1 / 151

Psychiatric Medications and Child Welfare

Psychiatric Medications and Child Welfare. Terry Lee, MD drterry@uw.edu UW School of Medicine Department of Psychiatry Developmentally-Informed Representation of Young Children in Child Welfare October 16, 2015. Overview. Psychiatry resources

Pat_Xavi
Download Presentation

Psychiatric Medications and Child Welfare

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Psychiatric Medications andChild Welfare Terry Lee, MD drterry@uw.edu UW School of Medicine Department of Psychiatry Developmentally-Informed Representation of Young Children in Child Welfare October 16, 2015

  2. Overview • Psychiatry resources • Child welfare and psychiatric medications: appropriate or inappropriate? • Bench card • Questions to ask psychiatrists • What some other states are doing

  3. Psychiatry Resources • aacap.org: American Academy of Child and Adolescent Psychiatry (AACAP)—main child psychiatry organization • Facts for Families • Practice Parameters • cebc4cw.org: California Evidence-Based Clearinghouse for Child Welfare—CW resources, rating scales, assessment tools, webinars, resources • nlm.nih.gov/medlineplus/: Medline Plus—medication information • ohiomindsmatter.org: Ohio Minds Matter—online toolkit for consumers and stakeholders to improve psychiatric prescribing to young people

  4. Youth in the Child Welfare System and Mental Health Needs/Psychiatric Medications

  5. National Data • Youth in foster care prescribed psychiatric medications at 2-10 times the rate of non-foster youth on Medicaid (MMDLN, 2010; Raghavan, 2005; Zito, 2008) • Any psychiatric medication • Multiple psychiatric medications at the same time • Children < 5 years old

  6. Stakeholder Concerns About Psychiatric Medications in Child Welfare (McMillen, 2006) • Evaluations and follow-ups are too short • Too quick to put kids on meds • Too many kids on meds • Too many meds prescribed • Doses are too high • Kids turned into “zombies”

  7. Factors Contributing to Increased Prescribing of Psychiatric Medications to Youth Involved with the Child Welfare System

  8. Causes: Good Reasons for Increased Prescribing • Youth involved with child welfare system have higher rates of MH needs: • Maltreatment/trauma • Removal from home, family, and ecology • Multiple placements, disrupted attachments • Poverty • Intrauterine exposures, genetic risks • Entry into foster care also: • Provides access to Medicaid • Systematic screening for behavioral health needs • Advocacy for behavioral health needs

  9. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Insufficient time for proper assessment • Limited information on youth history and current functioning • Poor continuity of care • Lack of critical clinical feedback to inform psychiatrist decision-making • Ineffective advocacy

  10. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Unrealistic hopes that medication will stabilize a complex psychosocial situation • Under-recognition of trauma etiology in formulating complex presentations • Lack of commitment of resources to parent skills training, especially if permanency is unclear

  11. Factors Potentially Contributing to Inappropriate Psychotropic Prescribing • Limited access to effective psychosocial interventions • Limited access to effective psychiatric prescribing practices • Limited integration of psychiatric and psychosocial treatments

  12. Evidence of Unmet or Underserved Mental Health Needs Too

  13. LA County CW Youth, Psychotropics and MH Needs (Zima, 1999a & 1999b) • Foster youth 6-12 years-old • 49% of youth diagnosed with ADHD had not received psychotropics in the previous year • 80% of youth identified with severe psychiatric disorder not recommended for medication evaluation in previous year

  14. National Survey of Child and Adolescent Well-Being (NSCAW) • National longitudinal survey • Youth and families referred to child welfare • Completed investigations • Two groups of children (0-14 years-old) randomly chosen between October 1999 and December 2000 • 5,504 youth entering the system • 727 youth in out-of-home placement>12 months • Evaluated at baseline and 12 months • Child Behavior Check List

  15. NSCAW 2-14 Years-Old (Burns, 2004) • 47.9% of youth scored in the clinical range on the CBCL • 39.3 % of youth in kinship care • Youth with strong evidence of mental health need (CBCL) were more likely to receive help, but only ¼ had received any care in the previous 12 months • Factors relating to increased likelihood of services: • Preschoolers: sexual abuse (versus neglect) • Elementary school age: Caucasian and living out-of-home • Adolescents: out-of-home and parent with severe mental illness

  16. NSCAW <6 Years-Old (Stahmer, 2005) • Assessed 5 domains: cognition, behavior, communication, social skills and adaptive functioning • Developmental and/or behavioral health needs: • Toddlers (0-2 years-old): 41.8% • Preschoolers (3-5 years-old): 68.1% • Youth with need receiving services: 22.7% • Factors relating to decreased likelihood of services: • Remaining at home • 0-2 years-old

  17. NSCAW II (Horwitz, 2012) • Children 12-36 months old with behavioral health needs • Only 19.2% received any type of behavioral health service, including parent skills training related to mental health problems

  18. NSCAW Out-of-Home for ~1 Year (Leslie, 2004) • Youth 2-15 years-old • Need defined by CBCL clinical range: 46.8% of youth • 75.8 % had accessed outpatient mental health services, 24.2% had not received services • Predictors of receiving services: higher CBCL scores, older age, history of sexual abuse • Lesser use of services: history of neglect, African-American race/ethnicity

  19. Youth at Risk for Underserved Mental Health Needs • African-American youth • Victims of neglect • Youth remaining at home or placed in kinship care • Utilize systematic screening!

