1. Understand that other interventions should be considered along with psychotropic medications.
2. Understand the need for a complete psychiatric evaluation (including physical examination) before making a decision about psychotropic medications and treatments.
3. Understand the responsibility of the medical consenter to decide whether or not to give informed consent for each psychotropic medication prescribed for a child.
4. Understand how psychotropic medications are used.
5. Understand how to monitor a child for possible side effects or to see if the psychotropic medication is working.
6. Know what to do if you have concerns about the psychotropic medications prescribed to children in your care
7. Know about the Psychotropic Medication Utilization Parameters for Children in Foster Care.
8. Be aware of how various classes of psychotropic medications work, their side effects, and examples of medications in each class.

Most children in foster care never need psychotropic medications.  Still, research shows that many children in foster care are on a significant number of medications.  As the primary caregiver for these children we need to be accountable for taking the decision to put children on medication seriously.   

Children who are traumatized by abuse, neglect or separation may show negative behaviors or signs of emotional stress that are a normal reaction to what they have been through. Also, all children act out at different stages of their lives. For example, two-year olds commonly have temper tantrums and teenagers often rebel.
Support from caregivers knowledgeable of trauma-informed care can help a child heal.
But some children need medication to cope with the trauma of abuse, neglect or separation. Other children need medication to treat behavioral health disorders that they inherited or developed, such as Attention Deficit Hyperactivity Disorder (ADHD), severe depression, or psychosis.

Psychotropic medications may help children function at home, in school, and in their daily lives. They may need these medications temporarily to treat emotional stress or long-term to treat life-long behavioral health disorders.

Facts:  

In Ontario 48.6% of children in care aged 5-17 yrs are on medication. This number increases to 57% for 16-17 yr olds

Foster Parent Accountability: 

• We need to ask questions of the physicians and psychiatrists to ensure we know everything we need to know about the medication on behalf of the children in our care
• We need to regularly re-assess whether the medication is working or not.  
• We need to assess one medication at a time so the child doesn’t inadvertantly end up on multiple medications because we are at a loss for what to do.  
• We need to consider “drug holidays” in the summer for stimulant medications for adhd.  
• We need to realize that not all behavior is fixed by medication.

Most children will heal with stability, consistency, nurture and support of caregivers knowledgeable of trauma-informed care.

This means that the child does not change placements and the caregiver:

• Is patient, understanding, kind, loving, and gentle.
• Gives clear instructions about expectations and house rules.
• Gives consistent consequences when rules are broken.
• Teaches the child coping skills and how to control their behavior and emotions in an age appropriate way.
• Praises the child for positive behaviors.

Children may act out as they adjust to a new home and learn new rules. Caregivers should expect that adjustment takes time and give appropriate support and acceptance. If given safe, positive, nurturing, consistent trauma-informed care most children will learn to trust, feel safe, and learn to control their emotions and behavior in way that is appropriate for their age.

Foster Parent Accountability:

• To parent from a Trauma Informed Parenting Style.
• To understand the impact of trauma and attachment on behavior
• To learn about and adjust your environment and parenting styles for various disabilities ie FASD, Autism, ADHD
• To seek services from community partners to help the child
• To be open and willing to learn and change your style and approach to each child.

Psychosocial therapies, behavior strategies, and other non-pharmacological (non-medication) interventions are to be considered by the Foster Parent before and definitely along with psychotropic medications.Non-pharmacological interventions are specific methods a caregiver can use to help a child manage behavior. This may include therapy and specific behavior modification strategies. Each child is different, so the strategies should be specific to the child’s needs and discussed with the child’s therapist or medical provider. 

Resources:

• Case Manager
• Child’s Worker
• Therapist
• Behavior Management Resource Team- or otherwise named by local CAS agencies.  This is a team of community service providers that reviews the child’s behavior, interventions that have been utilized and makes recommendations for services
• Community Services- local behavior and mental health care providers Ie New Path, Kinark, Childrens Treatment Network,  Autism Service Providers for ABA therapy
• Online Training- Positive Reward systems 

Be prepared to learn and be open to adjusting your style to meet the needs of the child.  

It could involve changing the words you use with the child or moving to visuals or boardmaker or any number of other modifications.  Don’t consider it a failure on your part, consider it a strength that you are willing to learn and adjust your style for each child.

