask to help develop needed resources/services? Can you partner with another agency/entity already engaged in this work? What is your next step?


Segment6:PsychotropicMedicationSegmentTime: 60minutes

Materials: Dice—oneforeachgroupoftwotraineesFlipchart

Slides: 52-68

DescriptionofSegmentWatch:Videoclipofformerfosteryouthdescribingtheirexperienceswithpsychotropicmedications.Read:FosterYouthMentalHealthBillofRights.Lecture:Someusesforpsychotropicmedications,aswellaspotentialrisks/benefitsofthesemedications.Watch:Videoclipsaboutsideeffects.Lecture:Howtofindinformationaboutsideeffectsandadversereactionsandhowtomonitortheseeffects.Activity:Roleplaysideeffectconversationsandsafetyplanning.

BeforetheSegment

Makesureyouhavediceforeachgroupoftwoparticipants.Ifyoudonothavedice,youcancalloutanumberbetweenoneandsixforeachgroupateachfive-minuteinterval.

DuringtheSegment

Slide52beginsSegment4

p Activity4A:ShowvideoSlide53—FosterYouthVoicesVideo

Watchvideoclipofformerfosteryouthsharingtheirthoughtsonpsychotropicmedication.5minutes.

Quicklydebriefasalargegrouptoansweranyquestionsorprocessthecontent.

Thesevideosservetwopurposeshere:tooutlinethemostdangerousissuestobeavoidedwithPsychotropicMedication,butalsotore-centerthegroupafterthelunchbreakontothechildrenandyouthwhoseoptimalhealthandwell-beingarethepurposeofthistraining.

PsychotropicMedication

Segment6

52

Video

FosterYouthVoices

52


p Activity4B:Slide54—Locatedonpage30intraineebinders.Havetheparticipantsreadovertheseoutloudasagroup.

53

FosterYouthMentalHealthBillofRights

53


p Activity4C:Lecture—uses,benefits,andrisksofpsychotropicmedicationinfostercare

Slide55—Psychotropicmedicationinfostercare

• Non-pharmacologicalinterventionsarefirst-linetreatmentapproach.Medicationistobeconsideredonlywhenotheroptionsarenotsufficient(outsideofemergencies).

• Medicationcanbeprescribedafterthoroughassessmentidentifiesneedandcleartreatmentgoals.Keepinmindthatitmaytakemorethanonemeeting/session/cliniciantoconductathoroughassessment.

• Whennecessary,medicationisbestused:o withothersupportiveinterventionsando aspartofacomprehensivetreatmentplan

• Respectforthedignityofthechildandfamilyisaprerequisiteforalltreatment.

Sciencehasyettofullydeterminetheeffectsthatpsychotropicmedicationmighthaveonthedevelopingbrainsandbodiesofchildrenandyouth,butitisclearthatsomesideeffectscanbequiteseriousandlong-lasting.Consequently,thedecisiontousepsychotropicmedicationshouldbeconsideredverycarefully.Dependinguponthesymptomsachildisexperiencing,therearethreegeneralpathsforusingmedicationoutsideofemergencies:1. Medicationmightnotbeusedatallintheexampleoflearned

defianceorifsymptomsaredeterminedtobetheresultoftraumaratherthanmentalillness.

2. Theteammaydecidetoincludemedicationafterotherinterventionsweretriedbutfailedtoaddressallthesymptoms.Moderateanxietyordepressionmightbeanexampleofthisscenario.

3. Medicationmaybepartofaninitialtreatmentplan,forexample,ifthechildwereexperiencingsevereAttentionDeficitHyperactivityDisorder,acutesymptomsofdepression,orpsychosis.

Ifthephysicianandchildandfamilyhavedecidedthatmedicationisnecessary,itshouldbeusedinconjunctionwithotherinterventionstosupporttheholistichealthofthechildexceptinrareemergencysituations.Inafewcases,psychosocialinterventionsarenolongerrequiredwhentheyhavealreadybeensuccessfullyemployed,butcontinuingmedicationisneededtopreventrecurrenceofsymptoms.Regardlessofwhattreatmentplanisdesigned,respectforthedignityofthechildandfamilyisaprerequisite.Alltreatmentplansshouldincludetheinputandconsentofthechildandfamily,identifyandutilizetheirstrengths,aimtoincreasetheirresilience,andprioritizetheirneeds.

54

PsychotropicMedicationinFosterCare

•Non-pharmacologicalinterventionsarefirst-linetreatmentapproach.Medicationconsideredonlywhenotheroptionsarenotsufficient.•Medicationprescribedafterthoroughassessmentidentifiesneedandcleartreatmentgoals.•Whennecessary,medicationisbestused:

• withothersupportiveinterventionsand• aspartofacomprehensivetreatmentplan

•Thechildandfamilyshouldbeinformedandinvolvedateverystageofdecisionmaking.

54


Slide56—InformedConsentforMedication

• Childrenandyoutharetobeincludedintheconsentandassentprocesstothemaximumextentappropriatebasedontheirdevelopmentalstage.

• Child,family,andcaregiverareinformedoftherisksandpotentialbenefitsof:

o Proposedmedication(name,dose,effects),and

o Alternativetreatmentsincludingtheabsenceoftreatment.

• Thoroughdiscussionofanyseriousadverseeffectstowatchforandwhenandhowtocontacttheprescriberifanythinghappens.

• PrescribersconsultwithSW/POaboutwhocanprovidelegalconsent,andreleaseofHIPAAinformation.

Slide57—Limitsonpsychotropicmedicationinfostercare

• ContinuumofCareReformTitle22makesitclearthatpsychotropicmedicationsshouldnotbeusedforthepurposesofdisciplineorchemicalrestraint.Inacutepsychiatricemergencies,chemicalrestraintmaybenecessary.Thisshouldbeextremelyrare,andveryshort-term.

• Youtharenottobecoercedintotakingmedicationasaconditionofgettingintoorstayinginafostercareplacement.

• Safeandconsistentadministrationofmedicineattheprescribedtime,frequencyanddosageisasafetyissue,andmustbeaddressedinthetreatmentplan.Ifsafeadministrationcannotbeachieved,theCourtshouldbenotifiedandmedicationshouldbereconsidereduntilsafetyconcernshavebeenaddressed.

• Safeandaccurateself-administrationofmedicationisideal.Ifitisnotpossibleforthechildoryouthtoadministertheirmedsthemselves,itisnecessarytoassistthem.

• Whenassistingachildoryouthwithadministrationofmedication,itisimportanttoconsidertheirpreferencesregardinghowandwhenheorshewouldliketotakethemedicineaslongasthosepreferencesareinlinewiththeprescriber’sinstructions.Assistonlyonechildatatimeoutsidethepresenceofotherchildren.Thishelpsprotecttheirprivacyandconfidentialityaswellaspotentiallyreducingstigmaandshamethatmayaccompanytakingmedication.