  20. Psychiatric Medication Bench Card • Help courts ask the right questions • Help child welfare workers prepare and have specific information in court • Mental health system and child psychiatrists are still responsible for providing good mental health and psychiatric care • But court can provide oversight and advocacy

  21. Some Possible Questions to ask a Child Psychiatrist

  22. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • How was the diagnosis made? Did you use information from other informants, like the school? • What is known about how helpful this medication is for other children who have a similar condition to my child’s? • How will the medication help my child? How long before I see improvement? When will it work? • What are the side effects that commonly occur with this medication? • Are there any serious side effects? • Is this medication addictive? Can it be abused?

  23. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • Who will be monitoring my child’s response to medication and make dosage changes if necessary? How often will progress be checked and by whom? • Are there any other medications or foods which my child should avoid while taking the medication? • Are there interactions between this medication and other medications (prescription and/or over-the-counter) my child is taking?

  24. Questions to Ask About Psychiatric Medications (Facts for Families, AACAP, 2004) • Are there any activities that my child should avoid while taking the medication? Are any precautions recommended for other activities? • How long will my child need to take this medication? How will the decision be made to stop this medication? • What do I do if a problem develops (e.g. if my child becomes ill, doses are missed or side effects develop)?

  25. Questions to Ask About Psychiatric Medications (Adapted from Facts for Families, AACAP, 2004) • What is the cost of the medication (generic versus brand name)? • Are there any psychosocial (non-medication) treatments that can help? How do they compare to medication treatments?

  26. Consider Psychiatric Medication Benefitrelative to Risk

  27. Psychiatric Medication Classes

  28. Stimulant Positive Effects • Very effective for ADHD, including long term • Relatively rapid onset of action • On-task behavior by all raters • Compliance as rated by teachers • Peer nominated rankings of social standing • Parent-child interactions • Attention during sports activities • Performance on paper-and-pencil and computerized tests of attention, math, short-term memory tasks, problem-solving, accuracy

  29. Stimulant Negative Effects • Appetite suppression • Sleep disturbance • Elevated pulse and blood pressure • Tics • Obsessive-compulsive behavior • Loss of spontaneity • Abuse potential • More tightly controlled prescribing (Schedule II medication) • Long term • Shorter height • Lighter weight

  30. Stimulant Diversion (Wilens, 2008) • Took stimulants without prescription • 5-9% of elementary through high school age • 5-35% of college age individuals • 16-29% of youth prescribed stimulants who were asked to sell, give or trade their stimulants • Cognitive enhancers? E.g. NY Times 4/18/15: “Workers Seeking Productivity in a Pill Are Abusing ADHD Drugs”

  31. Stimulants • Concerta (OROS-methylphenidate) • Adderall XR (mixed amphetamine salts extended release) • Dexedrine Spansules (dextroamphetamine spansules) • Ritalin LA, SR (methylphendiate) • Metadate (methylphenidate) • Focalin XR (dex-methylphenidate extended release)—isomer that provides most of the positive effect

  32. Relatively Newer Long-Acting Stimulants • Quillavent XR: long-acting liquid methylphenidate • Daytrana (methylphenidate transdermal patch) • Take off to stop action at some point • Can be taken off and • reattached (on someone else?) • Extract methylphenidate ? • To deliver 30 mg, 82.5 mg in patch • Vyvanse (lisdexamfetamine)-prodrug: • must be ingested to activate –less likely to be diverted and ingested by alternate route (snorting or injecting)? • not any more effective • Aptensio XR (methylphenidate MLR)-long-acting (12 hours) formulation

  33. Washington State Medicaid Second Opinion Dose Thresholds (>4 yo) • Methylphenidate total dose > 120 mg/24 hours • Amphetamine total dose > 60 mg/24 hours • Lisdexamfetamine total dose > 70 mg/24 hours

  34. Non-Stimulant Medications for ADHD • Atomoxetine (Strattera)* • Alpha Agonists—primarily treat hyperactivity • Guanfacine XR (Intuniv)* • Clonidine XR (Kapvay)* • Guanfacine(Tenex) • Clonidine (Catapress) • Buproprion (Wellbutrin) • Modafinil (Provigil) • Imipramine • *FDA-approved for ADHD

  35. Atomoxetine for ADHD • Atomoxetine (Strattera) not as effective as stimulants • Pros • Effective throughout the day? • Not Schedule II medication • No increase in tics • Less sleep disruption and appetite suppression