• If a child has serious symptoms or is not getting better with non-pharmacological interventions, the caregiver or medical consenter should talk to a doctor.
• Anytime a child is a danger to himself/herself or others, the caregiver or medical consenter should immediately contact the doctor.  Examples include suicidal or violent thoughts or actions.

A primary care provider may be able to diagnose and treat some behavioral health disorders including prescribing psychotropic medications.

For more complex problems, or if you would like a further assessment of the child you may request an appointment with a psychiatrist. The child and adolescent psychiatrist will do a complete psychiatric evaluation and make a recommendation about treatment. Ask the child’s primary care provider if you are not sure if the child needs to see a psychiatrist.

The medical system only works for children when they have reliable, honest information being provided on the child.The pediatrician relies on the information that the caregiver provides.  If you exaggerate a problem, the physician can’t accurately assess what the best treatment option is.  If you underplay it the same holds true.  Try to be as honest and realistic as possible about the challenges the child is experiencing

What the pediatrician or psychiatrist will need to know:

• Description of child’s problems and symptoms.  Bring feedback from the school but don’t rely soley on the school’s interpretation of the scope of the problem.  Often environmental factors exacerbate a child’s problems at school and these enviromental factors can be modified so medication might not be required.
• Description of interventions and behavior modification strategies being used and tried ie ABA, 4 square breathing, time in etc
• Information about health, illness and treatment (both physical and mental) including current medications
• Parent and family health and psychiatric histories
• Information about the child’s abuse and neglect history
• Information about the child’s development
• Information about school and friends
• Information about family relationships in the child’s birth family and current home or living arrangement.

It is important for a child’s caregiver or medical consenter to find out as much of this information as possible before taking the child to the psychiatrist. The psychiatrist needs to know how the child is doing in all areas of his or her life.

Ideas:

Keep a calender log of the child’s behavior or mental health challenges, then the psychiatrist has at a glance real data to help understand the problems the child faces.  ie Monday- 10 min violent outburst at school- throwing, hitting, Tues- good….  or Monday- depressed- not interested in toys, sleepy, cried 3x

Stimulants are commonly used to treat Attention-Deficit Hyperactivity Disorder (ADHD).

Symptoms of ADHD interfere with functioning at school and in daily living and may include:

• Short attention span.
• Inability to stay still.
• Being impulsive.

Stimulants may be short acting or long acting. Short acting means that they act right away but do not last a long time. Long acting means that they take longer to act but last longer. Some children need to take a short acting and a long acting stimulant to get coverage throughout the day. Taking a short acting and a long acting stimulant together counts as only one stimulant and is not outside the Parameters.

Examples of short acting stimulants:

• Amphetamine (Adderall)
• Dexmethylphenidate (Focalin)
• Methylphenidate (Ritalin, Metadate, Methylin)
• Dextroamphetamine (Dexedrine, Dextrostat)

Examples of long acting stimulants:

• Amphetamine (Adderall XR)
• Dexmethylphenidate (Focalin XR)
• Methylphenidate (Concerta)
• Lisdexamfetamine (Vyvance) 

Side Effects:

• Decreased appetite
• Weight loss
• Headaches
• Stomach aches
• Trouble getting to sleep
• Jitteriness
• Social withdrawal
• Tics, sudden repetitive movements or sounds
• Aggressive behavior or hostility
• Psychotic or manic symptoms

Adverse Reactions:

• Sudden death in children with pre-existing serious heart problems
• High blood pressure
• Problems with growing, such as a slower growth rate

Sometimes medications that are not stimulants are used to treat ADHD. These medications come from different classes. You will need to read the pharmacy insert to learn about side effects and adverse reactions to these medications. A child in your care may be prescribed one of these medications.

Examples are:

• Clonidine (Catapres, Kapvay)–used to treat high blood pressure in adults but causes sedation in children in small doses
• Guanfacine (Tenex, Intuniv)–used to treat high blood pressure in adults but causes sedation in children in small doses
• Atomoxetine (Strattera)–newer antidepressant, in rare cases causes suicidal thought risk
• Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)–newer antidepressant
• Imipramine (Tofranil)–older antidepressant, usually used to treat bed wetting, but may be used to treat ADHD

More About Treating ADHD

• Stimulants are usually the first medication tried for ADHD.
• Sometimes antidepressants are given for ADHD if 2 to 3 stimulants are tried and do not work.
• Your child’s doctor should start the stimulant at the lowest dose and only increase the dose as needed.
• A short acting stimulant should last for about 4 hours and a long acting stimulant for about 8-12 hours.

