Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 325 - ADMINISTRATION OF PSYCHOTROPIC MEDICATIONS TO CHILDREN FOR WHOM THE DEPARTMENT OF CHILDREN AND FAMILY SERVICES IS LEGALLY RESPONSIBLE › Appendix A - Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care

Current through Register Vol. 48, No. 28, July 12, 2024
Introduction
With few exceptions, children and youth in State custody have
				experienced abuse and/or neglect and often have chaotic caretaking histories
				with disrupted attachments and multiple placements. Additionally, they may be
				genetically predisposed to mental illness and may have been exposed in utero to
				substances of abuse. Not surprisingly, children in foster care are at higher
				risk for developing emotional and behavioral disturbances and mental illness,
				utilize mental health services at higher rates, and are more likely to receive
				psychotropic medications than children from comparable backgrounds.
The utilization of psychotropic medications, defined as drugs
				used to affect psychological functioning, perception, behavior or mood, for the
				treatment of children and youth in foster care with severe emotional and
				behavioral disturbances, has increased dramatically over recent years. The
				increased utilization of psychotropic medications is paralleled by an equally
				dramatic increase in the rate of polypharmacy, the co-administration of two or
				more psychotropic medications. Data on the safety and efficacy of many of the
				psychotropic medications used in children and youth and research supporting the
				practice of polypharmacy in this population is limited.
As a result of the increased use of psychotropic medications in
				children and youth, several highly publicized cases of seemingly inappropriate
				prescribing, and the recent FDA warnings on the psychostimulants (such as
				Adderall, Ritalin and Concerta) and the SSRIs (e.g., Prozac, Zoloft, Celexa,
				Lexapro and Luvox), the treatment of children and youth in State custody with
				psychotropic medications has come under intense scrutiny from the press, child
				advocacy groups, and State and federal regulatory agencies.
The provision of psychiatric care for children and youth in the
				child welfare system faces several hurdles. Not uncommonly, children in foster
				care are treated in multiple settings, including psychiatric hospitals,
				residential treatment centers, juvenile detention facilities, outpatient
				clinics and therapeutic day schools. Communication between providers in each of
				the settings is often quite poor resulting in fragmented psychiatric care.
				Additionally, the dependable, ongoing therapeutic and caregiving relationships
				these children desperately need are hampered by the high turnover among child
				welfare caseworkers and child care providers. Furthermore, unlike mentally ill
				children from intact families, often no consistent interested party is
				available to coordinate treatment planning and clinical care, provide informed
				consent for treatment, or provide longitudinal oversight of a foster child's
				treatment.
By law, the Illinois Department of Children and Family Services
				(DCFS) is responsible for consenting to the medical, surgical and psychiatric
				care for children and youth in its custody. To meet these guardianship
				responsibilities, DCFS established the Centralized Psychotropic Medication
				Consent Program in the Office of the Guardian to provide consent for the
				prescription of psychotropic medications. To support the consent process, DCFS
				has contracted with the University of Illinois at Chicago to provide an
				independent review of all consent requests from clinicians to prescribe
				psychotropic medications for children in its care.
In June 2006, DCFS convened an Expert Panel to provide
				consultation to the Department to establish a set of treatment guidelines for
				these children and youth. It was the consensus of the participants in the
				Expert Panel that children in the child welfare system present with such
				complicated clinical pictures that the formation of rigid treatment algorithms
				that clinicians must rigidly adhere to is unrealistic. Instead, the Expert
				Panel recommended principles to guide prescriptive practices. The guidelines
				that follow serve to inform the practice of pediatric psychopharmacology in
				this population and to provide a framework to assure the provision of quality
				psychiatric services to DCFS wards. These guidelines are not meant to supersede
				clinical judgment.
Guidelines
1.
This Part requires that written consent from the DCFS
				Guardian must be obtained prior to prescribing a psychotropic medication to a
				child or youth under 18 years of age.
In addition the child should give
				informed assent prior to starting the medication. In order to be effective,
				informed assent should be based on an honest discussion of risks versus
				benefits and potential side effects of the proposed treatment, availability of
				alternative treatments, prognosis with and without the proposed medication
				treatment, and potential for drug interactions. The treating clinician should
				document this discussion in the patient's medical record.
2.
The prescription of psychotropic medications is just
				one component of a comprehensive treatment plan that includes psychosocial and
				behavioral interventions.
Psychotropic medications are not to be used in
				place of psychosocial or behavioral interventions that the child or youth
				requires. Furthermore, 89 Ill. Adm. Code 384 (Behavioral Treatment in
				Residential Child Care Facilities) specifically prohibits the use of
				psychotropic medications for chemical restraint. Chemical restraint is defined
				as the use of any psychoactive medication that is not a part of the patient's
				treatment plan during a behavioral crisis or psychiatric emergency that results
				in the sedation of the child for the express purpose of restricting an
				individual's freedom of movement.
3.
All children and youth must receive a diagnostic
				assessment prior to starting a psychotropic medication.