• Documenttheappropriateprocedureforadministrationandeveryoccurrenceinthechild’srecordincludingdate,time,anddose.

• RemindtraineesthatthefullBillofRightsdocumentwithadditionalresourcesisinthesupplementalmaterialsintheirbinder.

55

InformedConsentforMedication

• Childrenandyoutharetobeincludedintheconsentandassentprocesstotheextentfeasiblebasedontheirdevelopmentalstage.• Child,family,andcaregiverareinformedoftherisksandpotentialbenefitsof:• Proposedmedication• Alternativetreatmentsincludingtheabsenceoftreatment

• Anyseriousadverseeffectstowatchforandwhenandhowtocontacttheprescriber• PrescribersconsultwithSW/POaboutwhocanprovidelegalconsent,andreleaseofHIPAAinfo.

55

57

LimitsonMedicationinFosterCare

• Medicationisnottobeusedfordiscipline,coercion,orchemicalrestraint.• Youthcannotbeforcedtotakemedicationasaconditionofgettingintoorstayinginafostercareplacement.• Monitoringschedule/dosageandarrangingcorrectadministrationarepartoftreatmentplanning.• Self-administrationshouldbesupportedwheneverpossible.

57


Slide58—AssistingwithSelf-Administration

Self-administrationofmedicationistheidealtreatmentplan.Itensuresresponsibilityandownershipoftheprocessandcanhelpempoweryoungpeople.Sometimesthiswillbeasimpleprocess;forotheryouth,itmaybemoreofachallenge.Asalways,utilizethewholeteamtohelp.Herearesomeideastoassistwithself-administration:

§ Makesurethattheyoungpersonisawareofandthoroughlyunderstandstheprescriber’sinstructionandhowtogetadditionalinformationifthereisconfusion.Goovertheplanthoroughlyandmakeparticularnoteoftheanticipatedeffects,bothpositive¾suchaspossiblesymptomrelief¾andnegative¾likepotentialsideeffects.

§ Regularlyreiteratetheimportanceoftakingthemedicationaccordingtotheinstructions.Itisnotenoughtosaythisonceatthebeginning.Itisimportanttoreinforcethismessagethroughoutthecourseoftreatment.Inparticular,makesuretheyouthunderstandsthatitcouldbequitedangeroustomissdosesorstoptakingmedicationwithoutthesupportofadoctor.Also,explainthattheywon’tbeabletotellifthemedicationisworkingornotunlesstheytakeitasinstructed,andthattheymaynotgetanybenefitfromthemedicationatallifitisn’ttakencorrectly.

§ Storethemedicationinasecurelocationthattheyouthcanaccesswhentheyneedto.Itisimportanttokeeptrackofmedicationandtobeawarewhenrefillsarecomingup.TheCommunityCareLicensingDivisionhasspecificguidelinesforgrouphomesandotherfacilitiesregardingmedication.

§ Becreativeaboutsupportingyouthtostayonschedule.Colorfulcalendarsorpillboxescanhelpmaketheprocessseemlessdullorclinical.Iftheyouthisusingacellphoneorcomputeranyway,somehelpfultoolscansupporttheirself-administration.

MangoHealthisamedication-trackingappthatisdesignedlikeagame.Participantscanearnpointsforstickingtotheirschedule,andtheycanevenwinreal-worldprizes,likegiftcards,forreachingtheirgoals.

MedHelperandMedCoacharetwoothermedication-trackingappsthatmighthelpkeepyouthontrackandprovidetheircaregiveranddoctorwithinformationabouthowtheyaredoing.Someyouthmayevenwanttokeeptrackoftheirsymptomsandsideeffectsusingthenotesfunctionwithintheappitself.

§ Whensymptomsimproveandthechildisfeelingbetter,itcanbeparticularlychallengingtokeeptakingmedication.Itisveryimportantthatthetreatmentteamandthecaregiverhaveregularlyscheduledcheck-insaboutsymptomsandmedication.Youngpeopleneedsupportthroughoutthecourseoftreatment,notonlywhenthingsaredifficult.Itisimportanttolistencarefullytowhattheysayabouthowtheyfeelandwhattheywantwhenitcomestotheirownhealthcare.

57

AssistingwithSelf-Administration

• Ensureyouthunderstandstheinstructions• Regularlyreiteratetheimportanceofinstructions• Usecalendars,pillboxes,textreminders,orappstohelpMangoHealth–earnrewardsforkeepingonscheduleMedHelper—freeappthatallowsusertotakenotesMedCoach—canproducereportforcaregiverordoctor

• Symptomimprovementcanbeachallengingtimetostayonschedule• Listentothedesiresandopinionsoftheyouth

57


§ Youngpeopledon’talwaysknowwhatisbestforthem,buttheyarealwaystheexpertsinhowtheyfeel.Buildingatreatmentplanthatwillworkbestforeachspecificpersonrequiresthattheybepartoftheplan.Everypersonisunique,soremainopentoalltheoptions.Continueaskingquestionsandexploringuntilyoufindtherightfit.

§ Scheduleregularcheck-inswiththeyouthandmembersoftheteamabouttreatmentandsymptoms.Anddiscussallchanges,notjustthetargetsymptoms.Bereliableandconsistent.

Slide59—Risks

Psychotropicmedicationsareassociatedwithanarrayofpossiblerisks.Theyvarywidelydependingupontheageanduniquecharacteristicsofindividualswhotakethem.Someoftheserisksarecalledsideeffects,meaningthatmedicationcancauseeffectsotherthanorinadditiontotheintendedones.

Individualshaveexperienced:• increasedsuicidalideation• sleepdisturbance• sleepinessandlethargy• difficultymovingaround• rapidweightgainleadingtoobesity• pronouncedchangesintheirbloodsugarandmetabolismsometimes

leadingtodiabetes• nervousness• restlessness• irritability• headaches• upsetstomachorchangesinappetitearealsopossible.Alltheserisksshouldbemadecleartothechildandfamilywhentreatmentdecisionsarediscussed.Childrenandfamiliescannotmakeinformeddecisionswithoutbeingawareofthesepotentialrisks.TheCaliforniaGuidelinesdirecttheprescribingphysiciantoinformthechild,family,andothersinvolvedintreatmentplanningabouttherisksandbenefitsofthemedicineandofothertreatmentoptionsincludingtherisksandbenefitsofnotreatment.Rarely,individualsmayhaveadversereactions• Chronicphysicaland/orneurologicalillness• Permanentfacialorbodyticsandtremors• DisabilityanddeathItispossibleforchildrenoryouthtobecomeaddictedtocertainmedications,andthisriskshouldbeincludedindecisionmaking.Additionalrisksarepresentwhenmedicationsarenottakenaccordingto

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RisksofPsychotropicMedication

• Increasedsuicidalideation• Sleepdisturbance• Sleepinessandlethargy• Rapidweightgainandobesity• Bloodsugarandmetabolism• Nervousnessandirritability• Headachesandupsetstomach

Otherissues:• Adversereactionsandchronicillness• Addiction• Usingandstoppingcorrectly

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theinstructions.Treatmentplansshouldincludedetailsaboutsafeandconsistentadministrationofthemedication,ensuringanadequatesupplyofmedication,andasafetyplanforhowtostoptakingthemedicationshouldthatbenecessary.