Antidepressants are used in children to treat symptoms of depression and other conditions.

Symptoms of depression may include:

• Feelings of hopelessness or helplessness
• Loss of energy
• Changes in appetite
• Weight gain or weight loss
• Not being able to enjoy activities the child used to enjoy
• Thoughts of suicide

Antidepressants help with other conditions:

• School phobias
• Panic attacks
• Eating disorders
• Autism
• ADHD
• Bedwetting
• Anxiety disorders
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorders (PTSD)
• Personality disorders
• Sleeping problems

Selective Serotonin Reuptake Inhibitors (SSRIs) are one of the newer groups of antidepressants. SSRIs are often used to treat depression and other disorders in children. SSRIs are popular because they are safer than some of the older antidepressants if overdose occurs.

Pills

Examples are:

• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Sertraline (Zoloft)
• Paroxetine (Paxil)

Possible Side Effects and Adverse Reactions of SSRI Antidepressants:

• Flu-like symptoms:
• Headaches
• Nausea
• Stomach upset
• Dry mouth
• Extreme sweating
• Other side effects:
• Trouble sleeping
• Irritability
• Weight changes

Warning

The caregivers of children taking SSRIs should monitor them for depression that is getting worse and thoughts about suicide. The caregiver or medical consenter should immediately talk to the doctor if this happens

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) are usually prescribed when SSRIs have not worked. SNRIs are not usually prescribed to children. However, they may be helpful in some cases.

Examples are:

• Venlafaxine (Extended Release Effexor XR)
• Duloxetine (Cymbalta)

Side Effects:

• Abnormal dreams
• Nervousness
• Body weakness
• Chills
• Cough
• Dizziness
• Headache
• High blood pressure
• Increased sweating
• Loss of appetite or weight
• Stomach or colon problems

Adverse Reactions:

Hallucinations

Thoughts of suicide

Panic attacks

Children who have been traumatized may have problems with sleep. Atypical antidepressants are more often used to help children with sleep problems than to treat depression. These medications are usually safer for children than standard prescription sleep medications (such as Ambien, Halcion, Lunestra, Rozerem, and Sonata).

Examples are:

• Bupropion (Wellbutrin)
• Mirtazapine (Remeron)
• Trazadone (Desyrel)

Side Effects:

• Sleepiness
• Headache
• Constipation
• Dry mouth
• Agitation
• Nervousness
• Weight changes
• Flushing
• Sweating
• Tremors
• Changes in blood pressure

Adverse Reactions:

• Male erection that is unwanted, painful and lasts a long time (Trazadone)
• Seizures (Wellbutrin)
• Low white blood cell count (Remeron)

• These medications may take a couple of weeks to work.
• A two-week break may be needed after finishing one medication and starting another one.
• A child should never stop taking antidepressants suddenly. Your child’s doctor will help you wean the child off of the medication slowly. This will help prevent dizziness and other side effects.
• The caregivers of children taking SSRIs should monitor them for depression that is getting worse and thoughts about suicide. The caregiver or medical consenter should immediately talk to the doctor if this happens.

Antipsychotics may be used to treat a number of conditions in children:

• Psychosis
• Bipolar disorder
• Schizophrenia
• Autism
• Tourette’s syndrome
• Severe aggression

Antipsychotics are divided into two groups:

Atypical (or second generation) antipsychotics, were first developed in 1994.Typical (or first generation) antipsychotics were first developed in 1950.

Atypical antipsychotics are the most common antipsychotics used in children. These antipsychotics are less likely to cause movement disorders (shuffling walk, tongue sticking out of mouth, drooling, etc. ) than the typical antipsychotics.

