The Rutgers CERT Helps Establish Updated Parameters for Psychotropic Medication Use in Texas Foster Children
By Andrea Humphries, Ph.D.
Foster parents can use this handout,"Mental Health Problems in Foster Care Children," to help prepare for doctor visits and make decisions about treating their child, who may have a mental health problem.
High rates of use of psychotropic medications among children in the foster care system in the United States, often in multidrug combinations, have aroused a national debate. Such medications may be beneficial to these children in ameliorating symptoms of aggression, mood swings, and psychotic thinking. Many mental health professionals believe that psychotropic medications may be life-saving and may relieve disabling symptoms. However, in contrast to studies in adults that have provided evidence for potentially serious side effects, much less is known about the effects of the long-term use of psychotropic medications in children.
A 2011 report from the U.S. Government Accountability Office highlighted the problem of overmedication of foster children in five representative States1—including Texas—that were selected because of the reliability of their data, their geographic diversity, and their large foster care population. The authors proposed two possible explanations for the overmedication of foster children: (1) the kinds of traumas they endure and (2) the unique challenges of coordinating their medical care.
In 2008, the State of Texas developed a single, comprehensive, managed-care system to provide medical and mental health services to children and youth in foster care. Texas was also the first State to publish oversight protocols for foster children with the release of Psychotropic Medication Utilization Parameters for Foster Children (hereafter, Parameters) in 2005. The Parameters are updated periodically—most recently in September 20132—and serve as a widely used point of reference for programs in other States as well. The combined efforts of multiple stakeholders, including the Rutgers Center for Education and Research on Therapeutics (CERT), have been associated with a steady reduction in the use of psychotropic medication in foster youth in Texas.
The Rutgers Center for Education and Research on Therapeutics (CERT), which is funded by the Agency for Healthcare Research and Quality (AHRQ), was invited to be an integral part of this collaboration because of the partnerships this CERT has built across the country to improve the appropriate use of antidepressant and antipsychotic medications among children and adolescents. These noteworthy partnerships include:
- Collaboration with the Medicaid Medical Directors Learning Network (also supported by AHRQ) in a 16-State collaborative project that examined medication use patterns across those States and published a report and resource guide for improving management of antipsychotics among children receiving Medicaid.3
- A cooperative relationship with six State Medicaid programs that created the Medicaid Network for Evidence-based Treatment (MEDNET) to develop, implement, and evaluate strategies to accelerate the dissemination of comparative effectiveness findings on mental health treatments.
- Participation in the Psychotropic Medication Round Table4 convened by the Children’s Commission of the Texas Supreme Court to review and update the Parameters.
The Rutgers CERT research team—headed by Stephen Crystal, Ph.D. (principal investigator), and Sheree Todd, M.A. (senior research project manager)—recommended several important changes in the Parameters to the stakeholders during the update process. Dr. Crystal explains, "We emphasized why additional information concerning evidence-based, nonpharmacologic treatments—such as Multidimensional Treatment Foster Care® and trauma-focused cognitive behavioral therapy—should be included. We also highlighted the importance of monitoring the overall health and metabolic status of foster youth receiving medications, especially antipsychotics, including blood glucose and lipid testing for youth prescribed antipsychotics." He continues, "We asked the stakeholders to give greater emphasis to the need for comprehensive clinical assessment. We also proposed a new polypharmacy threshold."
The updated Parameters are now available to primary care providers and mental health professionals across the nation at the Texas Department of Family and Protective Services Web site. Highlights of the updated Parameters include (1) a list of important general principles, (2) criteria that indicate the need to review a child's clinical status (i.e., a second opinion review or a psychotropic medication utilization review), including a stricter threshold for reviews of psychotropic polypharmacy; and (3) medication charts that break down the classes of psychotropic medications by patient age and dosages.
Some of the general principles regarding the use of psychotropic medications in foster children include the following:
- Before prescribing psychotropic medication (nonemergent situations only):
- Perform a comprehensive medical evaluation, health history, psychosocial assessment, mental status exam, and physical exam if possible.