A diagnostic
				assessment should include, at minimum:
a. history of the present illness;
b. past psychiatric history, including medication
				history;
c. medical and surgical history;
d. allergies;
e. current medications;
f. family history (when available and
				relevant);
g. mental status examination;
h. DSM-IV1 diagnosis;
				and
i. treatment plan.
In addition, a physical examination should be done.
				Baseline laboratory studies and/or an EKG should be obtained if medically
				indicated and in accordance with accepted standards of care and in congruence
				with the prescribing clinician's medical judgment.
4.
It is strongly recommended that the prescribing
				clinician communicate with other clinicians involved in the child's care,
				particularly other prescribers. The clinician must document that attempt in the
				medical record.
The purpose of this recommendation is to obtain
				collateral information to enhance continuity of care and to facilitate the
				monitoring of the outcome of the medication trial. This communication is
				particularly important in the treatment of wards hospitalized on a psychiatric
				unit. According to the Illinois Department of Healthcare and Family Services,
				50% of all medications prescribed to patients discharged from State operated
				psychiatric facilities are discontinued and alternative medications initiated
				within 2 weeks after discharge. Communication among prescribers is also
				important when a ward moves from one treatment setting to another (i.e., a
				lateral move from one residential treatment facility to another) or from one
				level of care to another (e.g., discharge from a psychiatric hospital back to a
				foster home). Treatment summaries from the treating clinician should follow the
				patient detailing the treatment course with particular emphasis on results of
				psychotropic medication trials.
5.
Prescription of a psychotropic medication should be
				based on research showing it to be safe and effective for the disorder being
				treated. Medications that have been approved by the Federal Drug Administration
				(FDA) for the treatment of a specific disorder in children or youth meet this
				requirement by definition and should be used preferentially over non-FDA
				approved medications when they are available.
Exceptions can be made
				when a patient has had a history of a successful trial of an off-label
				medication, if a first degree relative has responded to the medication being
				requested, if the patient is allergic to the FDA approved medication, or if the
				patient is on other medications that react unfavorably with the preferred
				medication. Few medications used to treat psychiatric disorders in children and
				youth are approved by the FDA for use in this age group; however, off-label use
				of drugs by prescribers is not only legal, but may represent the standard of
				care. Prescribers have the responsibility to be well informed about the
				product, to base its off-label use on firm scientific rationale and sound
				medical evidence, and to maintain records of the product's use and effects. If
				data supporting the use of the medication in children and youth are not
				available, data can be extrapolated from the adult literature, though caution
				is advised.
6.
Medications prescribed should be appropriate to the
				patient's diagnosis and target symptoms and must be part of the treatment
				plan.
For patients in whom the diagnosis is not clear or there is no
				appropriate DSM-IV diagnosis, the decision to prescribe a psychotropic
				medication may be based on the presence of target symptoms that are likely to
				be responsive to psychotropic medications.
7.
Existing medication algorithms should be consulted
				when making the decision about which medication to use for a specific
				disorder.
Algorithms designed for use by the consultants to the DCFS
				Centralized Psychotropic Medications Consent Line are based on the Children's
				Medication Algorithm Project (ADHD and depression), the American Academy of
				Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment
				and "Treatment of Children and Adolescents with Bipolar Disorder, and various
				AACAP Practice Parameters all available from the American Academy of Child and
				Adolescent Psychiatry, 3615 Wisconsin Avenue, NW, Washington DC 20016-3007,
				(202)966-7300 or AACAP's website at
http://www.aacap.or
and the American Academy
				of Pediatrics Attention Deficit Hyperactivity Disorder diagnostic guidelines
				available from the American Academy of Pediatrics, 141 Northwest Point Blvd.,
				Elk Grove Village IL 60007-1098, (847)434-4000 or AAP's website at
http://www.aap.org
.
8.
The decision to utilize polypharmacy (more than one
				psychotropic medication) or copharmacy (more than one psychotropic medication
				in the same medication class) should be based on a solid clinical rationale and
				accepted medical practice.
Research supports the use of polypharmacy in
				the treatment of certain co-morbid conditions, for augmentation for partial
				responders, for treating the adverse effects of other psychotropic medications,
				and for treating multiple symptoms of a single disorder. The following
				guidelines should be followed when considering polypharmacy or
				copharmacy:
a. Unless otherwise indicated in published treatment
				algorithms for children and youth, monotherapeutic options should be exhausted
				before considering polypharmacy or copharmacy.
b. When polypharmacy is necessary, the fewest
				medications should be used as possible.
c. Clinicians should be ready to support their use
				of polypharmacy or copharmacy should DCFS request a review of the case.
d. The concurrent use of slow-release and
				immediate-release formulations of the same chemical (e.g., Concerta and
				methylphenidate) is not considered to be polypharmacy or copharmacy.
e. To the extent possible, medications should be
				started and titrated one at a time. Copharmacy with antipsychotic medications
				has little evidence to support its use in adults and no quality data to support
				that practice in children and youth. All requests for concurrent
				pharmacotherapy with two or more antipsychotic medications will be closely
				scrutinized.
