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

• jcheng@casaservices.org• 780-644-3303

Sheena Stevens B.N. R.N. CPMHN(c)Mental Health Nurse Consultant

Sheena.Stevens@gov.ab.caOffice: (403) 297-6814

Main Office: (403) 297-2081