nurse consultant foster parent conference
TRANSCRIPT
Psychotropic Medication and Children in Care
November 5-8, 2015 Foster Parent Conference Jasper, AB
CASA Mission
To advance the mental health of infants, children, adolescents, and their families through excellent clinical practice, health promotion, education, research, and advocacy.
What are psychotropic medications?• Medicines that influence a person's thoughts,
behaviors, and feelings.
Common Psychotropic Meds:
• Antidepressants (celexa, prozac, citalopram)
• Antipsychotics (risperdone, quetiapine, olanzapine)
• Stimulants (concerta, vyvanse, adderal)
• Mood stabilizers (lithium, tegretol)
How do psychotropics help?Treat mental health problems like:– Bipolar Disorder– ADHD– Psychosis– Anxiety– Depression
Treat symptoms like:
– Sudden anger– Anxiety– Sadness– Inattention– Seeing and hearing things
that are not real
How might psychotropics help a child?Reducing symptoms that affect everyday functioning so a person can:– Be successful in school– Go to work– Enjoy favorite activities– Be present in relationships with family and
friends
How I help out…
• Provide info about mental health, community programs, and psychotropic medication
• Clarifying off label use of
psychotropic medication– Ie. Wellbutrin
antidepressant for ADHD
• Checking for rationale, safe dosing, and interactions between multiple medications
How I help out…
Lexicomp Database
CADDRA Guidelines
Consult with pharmacists
Clarify with Physicians
Confirm patient weight with clinics/foster
parents
How I help out…• Assisting with linkages to community or
medical resources for families and agencies:
Links to trauma-informed pediatricians for kids in care
Finding pediatricians working in the family’s community
Sharing contact info for medical specialists with caseworkers
Providing information about mental health clinics and programs
Stats and Observations
• Girls vs Boys• Clonidine is a best
seller• Stigma around
antipsychotics
Proportions of Different MH ProblemsMental Health Diagnoses of Children Served
Mental Health Concern Proportion of children with diagnosis (n=34)
Diagnosed or query ADHD 62%Behaviour disorders (Conduct Disorder, ODD) 41%
Reactive Attachment Disorder 26%Diagnosed or query FASD 24%Anxiety/OCD 21%Cognitive delays/Autism 15%Trauma or PTSD 12%Depression 12%Epilepsy 6%Other: (emerging borderline PD, emotional dysregulation, sleep issues, suicide ideation)
12%
No diagnosis 15%
Age
Average age of children served: 7.5 years
Gender
Girls: 48% Boys: 52%
Number of meds reviewed per case
• Average 1.6 medications per child
• Range 0-6 different meds
Frequently Consulted Medications• Clonidine / Dixarit - antihypertensive used to manage ADHD
symptoms, disruptive behaviors, restlessness, tics
• Risperdal / Risperidone - antipsychotic used to reduce mood lability,
aggression, and disruptive behaviors
• Concerta / Methylphenidate – long acting methylphenidate based
stimulant to manage ADHD symptoms
• Vyvanse / Lisdexamfetamine– long acting amphetamine based
ADHD medication behaviors
Frequently Consulted Medications• Intuniv XR / Guafacine - long acting antihypertensive used to manage
ADHD symptoms
• Sertraline / Zoloft– SSRI antidepressant for anxiety, PTSD, depression
• Celexa / Citalopram – SSRI antidepressant for anxiety, PTSD,
depression
• Seroquel / Quetiapine- antipsychotic used to reduce mood lability,
aggression, and disruptive behaviors
Recurring Concerns
Off label use of medications:• Antipsychotics are used to manage • Mood regulation• Help the child to pause, think, and act
– be more receptive to teaching and make transitions smoother
– Bicycle metaphor --- helps child get on bike and get from point A to point B in a quicker, faster, safer manner
Recurring Concerns
Off label use of medications• Use of clonidine (antihypertensive)
– manage symptoms of ADHD, irritability, disruptive behaviors
– physical agitation such as restless legs syndrome, tics
Recurring Concerns
Off label use of medications– SSRI antidepressants• anxiety• autistic rigidity• PTSD
Recurring Concerns
• Titration process when trialling effectiveness and response of new psychotropic medication– Explaining concept of loading dose and process of
gradual dose increases until therapeutic levels are achieved
Recurring Concerns• Why use meds at all?– Offering perspective on risk (side effects) and
benefits to global functioning (school, placement, relationships)
Recurring ConcernsConsidering medications within the context of the child’s story
Trauma
Medical and Mental Health History
Family Story
Developmental orCognitive concerns
Interpersonal relationships
School coding for IPP
Tips for Caregivers• Connect to a consistent Pediatrician• Having a consistent family physician will
also be beneficial in rural areas
Tips for Caregivers• Try to rule out any variables that may be
stressing the child before thinking of changing medication or dosage
Physiological Variables:Lack of sleepSensory triggers: noise, over stimulation, food textures and tastes
Tips for CaregiversPhysiological Variables:
HungerFood Intake is especially important if the child is on ADHD medication that can suppress appetite•Collaborate with school board to ensure that snacks are available to child when they get hungry•Tweak snack times at home as well
Tips for CaregiversEmotional Variables: Child reacting to changes in caregivers, placement
Child coming back from overnight short term stays with bio parents
Contextual Variables:Is there adequate priming/transitioning between activities?Structured vs unstructured daily routine: – predictability and structure reduces child stress
Tips for CaregiversCommunication Style Variables• Body language, intonation• Using short, concrete sentences• Allowing more processing time for child to answer or
follow cues/direction• Caregiver competency of how to interact effectively
with kids facing specific mental health challenges (ie. Autism)• Accommodation of challenges with cognitive and
receptive language delays
Tips for CaregiversWritten care plans
Consistency of plan should be across all environments that a child participates within– Collaborative multi-disciplinary approach
that may involve teachers, teaching aide, behavioral specialist, OT, mental health professionals, caregivers, youth workers, caseworker
– Involve the child if possible.• A version of the care plan should be written for
them in a way they can easily follow and understand.