Slide60—SubstanceUseandMedication• Carefulconsiderationofthechild’soverallhealthandneedsiscrucial

totreatmentplanning.Ifthechildoryouthusesun-prescribedmedications,otherdrugs,oralcohol,itisimportanttoassesstheriskofaddingapsychotropicmedicationaccordingly.

• Interactionsbetweenmedicationsanddrugsoralcoholcanbepowerfulandtoxic,evenlethal.

• Sometimes,individualsareusingdrugsoralcoholtoself-medicateandtoessentiallytreatthesamesymptomsthatthetreatmentplanisattemptingtoaddress.

• Alternatively,substanceusedisorderitselfcanmimicthesignsorsymptomsofotherdysregulations.Ifthatisthecase,thatdisordermustbetreatedfirstinordertoaccuratelydiagnosisthechildoryouth.

• Ifbothsubstanceusedisorderandotherbehavioralhealthissuesarepresent,dualdiagnosistreatmentshouldbeprioritizedinthetreatmentplan.Thismeanstreatmentthatfocusesontheintersectionandoverlapofproblematicsubstanceuseandseriousmentalhealthneeds.Onewaytostartistomakesurethatsomeonetrainedinsubstanceuseisonthetreatmentteam.

Slide61—PotentialBenefits

Thebesttreatmentplanforanindividualmayincorporatemedication,whichhasthepotentialto

• improveschoolperformanceandabilitytoconcentrate• decreasetheexperienceofanxietyorworry• reducesymptomsofdepression• improveoreliminatefrequentphysicalpainorsomatic

complaints• reduceoreliminatenightmaresandothersleepdisturbance• limitexcessiveaggressionortempertantrums• improvemood

Thesepotentialbenefitsaretobeweighedagainstthepotentialriskswhendecidingwhetherornottoincludemedicationinachildoryouth’streatmentplan.Itisimportanttonotethatallthesebenefitsarealsopossibletoachievewithouttheuseofpsychotropicmedication—everythingdependsontheuniquecircumstanceofthechildandtheirenvironment.

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SubstanceUseandMedication

• Drugsandalcoholcaninteractdangerously—evenlethally—withpsychotropicmedication• Substanceusecanmimicthesignsandsymptomsofmentalillness• Isoftenself-medicationfortraumaand/ormentalhealthissues• Dualdiagnosistreatmentispriority

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PotentialBenefitsofMedication

• Betterschoolperformanceandconcentration

• Lessenanxietyorworry

• Decreasedepressionsymptoms

• Addresssomaticcomplaints

• Reducenightmares• ImprovemoodandmoodregulationNOTE:Allthesebenefitsarealsopotentiallyachievablewithouttheuseofpsychotropicmedication

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Forchildrenandyouthinfostercare,notallofthesepotentialbenefitsarefullybackedbyevidence.Therefore,itisvitalthattheintroductionofmedicationsisincremental;beginningwithalowdose,andslowlyadjustedwhilecarefullytrackinganypositiveornegativeeffects.

Slide62—AttentionDeficitandAnxiety/DepressionMedications

AttentionDeficitandHyperactivityDisorderorADHD:Arelativelycommondiagnosisforchildrenandyouth.PsychomotorstimulantslikeRitalinandAdderallareoftenprescribedtotreatthesymptomsofADHD.Theycanhelpchildrentoconcentrateandcontrolhyperactivity.Commonsideeffectsincludedecreasedappetiteorstomachdiscomfortandpoorsleep.Non-stimulantssuchasStratterahavethesamebenefitsaswellasdecreasedcompulsivebehaviors.Thecommonsideeffectsarealsosimilar—stomachdiscomfortandpoorsleepalongwithheadache.AnxietyandDepression:Symptomsrelatedtoanxietyanddepressionmayalsobeaddressedwithmedication.SelectiveSerotoninReuptakeInhibitorsandAtypicalAntidepressantssuchasProzac,Zoloft,Celexa,WellbutrinorLexapromaydecreasedepressivesymptoms,improvemood,anddecreaseanxiety.Theycancausenausea,anddisturbsleep.Theyalsoposeanincreasedriskofseizureandanincreasedriskofsuicidalideationespeciallyinadolescents.Thesesideeffectsmayincreasewithirregularadministration,soshouldbecarefullyconsideredifproperadministrationisdifficultorunlikely.

Slide63—MoodandPsychoticDisorderMedications

Mooddisorders:ToaddressthesymptomsofmooddisorderssuchasBipolarDisorder,doctorsprescribemoodstabilizerslikeLithiumorAnticonvulsantslikeDepakote.Thesemedicationsmayimproveorstabilizemoodsymptomsandimproveimpulsecontrol.Lithiumcancausedrymouth,tremor,stomachdiscomfort,weightgain,memoryproblems,thyroidandkidneyproblems.Anticonvulsantsalsohaveseriouspotentialsideeffectssuchasdrowsiness,nausea,seriousrashes,liverproblems.Periodiclabtestsandcarefulmonitoringbyaphysicianisnecessarywhilechildrenoryoutharetakingthesemedications.Psychoticdisorders:Antipsychoticmedicationsareapotentclassofpsychotropicmedications.Theyaredividedintotwocategories,NewerandOlder.Theyareusedtotreatveryserioussymptomssuchashallucination,delusions,anddisorderedthinking.Theycancauseextrapyramidalsideeffects(EPS)suchasshakiness,drooling,andstiffness.Theyoftencauserapidweight

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UsesofPsychotropicMedication:MentalHealthDiagnoses

AttentionDeficit/Hyperactivity• Psychomotorstimulants• Non-stimulantsü Bothcanhaveanegativeeffectonappetiteandsleep

AnxietyandDepression• SelectiveSerotoninReuptakeInhibitors(SSRIs)• Atypicalantidepressantsü Increasedriskofsuicidalideationandseizure

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UsesofPsychotropicMedication:Mood,PsychoticDisordersMooddisorderslikebipolardisorder•Moodstabilizers• Anticonvulsantsü Bothimprovemoodandimpulsecontrolü Bothhaveserioussideeffectstobemonitoredclosely

Psychoticdisorders• Antipsychotics—newerorolder• Neuroleptics/Tranquilizersü Decreasepsychoticsymptomsü Cancausemovementdisordersaswellasweightgain

andseriousphysicalhealthproblems


gain,heartandbloodirregularities,permanentticsandtremors,anddiabetes.