- Provide a DSM-55 psychiatric diagnosis.
- Consider nonpharmacologic interventions before or concurrent with the prescription of psychotropic medication.
- When medication is prescribed, define target symptoms and treatment goals to measure at followup visits that occur at least once every 90 days.
- Consider potential side effects—including rare but severe side effects—in the decision to prescribe psychotropic medication.
- Except in emergent cases:
- Obtain informed consent from the appropriate party.
- Discuss the diagnosis and the expected benefits and side effects of treatment.
- Discuss laboratory findings.
- Discuss the possibility of rare but severe adverse events.
- Discuss alternative treatments, the risk associated with no treatment, and the overall potential benefit-to-risk ratio of treatment.
- Involve caregivers and youth in treatment decisions when possible.
- For children on antipsychotics:
- Monitor glucose and lipid levels at least every 6 months.
- Try monotherapy before polypharmacy regimens when possible.
- Systematically introduce polypharmacy regimens, which should be accompanied by ongoing monitoring.
- Start medications at the lower end of the recommended dose and titrate carefully as needed, changing only one medication at a time if possible.
In addition, there are nine criteria that indicate the need for further review of a child's clinical status. These include the absence of a thorough assessment for the DSM-5 diagnosis, polypharmacy regimens of four or more psychotropic medications, certain psychotropic medications prescribed for children aged 4 years or younger, and the lack of glucose and lipid monitoring for children on antipsychotics.
Because primary care providers vary in their training and clinical experience in managing mental health problems, the Parameters also provide a link to an online physician toolkit titled Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit.6 The toolkit was developed by the American Academy of Pediatrics and is available for purchase. In addition, the Parameters reference the Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines7 whose development was led by the Rutgers CERT.
According to Dr. Crystal, the process of updating the Parameters is a "perfect example of how, through collaboration, research results can be translated into practice and ultimately have an impact on the actual health care people receive." Dr. Crystal projects that the future focus of the Rutgers CERT will be on "continuing to find ways to initiate and support cross-State initiatives that help States disseminate their successful practices from one State to another" and on "finding ways to successfully fulfill both the research and education missions of the CERTs." He continues, "The Rutgers CERT is well positioned to continue to develop educational interventions in partnership with payers who can use their policy tools to assure research sustainability" and the best mental health care possible for foster children.
About 25 percent of the U.S. population suffers from a mental illness. The Rutgers CERT is working to improve the use of mental health therapeutics and patient outcomes, particularly in publicly funded programs. Through sustainable research, it aims to resolve the noticeable mismatch between evidenced-based recommendations and widespread practices; address emerging safety concerns, the off-label use of psychotropic medications, and the critical weaknesses in the knowledge base for these medications; and to refine interventions related to mental health therapeutics.
- Kutz GD. Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. GAO Publication No. 12-270T. Washington, DC: U.S. Government Accountability Office; December 2011. Available at http://gao.gov/assets/590/586570.pdf.
- Texas Department of Family and Protective Services; University of Texas at Austin College of Pharmacy. Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care. Austin, TX: Texas Department of Family and Protective Services; September 2013. Available at http://www.dfps.state.tx.us/Child_Protection/Medical_Services/documents/pdf/TxFosterCareParameters.pdf.
- Foti ME, Harper G, Moon R, et al. Antipsychotic medication use in Medicaid children and adolescents: report and resource guide from a 16-state study. MMDLN/Rutgers CERT Publication No. 1. June 2010. Available at http://www.rci.rutgers.edu/~cseap/MMDLNAPKIDS/Antipsychotic_Use_in_Medicaid_ Children_Report_and_Resource_Guide_Final.pdf.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA; 2013.
- American Academy of Pediatrics. Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. http://www2.aap.org/pcorss/demos/mht.html. Accessed November 6, 2013.
- Knapp P, Chait A, Pappadopulos E, et al; T-MAY Steering Group. Treatment of maladaptive aggression in youth (T-MAY): CERT guidelines I. Engagement, assessment, and management. Pediatrics. 2012 Jun;129(6):e1562-76. PMID: 22641762.