  36. Atomoxetine for ADHD • Cons • FDA black box warning for suicidal ideation • Rare, severe liver injury • Very rare sudden cardiac death at therapeutic doses • Increase blood pressure and pulse—less than stimulants • Weight loss—less than stimulants • Effects on growth? • Nausea and vomiting • Headache • Sedation • Lightheadedness and dizziness

  37. Positive Effects of Alpha-Agonists for ADHD • Helps decrease hyperactivity • Support for adding to stimulants for further effect • Decreases tics • Helps with sleep (sedating)

  38. Negative Effects of Alpha-Agonists for ADHD • Sedating • Dizziness upon standing • Lower blood pressure and pulse • Tolerance develops to above 3 bullets • Rebound hypertension if stopped suddenly

  39. Some Specific Serotonin Reuptake Inhibitors (SSRIs) • Fluoxetine (Prozac) • Sertraline (Zoloft) • Citalopram (Celexa) • Paroxetine (Paxil) • Escitalopram (Lexapro)

  40. Number Needed to Treat (NNT) • Goes beyond “statistical significance” • The number of patients who must receive the treatment to get a response that is attributable to active treatment • More effective treatments will have a lower NNT

  41. Specific Serotonin Reuptake Inhibitors (SSRIs) • Meta-analysis of SSRI NNT for youth disorders (Bridge, et al; 2007) • Anxiety disorders (adjusted): 4 (95% CI 3-6) • Depression: 10 (95% CI 7-15) • OCD: 6 (95% 4-8) • (for comparison, stimulant for ADHD NNT typically range from 1.5-3) • Effective for youth PTSD?

  42. Specific Serotonin Reuptake Inhibitors (SSRIs) • Negative Effects • Slight increase in suicidal ideation, especially for youth with depression: 2%? • Induce mania? If youth has bipolar disorder • Activation, insomnia or irritability—usually transient • Sedation • Gastrointestinal symptoms • Headache • Increased bleeding risk—less common • Apathy—sometimes a sign of too high a dose • Decreased libido—rare in adolescents

  43. Lithium Carbonate (LiCO3) • Positive effects • Effective for classic bipolar disorder • Mild short term positive effects for other disorders • Negative effects • Weight gain • Acne • Sedation—may be transient • Tremor—may be transient • Increased thirst • Depressed thyroid function, which may lead to hypothyroidism • Kidney effects, usually insignificant

  44. Divalproex (Depakote) • Positive Effects • Anti-seizure medication • Effective in classic or “real” bipolar disorder—the type seen in adults and post-pubertal youth • Mild positive effects on (controversial) pediatric bipolar disorder

  45. Divalproex (Depakote) • Serious Negative Effects • Hormone-like effects, including increased rate of Polycystic Ovaries in females • Neural Tube Defects increased in children of women taking Depakote during pregnancy • Serious but rare • Hepatoxicity-potentially fatal liver damage • Pancreatitis-potentially fatal (~2 per 1,000 patient years) • Severe bone marrow suppression • Withdrawal seizures if stopped suddenly

  46. Divalproex (Depakote) • Negative Effects • Common—usually temporary • Nausea • Sedation • Dizziness • Weight gain • Vomiting • Weakness • Gastrointestinal symptoms • Rash • Mild elevation of liver enzymes • Mild suppression of bone marrow function, such as platelet function, which can lead to easy bruising or nose bleeds

  47. Atypical Antipsychotics • Olanzapine (Zyprexa) • Risperidone (Risperdal) • Quetiapine (Seroquel) • Ziprasidone (Geodon) • Aripiprazole (Abilify) • Asenapine (Saphris) • Iloperidone (Fanapt) • Lurasidone (Latuda) • Paliperidone (Invega)

  48. Atypical Antipsychotics • Positive Effects • Effective for psychosis • Effective for classic mania and bipolar disorder • Less effective for controversial pediatric bipolar disorder • Moderately effective for tics and Tourette’s Disorder • In the short term, unlikely to have irreversible negative effects

  49. Atypical Antipsychotics • Negative Effects • Common • Sedation • Weight gain (depending on which antipsychotic, 9.7-18.7 pounds in ~11 weeks in one study (Correll et al, 2009)) • Dyslipidemias • Glucose intolerance, which may lead to diabetes • Extra-pyramidal side effects (EPS)-muscle stiffness, sometimes with tremor • Akathisia-inner restlessness associated with urge to keep moving • Blurred vision

  50. Atypical Antipsychotics • Negative Effects • Less common • Diabetes • Acute dystonia-temporary and non-fatal, but very uncomfortable, muscle spasm when starting antipsychotic medication • Rare but serious • Tardive dyskinesia-irreversible movement disorder • Neuroleptic Malignant Syndrome-muscle rigidity, fever, autonomic instability and altered mental status which, in rare instances, may lead to death

More Related