Slide64—Medicationstoaddresssideeffects

Sleep:Manypsychotropicmedicationshavethepotentialtocausesleepdisturbance.Doctorsmayprescribesedativesorhypnotics,andsometimessleep-promotingmedicationslikeBenadryltohelpchildrensleep.Thesemedicationshavethepotentialtobehabit-formingandcancauseadditionalsideeffects.Extrapyramidal(EPS):Theseveresideeffectsfromantipsychoticscanbetreatedwithanticholinergicmedications.Thesecanreducetheshakiness,drooling,andstiffnessassociatedwithEPS.Multiplemedications:Itisimportanttonotethatmultiplemedicationsandusingmedicationtotreatsideeffectsofothermedicationisnotrecommendedpractice,butdoesoccur.Aswithallmedication,thesedecisionsshouldbecarefullyanalyzedbytheentiretreatmentteamtoensurethebestoutcomesforthechild.Childrenwithseveralsimultaneousprescriptionsareatincreasedriskforadverseeffects.Useofmultiplemedicationsshouldbecarefullymonitoredbythefamilyandthephysician.

Slide65—Watchvideoclipsofformerfosteryouthdescribingthesideeffectstheyexperiencedwhileonmedication.

Rochelleclipis29secondsSadeclipis49seconds

Theseclipsareareminderofwhythistrainingmattersandwhatthelong-termresultscanlooklike.NOTE:ThemonitoringofsideeffectscanbeachargedsubjectforPHNsandchildwelfareworkers,manyofwhombelieveitisonlywithinthescopeoftheprescriber’sroletodothatmedicalportionofoversight.

Usethistimetoencouragethemtoapproachthetopicofsideeffectsandotherchangesthatresultfrommedicationassomethingtheentireteammustbevigilantaboutintheinterestsofthechild.

Again,theydon’tneedtobemedicalexperts,theyonlyneedtousetheresourcesattheirdisposalintheGuidelinesandontheirtreatmentteam(includingandespecially)thechildandfamily)toadvocateforthechild.

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MedicationstoTreatSideEffects

Sleepdisturbance• Sedatives,hypnotics,orothersleep-promotingmedicationsü Cancausedependencyandtheirownsideeffects

Extrapyramidal(EPS)• Anticholinergicmedicationsü DecreaseEPSsymptoms—shakiness,drooling,

andstiffnessü Drymouth,blurredvision,anddrowsiness

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SideEffects

Rochelle• https://youtu.be/qQ7sUvIKzvs

Sade• https://youtu.be/kwp8i7mhNRs


Slide66—SideEffectsSafety:Ifsideeffectsaresuspectedoridentified,safetyisthepriority.Followallemergencymedicalproceduresifnecessary,andtakenecessarystepstoensurethesafetyofthechild.

• Consultwiththeprescribingphysicianimmediatelytodetermineifchangesneedtobemade.

• Donotallowthechild/youthtosimplystoptakingmedication.Thereisusuallyaprotocolforweaningoffpsychotropicmedications,anditisvitaltofollowthosedirections.

• Ifdoseorschedulechanges,followupwiththerequiredCourtdocumentsanddocumentthechangeinthehealthrecordandthechild’sfile.

Planahead:Findoutwhatsideeffectsarepossiblewhenthetreatmentplanwithmedicationismade.Haveasafetyplancreatedintheeventthatsideeffectsemerge.Itisimportanttobeawareifthereareanyknowninteractionswithotherdrugsoralcoholaswellasstepstotakethatmightreducethelikelihoodofsideeffects.

• AppendixBoftheCAGuidelinesistheprimarydocumentCDSShasidentifiedforreferenceaboutspecificmedicationsandtheparametersfortheiruse(dosage,sideeffects,potentialinteractions,etc.)LACountyiskeepingthisdocumentup-to-dateandpubliclyavailableontheirwebsite.

• Youcanlearnmoreaboutpossiblesideeffectsbyresearchingonsiteslikemedlineplus.govorfindingthepackageinsertfortheprescribedmedication,whichareusuallyavailableonline.

Slide67—DocumentingSideEffects• Socialworkersandprobationofficersmustensurethat

monitoringoccurs.ItmaybethePHNorcaregiverwhodospecifictasks,butthesocialworkerisresponsibleformakingsureithappensasoftenandthoroughlyasnecessary.

• Socialworkersandprobationofficersdon’tneedtobetheexpertsinknowingallthedetailsofthisinformation,buttheymustcollectitfromthedoctorsandhealthprofessionalswhoareexpertsandmakesurethatthechildandcaregiverandfamilyhavereceivedtheinformationandunderstandit.

• Regularlyaskthechildoryouthtodescribetheirexperiences—bothphysicalandemotional—sincetakingthemedication.Askthemtocomparethoseexperiencestohowtheyfeltbeforetakingmedication.Thisassessmentshouldoccurthroughoutthedurationofthetreatmentassideeffectscandevelopatanytime.

• Ifdevelopmentallyappropriate,thechildshouldbeawareofeffectstowatchoutforandwhotheyshouldtelliftheyexperiencesomethingnew.

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SideEffects

• Followallemergencyandsafetyprotocols• Consultwiththeprescribingphysician• Documentationandcourtformneededifchangingmedicationordose

• Beprepared• Safetyplan• Gotomedlineplus.gov fordetailedinformation• Readthepackageinsertfromthemedicine(usuallyavailableonline)

• Possibleinteractionswithalcoholorotherdrugs• Howtoreducepotentialsideeffects

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DocumentingSideEffects

• Socialworkerisresponsible,butnotexpectedtobetheexpert• Askthechildoryouthdirectlyandfrequentlyabouttheirexperiences—physicalandemotional• Reportanddocumentanychanges• Ensuredoseisappropriate• Speakwithfamily,caregiver,andothers(schoolpersonnel,churchandcommunitymembers)aboutchangesinbehavior,mood,orphysiology


• Theprescribingphysicianshouldmakecleartothetreatmentteamhowtheycanbecontactedshouldsomethingarise.

• Therecommendeddoseshouldbeageappropriate.• AppendixAoftheCaliforniaGuidelineshasageparameters.Even

ifthedosefallswithinacceptableguidelines,itmaybetoomuchortoolittleforaspecificindividual,soitisimportanttomonitortheirresponses.

