“psychotropic medications and children: science, law, and policy” uc hastings college of law...
TRANSCRIPT
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“Psychotropic medications and children: science, Law, and Policy”
UC Hastings college of law symposium on children’s health, mental health & the law
March 29, 2014
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Federal Focus & Action
Court Resolution & The JV220 Process
State Initiatives
Psychotropic Drug Concerns
Standard of Care
Prioritizing Policies & Actions
Improving Prescribing Practices
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Federal Focus and Action
February 2006: Senate Finance Committee TestimonyOctober 2008: Federal Fostering Connections to Success and Increasing
Adoptions ActSeptember 2011: Child and Family Services Improvement and Innovation ActNovember 2011: Joint Letter from ACF, CMS, SAMHSA, HHS December 2011: GAO Report Foster Children April 2012: Children’s Bureau Information MemorandumAugust 2012: ACF Because Minds Matter ConferenceDecember 2012: GAO Report Children’s Mental HealthAugust 2013: HHS Office of the Inspector General InvestigationMarch 2013: The President’s Budget - $750 million
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Federal Focus and Action“I think putting me on all these stupid meds was the most idiotic thing I have ever experienced in foster care and was the worst thing someone could do to foster kids. I was upset about my situation, not bipolar or ADHD.”
Testimony of Ke’onte Cooke, 12 year old former foster child, before Congress, December 1, 2011
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Court Resolution & The JV220 Process
National Council of Juvenile & Family Court Judges Resolution
Whereas, Judges in child welfare and juvenile justice cases are responsible for overseeing the safety and well-being of children under court jurisdiction;
Whereas, the NCJFCJ believes that this oversight responsibility extends to children prescribed psychotropic medications, including ensuring that medications are safe and appropriate…
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Court Resolution & The JV220 Process
JV-220 Process
• Statute enacted in 1999• Intended to reduce use
of psychotropic drugs
Is the Court Review & Authorization Process effective?
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% % % % % % %JUL2006-SEP2006
JUL2007-SEP2007
JUL2008-SEP2008
JUL2009-SEP2009
JUL2010-SEP2010
JUL2011-SEP2011
JUL2012-SEP2012
13.1 13.1
15.817.8 18.6 18.8 19.4
Percentage of Children in Care Authorized Psychotropic Med-ications
2006-2012
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COURT RESOLUTION & THE JV220 PROCESS
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Pre-
Adop
t
Kin
Fost
er
FFA
Cour
t Spe
cifie
d
Gro
up
Shel
ter
Tran
sitio
nal H
ousi
ng
Gua
rdia
n-D
epen
dent
Runa
way
Tria
l Hom
e Vi
sit
Oth
er
Mis
sing
Placement Type All
0
10
20
30
40
50
60
12.79.4
25
16
29.8
56
31.1
22 19.527.3
8.7
20 19.9 19.4
Percentage of Children Authorized Psychotropic Medications By Placement TypeApr-Jun 2013
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COURT RESOLUTION & THE JV220 PROCESS
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COURT RESOLUTION & THE JV220 PROCESS
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San Francisco Contra Costa Los Angeles State
18.50%
9.10%
13.10% 12.60%
Percentage of California Foster Children Au-thorized Psych Drugs
% Authorized Psych Drugs
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State Initiatives September 2010: AB 12 Passed
August 2012: Because Minds Matter ConferenceOctober 2012: Quality Improvement Project Charter Kick-off January 2012: “Monthly” Workgroup Calls
Clinical WorkgroupData and Technology Workgroup
Youth, Family and Education Workgroup
August 2013: Draft Action Plan CirculatedSeptember 2013-February 2014: State Process SuspendedFebruary 26th, 2014: Invitation Only Meeting
March 26th, 2014: Meeting to Kick-off Workgroups
10/21/13
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Psychotropic Drug ConcernsToo ManyToo Much Too SoonToo Long No Monitoring (Mis- Over- Inaccurate) DiagnosesNo Risk/Benefit ProfilesUntestedOff-labelNo AlternativesAdverse EffectsPowerful OppositionUntrained CaregiversLack of educational resources
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Too Many• Children in care
medicated• Children on multiple
medications• Inaccurate
diagnoses
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ABC News Investigation
Psychotropic Drug Concerns
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Too Much• Above maximum
dosages• Adult dosages for
children
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Gabriel Myers Story
Psychotropic Drug Concerns
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Too Soon• Very young ages• Too early in placement• Before other
interventions
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Tiffany's Story
Psychotropic Drug Concerns
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Too Long• No set monitoring• No timeline to taper
off• Authorization for
indefinite amount of time
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Tristen's Story
Psychotropic Drug Concerns
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Standard of Care
Policy Sources: Appropriate Use of PsychotropicsAmerican Academy of Child & Adolescent
Psychiatry (AACAP)Child Welfare League of America (CWLA)HEDISAmerican Academy of Pediatrics (AAP)State LegislationMedicaid Medical Directors Learning Network
(MMDLN)3/29/14
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Prioritizing Policies & Actions
Special Populations
Very young children Child-bearing age youth Youth transitioning from
care Group home youth
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Prioritizing Policies & Actions
Antipsychotics
Limited FDA approval Off-label prescription Adverse Effects Disruptive Behavior
Diagnoses
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Maximum Dosing
LA Parameters Connecticut Guidelines
Prioritizing Policies & Actions
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Prioritizing Policies & Actions
Polypharmacy
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Prioritizing Policies & Actions
Gaps in Medications
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Improving Prescribing Practices
Consultation & Second Review
CaliforniaChild PsychiatristsPublic Health NursesPharmacists
Minnesota Washington
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Improving Prescribing Practices
Prior Authorizations/TARS
CA 2006 TAR for antipsychotic prescriptions for children under six
Prescriptions fell from 5686 to 4200
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Improving Prescribing Practices
Monitoring Requirements & Baseline Metabolic
Testing
AK requires baseline lab testing and 9 month follow ups
NJ has a detailed monitoring protocol by drug class
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Improving Prescribing Practices
Outlying Prescriber Identification
Many states use Medicaid pharmaceutical data to identify inappropriate prescribing patterns
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Improving Prescribing Practices
Academic Detailing
Prescriber education and outreach
Safe Rx Amendment Act of 2008 established an academic detailing program in Washington, D.C.
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Discussion and Questions
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