9.
The prescription of psychotropic medications should be
				accompanied by education for the patient, his or her foster family or treatment
				team, and (when indicated) his or her family of origin.
The nature of
				the diagnosis, the prognosis, and the risks and benefits of treatment, as well
				as non-treatment, and alternative treatment options should be discussed in
				detail.
10.
Pharmacotherapy with psychotropic medications must be
				monitored closely. The frequency of visits depends on the phase of
				treatment.
a. Initiation phase - the initiation phase of
				treatment warrants frequent visits, weekly for some treatments, to monitor
				early treatment emergent side effects, the development of suicidal ideation in
				patients treated with antidepressant medications, and the effectiveness of
				treatment. Clinicians should not implement treatment with psychotropic
				medications that cannot be monitored closely.
b. Acute treatment phase - this phase is defined as
				the period of time between initiation of treatment and remission of symptoms
				and is characterized by frequent visits. The duration of the acute duration
				phase of treatment is variable.
c. Continuation phase - once the symptoms have
				remitted, treatment continues to prevent relapse. This phase of treatment lasts
				between four and six months and is characterized by regular visits.
d. Maintenance phase - treatment after the
				continuation phase is for the prevention of recurrence of the underlying
				disorder. Not all pharmacotherapy requires maintenance treatment. For example,
				successful treatment of a single episode of depression in a child does not
				require maintenance treatment. In contrast, treatment of ADHD with stimulants
				often requires a long maintenance phase. Visits during the maintenance phase
				can be less frequent. Depending on the stability of the patient, visits could
				be as infrequent as two to three times per year.
e. Discontinuation phase - the prescribing clinician
				should consider discontinuation of the psychotropic medications when the
				patient has recovered from the underlying episode and is no longer at risk for
				relapse. Medication discontinuation requires a separate treatment plan with
				increased frequency of visits to monitor for signs of relapse. Medications
				should be tapered slowly to prevent withdrawal effects.
11.
Response to treatment should be monitored through the
				use of standardized symptom severity scales and instruments to measure
				treatment emergent side effects.
Follow-up may also include height,
				weight, abdominal girth, blood pressure, pulse, CBC with differential, thyroid
				function studies, lipid profile panels, liver function tests, EKGs and drug
				levels as indicated by the patient's medication regimen.
12.
In order to be effective, medication trials must be
				adequate in terms of dosage and duration.
A medication may be falsely
				characterized as ineffective if the trial is inadequate. Inadequate medication
				trials frequently occur due to changes in treatment setting. For example,
				admission to and discharge from an inpatient unit is often accompanied by a
				change in medication, often before an adequate trial has been completed. When
				available, blood levels of medications should be followed to assure an adequate
				dosage. At times the dose of a medication needed to maintain a therapeutic
				blood level may exceed the maximum recommended dosage for that medication. In
				those cases, the blood levels, not the dosage, should inform treatment.
13.
If a child does not respond to the medication trial
				despite adequate dosage and duration, the prescribing clinician should assess
				patient compliance, reassess the diagnosis, rule-out the presence of co-morbid
				conditions, including substance abuse and general medical disorders, and
				evaluate the influence of psychosocial stressors.
14.
DCFS specifically prohibits the use of pro re nata
				(PRN) medications.
Prior consent for the one-time administration of a
				psychotropic medication is not necessary when an emergency exists. However, all
				administration of emergency medications must be reported to DCFS.
Case Review
The following situations will trigger a closer review of a
				patient's care and possible denial of psychotropic medication requests:
1. Four or more psychotropic medications prescribed
				concomitantly (three or more for children six years of age or younger).
2. Prescription of psychotropic medications, with the exception
				of stimulants, for children under the age of four.
3. The concomitant prescription of:
a. two or more
				antidepressants2;
b. two or more antipsychotic medications;
c. two or more stimulant
				medications3; or
d. three or more mood stabilizer medications.
4. Frequent changes of psychotropic medications without a clear
				rationale, such as adjusting medication dosages or in response to treatment
				emergent side effects.
5. The requested psychotropic medication is not consistent with
				the patient's diagnosis or the patient's target symptoms.
6. Polypharmacy is utilized before exhausting monotherapeutic
				options.
7. The psychotropic medication dose exceeds usually recommended
				doses for weight and age.
8. The prescription of psychostimulants to an actively
				psychotic child.
9. Children for whom emergency medications are used more than
				twice a day for three or more consecutive days.
End Notes:
1 "DSM-IV" means the Diagnostic and Statistical Manual of
				Mental Disorders, Fourth Edition (American Psychiatric Association, 1400 K
				Street NW, Washington DC 20005 (1994)) or most current edition.
2 The prescription of trazodone or mirtazepine as a sleep aid
				in addition to another antidepressant does not constitute concomitant
				prescribing.
3 The prescription of a long-acting stimulant and an immediate
				release stimulant of the same chemical entity (e.g., Concerta and
				methylphenidate) does not constitute concomitant prescribing.