• Itisalsoimportanttocheckwiththefamilyandcaregiversofthechildoryouthtoseewhethertheyhavenoticedanychangesinthechild’smood,behaviororappearance.Schoolpersonnel,friendsfromchurchandthecommunitymayalsobeabletoidentifyiftherearechangesinthechild’sbehaviorintheseotherenvironments.

• Collectivevigilanceandfrequentcommunicationcanhelpidentifyandaddresssideeffectsfrompsychotropicmedications.

p Activity4D:Quickroleplay(Total20minutes,4scenariosat5mineach)

Slide68—Conversationtopicsrelatedtomedication

Pairtraineesintogroupsoftwoandletthemdecidewhowillplaytheroleofsocialworker/probationofficer/orPHNfirst.Theothertraineewillplaytheroleofthechildorfamilymember.

Eachpairofparticipantsrolltheirdietodeterminewhichscenariotheywillworkonfirst.

Letthemroleplayforfiveminutesbypracticingtheconversationsthataccompanyrisks/benefits,sideeffects,andsafetyplanninginthatscenario.

ThenthepairwilltradewhoistheSO/PO/PHNandrollthedieagaintoidentifythenextscenariotheywillroleplay.

Repeatsteps2-4fourtimesuntileachparticipanthasplayedthehelperroletwice.

Walkaroundtheroomtoobservefordevelopmentallyappropriateconversation,useofthesafetyplanningtool,andtoanswerquestions.Ifitcomesup,remindfolksthattheyaren’texpectedtobetheexpertsonthemedicalaspects,butinsteadtoaddresstheneedsandcontext.ActasLINKtoresources,notBEalltheresources.

Havethegroupreportback—

Whatresonated?

Whoelsewouldbeinvolvedintheseconversationsinrealsituations?

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PracticeConversations

• Risks/benefits

• Assessingandmonitoring

• Safetyplanning

• Advocacy

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SIXSCENARIOS(locatedonpage37ofTraineebinder):1.Six-year-oldElizabethhasrecentlybeenprescribedRitalintoaddressrestlessness.Hertreatmentplancallsforevaluationofsymptomsandsideeffects.

2.Juliusis17yearsoldandabouttotransitionoutoffostercare.HecurrentlytakesaSelectiveSerotoninReuptakeInhibitor(Celexa)foracuteanxiety.Hisfostermotherisconcernedthathewillstoptakingitonceheleavesherhome,andwouldlikehimtohaveasafetyplan.

3.Afterherappointmentwiththedoctor,Phoebehassomequestionsabouttherisksandbenefitsoftakingtheantipsychotic(Zyprexa)thatherdoctorisrequestingfromthecourttoaddressherimpulsivityandaggression.Sheis15yearsoldandlivesinagrouphome.

4.CharlotteistenyearsoldandshehasbeentoseehertherapistweeklyforthreemonthsandistakingVistariltohelphersleep.Shefeelsthathersleepisbetter,butthetherapyismakingthingsworse,andtheconversationsshehasmakehermoreupset.Shewantstostopgoing.

5.Derrickisafosterparent.Hewastoldbythedoctorathisfosterson’slatestappointmentthatAdderalldoesnothaveanysideeffects.Hiseight-year-oldfostersonwasalreadytakingitwhenhecametoDerrick’shome.

6.TheJV-220ApplicationforSamtostarttakingZolofttoaddresssymptomsofseveredepressionwasapprovedbythecourt.Samis13yearsold.Discusstheriskofsuicidalideationrelatedtothisdrugandaboutsafetyplanning.


Segment7:UsingtheCaliforniaGuidelinesDocumentsSegmentTime: 60minutes

Materials ScenariosCaliforniaGuidelinesdocumentandappendicesCopiesoftheAnswerKeyforUsingtheGuidelines

Slide: 69-81

DescriptionofSegmentLecture:WhataretheGuidelinesforandwhatisincluded.Activity:GetfamiliarwiththeGuidelines

BeforetheSegment

InstructtheparticipantstoretrievetheircopyoftheGuidelinesfromthebackpocketoftheirbinder.Thisisacopyofthemostrecentdocumentandallappendices.Makesuretoinformthemthatitwillberevisedatleastyearly,sotheyshouldplantoretrievenewcopiesregularlyfromtheCDSSwebsiteortheircountyagency.

DuringtheSegment

Slide69beginsSegment7p Activity7A:LectureSlide70—WhataretheGuidelines?CreatedcollaborativelybyCDSSandDHCS.Itoutlines:

Sharedvalues,expectations,andprinciplesofpsychotropicmedicationuseinfostercare.Itisdesignedtobeanadvocacytooltohelpguidenon-medicalprofessionalswhenworkingwithdoctorsandpsychiatristsandothermedicalpersonnelorserviceproviders

Ithasseveralimportantgoals:1. Increasedvisibilityofstrengthsandneedsofchildrenandyouth

withemotional,cognitive,and/orbehaviordysregulation2. Reductionofsocialstigmaduetodysregulation3. Promotingbestpracticesinthestate’scommitmenttoprovideboth

formalandinformalmental/behavioralhealthservicestochildrenandyouthincare.

Slide71—WhataretheGuidelines?(con’t)Expectationsabout:

• Treatmentplans,assessment,anddiagnosis• Whatprescribersshouldconsiderforcertainactivities• Beforeprescribing• Whenprescribing• Whenevaluatingwhetherornotatreatmentiseffective• Prescribinginanemergency

FourAppendicesA:PrescribingStandardsbyAgeGroupB:Parametersfordoserangeandschedule(LACounty’sParameters3.8)

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UsingtheCaliforniaGuidelines

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Segment7

70

WhataretheGuidelines?

• Sharedvalues,expectations,andprinciplesasagreeduponbyCDSSandDHCS• Tooltousewithprescribers,thecourt,servicedeliveryagencies,caregivers,andotherstoreachoptimaltreatmentdecisions• Goals:ü increasingvisibilityofthestrengthsandneedsof

childrenandyouthwithemotional,cognitive,and/orbehavioraldysregulation,

ü eliminatingsocialstigma,andü promotingbestpracticesintheprovisionofformal

andinformalmentalhealthservices70

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WhataretheGuidelines?

Theyoutlineexpectationsabout:• Treatmentplans,evaluation,anddiagnosis• Prescribers’considerationsforcertainactivities

ü Beforeandwhenprescribingü Evaluatingtreatmentefficacyü Prescribinginanemergency

Fourappendices:• PrescribingStandardsbyAgeGroup• Parametersfordoserangeandschedule(3.8)• ChallengesinDiagnosisandPrescribingwithrecommendations• PrescribingAlgorithm(DecisionTree)

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C:ChallengesinDiagnosisandPrescribingincludingrecommendationsD:DecisionTreeforPrescribingSlide72—PrinciplesandValuesTheGuidelinesoutlinethesharedprinciplesandvaluesofCDSSandDHCSregardingtheuseofpsychotropicmedicationwithchildrenandyouthinfostercare.