Tips for CaregiversWhat can be outlined in a care plan?• Medication admin times• actions, body language, or gesturing that may
precede disruptive behaviors• Behavioral interventions (ex. spatial
boundaries, specific social skills)• Sensory concerns that may overstimulate or
engage a child in activity
Tips for CaregiversWhat can be outlined in a care plan?• De-escalation tactics that have been historically
successful »Taking child out of class for a walk if they begin to
wind up» Sensory object to soothe or use when feeling
frustrated or overwhelmed»Alternative step down activities in class if having a
challenging day• Whether the child works better with males
vs females
Tips for Caregivers• The use of a care plan can help the team stay
consistent in managing a child across environments and interventions.– Can help reduce splitting and confusion that a
child may otherwise experience and contribute to their frustration and acting out behaviors
– The resulting display of disruptive behaviors may then be dealt with the prescribing of additional medication
Tips for Caregivers
Psychotropic Medication Safety Planning• Should be in place between child, caseworker,
mental health professionals, school board, caregivers for activation of suicidal ideations or self harming gestures– Planning should take place prior to
commencement of any psychotropic medication– If possible, involve child/teen in planning
Tips for CaregiversAWOLS and Party Favors
• Coordinate a treatment plan to deal with AWOLS, and illicit substance/alcohol ingestion– Be proactive and have a plan in place before such
an event occurs– Make sure to speak with prescribing physician to
get direction– Involve the child and treatment team (SW, school,
prescribing doctor, youth worker etc.)
Tips for CaregiversAWOLS and Party Favors
• Drugcocktails.ca– Resource to look up interactions between street drug and
psychotropic medication– Can be accessed by caregivers and youth
• Concerta and marijuana– Can make heart beat too fast
• Risperdal and alcohol– can worsen the uncontrolled movements (also called 'EPS') that risperidone sometimes
causes. – risperidone can make people sleepy, dizzy and confused, especially at first as your body
gets used to it. Alcohol can make this worse.
Tips for CaregiversStay Organized
• Keep a list of most current active medications with frequency of admin and dosage– Communicate all changes in medications to the
caseworker– Verify medications each time child is discharged from a
hospital or remand setting and communicate changes to caseworker
– Caseworker can then contact consultant to review medications
Tips for Caregivers
• Discuss drug monitoring practice with prescribing doctor– Monitoring is at the discretion of the attending
physician. – Clinics may have their own systems in place for
monitoring.– Don’t leave the clinic without securing a follow up
appointment date
Tips for Caregivers
• Keep a record of vital signs which can be communicated to the caseworker– Blood pressure, heart rate, height, weight, body
mass index (BMI), waist circumference– Weight is especially helpful for med reviews in
cases where medication dosing is weight based
Tips for Caregivers
• Look for a streamlined medication regimen– One medication per psychotropic class– If there is more than one medication within a
psychotropic class• Discuss with prescribing doctor and learn about the
rationale behind using more than one• Example: Using two antipsychotics. One to help reduce
disruptive behavior, the other to help sleep and calm at night
Caregiver Resources
• CASA Caregiver Villagehttp://www.caregivervillage.ca/
• Triple Phttp://www.triplep-parenting.net/alb-en/home
• NAMI Psychotropic Medicine Overviewhttps://www.nami.org/getattachment/Learn-More/Fact-Sheet-Library/Medications-Overview-Fact-Sheet.pdf
• My Health Alberta Medication Look Up page– https://myhealth.alberta.ca/health/medications/Pages/default.asp
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Caregiver Resources
• On the Pointhttp://www.excellenceforchildandyouth.ca/resource-hub/psychotropic-materials
• Kelty BC Mental Health – http://keltymentalhealth.ca/treatment/medications
• Drug Cocktails– www.drugcocktials.ca
Mental Health Resources for Youth• Head Meds–http://www.headmeds.org.uk/
• Mind Check–http://mindcheck.ca/
• On the Point–http://
www.excellenceforchildandyouth.ca/resource-hub/psychotropic-materials
Mental Health Resources for Youth• Young Minds
– http://www.youngminds.org.uk/for_children_young_people
• Mind Your Mind– http://mindyourmind.ca/
• Youth Smart– http://www.youthsmart.ca/
• Help4Me– http://www.help4me.ca/
• Drug Cocktails– www.drugcocktails.ca
Questions?
• Jeffrey Cheng, RN BscN, Mental Health Nurse Consultant
• [email protected]• 780-644-3303
Sheena Stevens B.N. R.N. CPMHN(c)Mental Health Nurse Consultant
[email protected]: (403) 297-6814
Main Office: (403) 297-2081