• Alwaystopromotesafety,permanence,andwell-being• Realpartnershipswiththeimportantpeopleinthechild’slife• Workingfromachild-centered,strength-basedperspectiveto

createtrulyindividualizedtreatment• Providingthehighestqualityofcarethatisintegratedwithinthe

child’scommunityandincollaborationwithanyhelpfulpartners.• Psychotropicmedicationisnottobeemployedasthesole

intervention(exceptinextremelyrarecaseswhentreatmentwithmedicationissuccessful,butneedstobecontinued),butratheraspartofarobustoveralltreatmentstrategyemployingbothformalandinformalinterventions.

Slide73—TreatmentPlan

Atreatmentplanisthedetaileddescriptionofservices,supports,andtreatmentsthatwillbeemployedtoeliminateorreducethechildoryouth’sidentifiedsymptoms,emotionaldistress,and/orproblematicbehaviors.Itisthedocumentthatdescribeshowtheteamwillattempttoimprovethingsforthechild.Treatmentplanningisalwaysdonecollaborativelywithchildrenandtheirfamilies,whetherornotaChildandFamilyTeamiscreated.Amulti-disciplinaryteamfunctionsverysimilarly,oranevenless-structuredsupportivegroupcanbesuccessfulincreatingaqualitytreatmentplan.Theimportantthingistoincorporatediverseperspectivesthatbuildaroundtheuniqueresources,abilities,strengths,andneedsofeachspecificchildandhisorhernaturalsupportnetworkandcommunity.Ifachildistooyoung,oriftherearedevelopmentalorprotectiveissuesinthecasethatpreventcollaboration,everyeffortshouldbemadetoinvolvearepresentativetospeakonbehalfofthechildindecisionmakingmeetings.Toeveryextentpossible,thechildortheirrepresentativeshouldbeincludedinalltheplanning,review,andre-assessmentofthetreatmentplan.Treatmentplansshouldseektoutilizeavarietyofinterventionstoaddresstherootcausesofdysregulationwhetherthatcauseistraumaormentalillnessoracomplexinteractionofmultiplefactors.Alleviationofspecificsymptomsisimportant,butisonlyPARTofacomprehensivetreatmentplan.Includinginterventionsthatarebackedbyevidencewheneverpossibleisideal.Plansshouldseektobecomprehensiveandtreatthewholechildnotsimplyperceived“problems”withthechild’s

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PrinciplesandValues

• Promotesafety,permanency,andwell-being• Partnershipswithpeopleandagenciesinthechild’slife• Child-centered,strength-based,individualizedcare• High-quality,integrated,collaborativeservices• Psychotropicmedicationisonlypartofanoveralltreatmentstrategy

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TreatmentPlan

•Developedincollaborationwiththechildandfamilyaroundtheiruniquestrengthsandneeds• Individualized,flexible,robust•Varietyofinterventions•Addressrootcause(s)ofdysregulation•Notlimitedtosymptomrelief•Evidence-based•ComprehensiveandHIPAACompliant

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behaviororfunctioning.HIPAAcomplianceisasimportantintreatmentplanningasitisinallareasofhealthcare.

Slide74—What’sIncludedinaTreatmentPlanTheCaliforniaGuidelinesindicatethecomponentofatreatmentplanthatadherestobestpracticestandardsshouldcontainthefollowing:

1. Thechild’sdiagnosisand/oroutlineofemotional/cognitive/behavioraldysregulationbasedonthechild’shistoryofabuse,neglect,and/orremovalfromthehome;

2. Adescriptionofthechild’sbaselinestrengthsandneeds;3. Targetsymptomsasagreedtobythechild,family,andteam

membersandexpressedinclear,everydaylanguage;4. Short-andlong-termtreatmentgoals;5. Interventions,includingevidence-supportedtreatments,

psychosocialinterventions,substanceabusepreventionortreatment,casemanagement,informalmentalhealthservices,educationalorbehavioralservices,extracurricularandrecreationalactivitieswithstartdatesandanticipatedduration;and

6. Aclearandspecificplanforperiodicreviewandreassessment.KatieA.plansmustbereviewedatleastevery90days.Ifreassessmentinvolveschangesinpsychotropicmedication,thoseplansmustbecommunicatedwiththeCourtasanattachmenttoformJV220,whichwediscussfurtherinthenextsectionofthistraining.

Slide75—Assessmentofneeds

Childrenwhohaveemotional,cognitive,and/orbehavioraldysregulationfromtrauma,mentalhealthconcerns,orforotherreasonsrequireanddeserveatreatmentplanthatcontainsavarietyofinterventionstoalleviatetheirsymptomsandtopromotetheirsafetyandwell-being.Thefirststepinthatprocess,isahigh-quality,trauma-informed,child-centeredassessment.

Childrenwhohaveemotional,cognitive,and/orbehavioraldysregulationfromtrauma,mentalhealthconcerns,orforotherreasonsrequireanddeserveatreatmentplanthatcontainsavarietyofinterventionstoalleviatetheirsymptomsandtopromotetheirsafetyandwell-being.Thefirststepinthatprocess,isahigh-quality,trauma-informed,child-centeredassessment.

Aswementionedbefore,anyassessmentofchildrenoryouthinfostercareshouldbeconductedbyalicensedpractitionerwhoisinformedabouttheconditionsandeffectsoftrauma.Andshouldthoroughlycoveralloftheseitems:• PhysicalANDmentalstatusexaminations,• Identificationoftargetsymptomsandthegoalsoftreatment,

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TreatmentPlan

Documentationshouldinclude:• Diagnosisordysregulation• Strengthsandneeds• Targetsymptom(s)• Measurabletreatmentgoals• Interventionswithstartdates• Ifpsychotropicmedicationisoneoftheinterventions,thedosageandmonitoringschedule*

• Reassessment/monitoringscheduleandwhoisresponsible

*MedicationtreatmentplansmustbecommunicatedasanattachmenttotheJV220aswellassharedwiththechild/youth,family,caregiver,andsocialworkerand/orprobationofficer.

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45

NeedsAssessment

• Trauma-Informedandchild-centered• Assessmentshouldcover• PhysicalandMentalHealth• Identificationofwhatthechildandfamilywantaddressed(targetsymptomsandgoals)• Planforre-assessmentandmonitoring• Clearrisk/benefitoutlineofpotentialtreatmentoptions

• Oftenwillrequiremorethanonesession

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• Aclearplanandtimelineforre-assessmentandhowmonitoringprogresswilloccurandwhoisresponsibleforwhichpartsoftheplan,and

• Aclearrisk/benefitanalysisofeachtreatmentintheplanincludingtherisksandbenefitsofnotreatment

Slide76—PhysicalExam

Theresultsofthemostrecentphysicalexaminationofthechild—withinthepastyear—shouldbereviewedaspartofthetreatmentplanningprocess.Theseresultswillbeusedtoruleoutmedicalconditionswhentheymaycontributetoorcausethepresentingsymptoms,andtoprovidebaselineinformationformonitoringpotentialsideeffects.Asappropriate,thetreatmentteammayconsiderapregnancytestorsubstanceusescreen,asbothcouldhaveseriousimplicationsforwhetherornottoprescribepsychotropicmedication.Theseinitialexaminationsareparticularlyimportantforfollow-upandmonitoringsideeffectsbecausewithoutabaseline,itmaytakelongertonoticechangesthatmayindicatedangerousdevelopmentsorsideeffectsthatneedtobeaddressedquickly.

Slide77—MentalHealthExam

Theexaminationofthechild’smentalstatusshouldbedevelopmentallyappropriate.Anyapplicablediagnosisshouldbeinlinewithprofessionalstandardsandbesupportedbysufficientdocumentationtoruleoutotherpossiblediagnoses.Theassessmentshouldidentifythetargetsymptomsandgoalsoftheselectedtreatment,alongwithatimelineforwhenresultsshouldbeexpectedandhowlongthetreatmentisintendedtolast.Itisimportanttosharetheresultsofthisassessmentwiththechildandtheirsupportnetwork,butitisespeciallyimportanttosharethegoalsandtargetsymptomswiththem.Inthisway,everyonewillunderstandwhatthetreatmentisforandwhattoexpect.Itisalsoimportanttoconsiderifthegoalsarefocusedontreatingtheunderlyingemotionaldistressthatthechildisexperiencing,andtorefocusthemontoalleviatingthatdistressifnecessary.Regularre-assessmentisanexpectedactivity.Thetreatmentteamshouldmonitorsymptoms,sideeffects,andthechildandfamily’sneedsanddesires.Alltreatmentplansshouldexplicitlyincorporatearisk–benefitanalysisthatcomparesatreatmentplanwithoutmedicationtothepotentialbenefitsandrisksofaddingaprescription.

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PhysicalExamination

•Reviewpastexam(withinpastyear)•Baselinelabtests•Pregnancytestifappropriate•Screenforsubstanceuse•Useformonitoringchangeovertime

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77

MentalHealthExamination

•Sensitivetoage,developmentalstage,andtrauma•Diagnosisoftenrequiresmultiplesessions• Ideallyinterviewchildwithandwithoutparentsorcaregiver

Diagnosis•Usingaccepteddiagnosticcriteria•Reconcileifnotconsistentwithpreviousorothers•Allprofessionalsworkwithsamediagnosisandcaseconceptualization

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Slide78—GoalsandTargetSymptomsTremendouslyimportanttothequalityofthetreatmentplanistoidentifyspecificsymptomsthatthetreatmentisintendedtoaddress.Thisiswherethevoiceandopinionofthechildiscrucial.Treatmentplansshouldnotjusttargetthebehaviorsthatacaregiverfindsproblematic,butattempttoaddressthecoreissuesandsourceofdysregulation.Ideally,NOTjustmedicationwillbeusedtoreachthegoalsstatedhere.

Slide79—InformedconsentforANYtreatment

Itisimportanttoobtaininformedconsentforanyandalltreatment,notjustformedication.Theroleofthesocialworker,publichealthnurse,and/orprobationofficeristoensurethatthechildunderstandstheirrightsandtherisks/benefitsoftheproposedplan.Useterminologythatisclearandeasytounderstand.Informationshouldbeprovidedinthechildandfamily’sprimarylanguageandinwrittenform,ifpossible.InCalifornia,achildtheageof12andoverhastherighttoconsenttotreatmentandtherighttorefuseconsent.Theassent,oragreement,ofchildrenyoungerthan12isveryimportant.Thesocialworkerisresponsibleforknowingwhoisandwhoisnotabletoprovidelegalconsent.

Slide61—GuidelinesforPrescribing

• StartLow,GoSlow—tobestmonitoreffectivenessandsideeffects,itisimportantthatpsychotropicmedicationsareintroducedoneatatime,andstartingfromthelowestrecommendeddose.Thedosecanbeincrementallyincreaseduntilthelowesteffectivedoseisidentified.

• On-labelUse—preferenceshouldalwaysbegiventomedicationsthatareFDAapprovedfortheagegroup,diagnosis,anddoseforwhichitisbeingprescribed.Medi-Calhasalistofbrandsandgenericsthatshouldbeusedwhenpossible.

• Ifchangesarenecessary,theyshouldbemadetoonemedicationatatime.Itisverydifficulttodeterminewhatisworkingandwhatisn’tifmultiplechangestakeplaceatonce.

• Ifyouthinktheremaybetoomuchinaprescribeddoseortoomanymedicationstotal,talktoapsychiatricspecialistatyourcounty.Donotassumethatthedoctorisright.It’sokaytogetasecondopinion.

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GoalsandTargetSymptoms

•Dysregulation•Focusonunderlyingemotionaldistressratherthanbehavioralone•Reassessoften•Whatmeasuresofpsychosocialfunctioningwillshowimprovement?(i.e.improvedgrades,peerrelationships)•Evaluatemedicationprosandcons•Prioritizewhatthechildandfamilyreportanddesire

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79

InformedConsentforANYTreatment

•Alltreatmentrequiresinformedconsent,notjustmedication.•Goalistoinformthechildandfamily,andtoensuretheyunderstandandagreewithproposedplan.•Nota“formality”justtogetthemtoagree.•Useclearandunderstandabletermstoexplaintreatment,risks,andpotentialbenefits.•Provideinformationinthefamily’sprimarylanguageandinwrittenform,whenavailable.•Aminorage12andovercanconsent(ornot)totheirowntreatment.

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GuidelinesforPrescribing

• Startlow,goslow• PreferencegiventomedicationthatisFDAapprovedfor

üAgegroupüDiagnosisüDose

• Usebrand/genericspecifiedinMedi-Callist• Trysinglemedicationfirstbeforeaddingothers• Changeonemedicationatatime• Consultwithpsychiatricspecialistwhenconsidering

üMorethanonemedicationfromthesameclassüUseofthreemedicationsconcurrently

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p Activity7B:Slide81GetfamiliarwiththeGuidelines

HaveparticipantsturntotheCaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCaredocumentintheirbinders.Theyareattheendofthissegment.

GivethemafewminutestogetfamiliarwiththelayoutoftheGuidelinesbutnotreallytryingtoreaditallasthereisnottime.

Then,havethemcompletetheGetFamiliarwiththeGuidelinesworksheetonpage42oftheirbinder.

Thegoalistohavethemlookingthroughthecompletedocumentandappendicestobecomefamiliarwithhowtheymightusethemintheirpractice.

Reviewtheworksheetwiththewholegroup,callingonindividualstoanswerandaddressingquestionsastheyarise.

Spendtimeonthefinalquestion,andtrytogetparticipantstoreallyconsiderspecificwaysthattheGuidelinesdocumentandAppendicescanbeusedasatoolwithinteams.

Whenyou’vefinishedreviewingallthequestions,passaroundtheAnswerKeyHandoutforthemtokeepasareference.

GuidelinesAnswerKey(thisoneisforTraineruse,theAnswerKeyhandoutisincludedintheHandoutPacketandshouldbecopiedbeforehand)

1. Whatpagewillhelpyoudeterminetheprescribingstandardsforachildwhois13yearsold?

AppendixA,pages1and2outlinetheprescribingstandardsforyouthwhoare12-17yearsold.

2. WhatareallthepotentialcomplicationsandsideeffectsforSerotonergicAntidepressants?

AppendixB,page11indicatesthatSerotonergicAntidepressantshavethefollowingpotentialcomplicationsandsideeffects:

• Agitation,restlessness• Bipolar(manic)switching• Withdrawalsymptomsondiscontinuation• Serotenergicsyndrome• Obesity• Headache• Sweating• Sleepdisturbance• Gastrointestinalproblems• Sexualdysfunction• AndthefollowingCautionsandContraindications:• Allergytodrug,liverfailure,pregnancy/breastfeeding,donot

usewithMAOI’s

***BESURETODRAWATTENTIONTOTHESOMEWHATHIDDENWARNINGATTHEBOTTOMOFTHEPAGETHATREADS:“Antidepressantsmayincreasesuicidality(thoughtsorbehaviors)in

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Worksheet

Getfamiliarwiththe

CaliforniaGuidelinesfortheUseofPsychotropicMedicationwithChildrenandYouthinFosterCare

andAppendices

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children,teenagersandyoungadultsduringinitiation.(Idon’tknowwhyintheworldthisisn’tinthesideeffectssection.)Usethistore-inforcethattheyreadalltheinformationgiven.

3. AccordingtotheGuidelines,whoisresponsibleforobtaininginformedconsent?

TheInformedConsentsectiononPage11indicatesthatthe“..theprescriberinformsthechild,family,andcaregiveroftherisksandbenefitsoftheproposedtreatmentandtherisksandbenefitsofalternativetreatments,includingabsenceoftreatment.”However,itisimportanttorememberthatitisthesocialworker’sresponsibilitytobesurethishappensandthattheychild,family,andcaregiverunderstandwhattheyhavebeentoldbytheprescriber.

4. Sometimesdoctorsprescribemedicationtotreatasymptomotherthanthemedication’sindicateduse.Thisiscalledofflabelorblackboxprescription.WhereintheGuidelinescanyoufindinformationaboutthechallengeofoff-labelor“blackbox”prescription?

Thedocumentrecommendsthatall“off-label”prescribingshouldhavepeer-reviewed,publishedevidenceavailabletosupportitsuse.FoundonPage4ofAppendixC.Thisdocumentdescribesmanyofthechallengesthatoccurinpsychiatricdiagnosisandprescribingforfosteryouth.Itisagoodresourcefordeterminingwhenconsultationoradditionalsupportshouldberequested.

5. WhatarethethreesectionsofthePrescribingAlgorithm(DecisionTree)?Follow-upquestion,whatisSectionCactuallyusedfor?

• Beforeprescribing,havethefollowingconcernsbeenconsidered

• Whenprescribing,considerthefollowing

• Ifthisisnotthefirstprescriptionforpsychotropicmedicationforthischild,periodicevaluationoftreatmentefficacyandtolerabilityshouldoccur,asdescribedabove.Ateachsubsequentappointmentformedicationmanagement,thisevaluationincludesthereviewofthefollowing

SectionCintheDecisionTreeisachecklistofitemstobeevaluatedatmedicationmonitoringappointments.Itcanbeusedbytheclinicianwhoprescribedthemedication,butisalsoausefulguideforgatheringmuchoftheimportantinformationforProgressReviewsintheJV-220process.

6. HowdotheGuidelinesdocumentsconnectwiththeJV-220Process?

TheGuidelinesandthetoolsintheAppendicesaresupportiveofalltheinformationrequiredintheJV-220Processforms.TheGuidelinescaninformtheentiretreatmentteamregardingexpectationsandbestpractices.


Segment8:SummaryandEvaluationSegmentTime: 10minutes

Materials:

Slide:

Evaluations

82-85

DescriptionofActivityDebriefandreflectionontheinformationcoveredthroughouttheday.Activity:Courseevaluations.

DuringtheActivity

Slide83—SummaryandEvaluations

p Activity8AIfthereistimeforadebrief,facilitateagroupconversationusingthequestionsbelow.Askparticipantsthefollowingquestions,alsolocatedonpage43oftheirbinders:

o IsthereanythingmissingfromtheGuidelinesthatyouthinkmighthelpyouwiththeissuesofpsychotropicmedicationandchildrenandyouthinfostercare?

o Whatresonatesmostwithyouaboutworkingfromatrauma-informedperspective?

o Anyquestions?

Slide84—Ombudsperson’sOffice

RemindparticipantsthattheycancontacttheFosterCareOmbudspersonaboutthistopiciftheyhavequestions,orneedresourcesorrecommendations.Contactinformationisprovidedhereandintheirbinders.

p Activity8BInstructparticipantstocompletethecourseevaluation(notincludedinthisguide).

WrapUpandEvaluations

Segment8

83

SummaryandEvaluations

• IsthereanythingmissingfromtheGuidelines thatyouthinkmighthelpyouwiththeissuesofpsychotropicmedicationandchildrenandyouthinfostercare?

•Whatresonatesmostwithyouaboutworkingfromatrauma-informedperspective?

• Anyquestions?

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77

QuestionsorConcerns?

Ifyouhaveanyquestionsorconcernsaboutpsychotropicmedicationinfostercare,theFosterCareOmbudswomanofCaliforniahasagreedtohavehercontactinformationincludedinthistraining.

Herofficeisavailableforsupportandresourcesonthistopic.

Toll-freephone:1.877.846.1602E-mailaddress:[email protected]

Thankyou.