Examples are:

• Aripiprazole (Abilify)**
• Quetiapine (Seroquel)**
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Clozapine (Clozaril, Fazaclo)**
• Ziprasidone (Geodon)
• Paliperidone (Invega)
• Iloperidone (Fanapt)
• Asenapine (Saphris)
• Lurasidone (Latuda)

Common Side Effects:

• Sleepiness or tiredness
• Dizziness
• Constipation
• Dry mouth
• Blurred vision
• Difficulty urinating
• Sensitivity to lights
• Weight gain
• Change in menstrual cycle

 
Less Common Side Effects:

• Dystonia: muscle spasms; Stiff neck; tongue sticking out of mouth, trouble swallowing
• Akathisia: restlessness, unable to sit still
• Akinesia: rigid muscles; shuffling walk; drooling; tremor

• Tardive dyskinesia (permanent involuntary movements of tongue, mouth, face, trunk, arms and legs that are more common with typical antipsychotics than with atypical)
• Overheating or heatstroke (prevent by drinking water and staying out of heat)
• Metabolic Syndrome (excess weight gain, increased blood pressure, high blood sugar and triglyceride levels)
• Type II Diabetes, Heart Disease, and Stroke
• Neuroleptic malignant syndrome (extreme muscle stiffness, high fever, sweating, tremors, confusion, unstable blood pressure and heart rate). 
  • This is a medical emergency.

Other Information About Antipsychotics

• Each child is different, so a child may need to try different medications in order to find the one that works best.
• You should start seeing positive changes in 2-3 weeks, but it may take 6-8 weeks.
• A child should never stop taking an antipsychotic suddenly. This may cause fast changes in mood, agitation, aggression, nausea, sweating or tremors. The child’s doctor will help you wean the child off the medication slowly.
• The child’s weight, glucose levels and lipid levels should be monitored regularly by a doctor while taking antipsychotic medication.

Mood stabilizers are used to treat children with mood disorders, such as bipolar disorder. Children with bipolar disorder have extreme mood swings (manic or depressed states).

When children are in the “manic” state, they may be very active, talk too much, have a lot of energy, and sleep very little. They may also be angry, irritable, or feel overly self-important.

Children in the “depressed” state may:

• Feel hopeless or helpless.
• Have a loss of energy.
• Have changes in appetite.
• Gain or lose weight.
• Not enjoy activities the child used to enjoy.
• Have thoughts of suicide. 

Some medications used to treat mood disorders are also used to treat seizure disorders. If it is used to treat seizures, it is not considered a psychotropic medication.

Used to Treat Seizures:

• Lamotrigine (Lamictal)
• Divalproex (Depakote)
• Carbamazepine (Carbatrol, Tegretol, Tegretol XR)

Medications that are only used as mood stabilizers:

• Lithium (Eskalith, Eskalith CR. Lithobid)

Adverse Reactions:

• Vary by mood stabilizer but some can have quite serious sideffects so please discuss thoroughly with physician and pharmacist
• Mood stabilizers may effect the metabolism, liver, kidneys, and thyroid.
• Children taking Tegretol, Depakote or Lithium should have routine blood work. Levels are usually checked in the morning before the medication is given to the child.

The psychiatrist must obtain “informed consent” from the child’s foster parent, social worker and or the child (depending on comprehension level) before prescribing a psychotropic medication.

This means the doctor must give the medical consenter enough information to decide whether or not to consent for the child to have the medication. The doctor must also allow the medical consenter to ask questions. The process of understanding the risks and benefits of giving the medication to the child is a vital part of informed consent.

Making the Decision without Undue Influence

• Making an informed decision about behavioral health treatment or medications without “undue influence” means that the foster parent is deciding based on what is best for the child, taking into account what success looks like offset by potential side effects, not because of pressure to consent to the medication or treatment.
• For example, a decision should not be based on the child’s school insisting the child be put on medications before they can return to school.

Foster Parent Accountability:

• Get answers to questions about medication and therapy
• Find treatments that help the child get better
• Determine what treatment is in the best interest of the child
• Ask about referrals for non-pharmacological interventions as well
• How do we assess whether this medication is working.
• Ask about the timeline for pharmacological intervention- how long do you expect the child will need to be on this medication etc 
• Psychotropic Informed Consent Form and Medical treatment report must be filled out and signed.

The Purpose of the Psychotropic Informed Consent Form is to have a signed document showing that we are making a decision in the best interest of the child and  the following information has been discussed and considered as part of consent

• the specific condition to be treated;
• the beneficial effects on that condition expected from the medication;
• the probable health and mental health consequences of not consenting to the medication;
• the probable clinically significant side effects and risks associated with the medication; and
• the generally accepted alternative medications and non-pharmacological (non-medication) interventions to the medication, if any, and the reasons for the proposed course of treatment.

Coming Soon

• What is the name of the medication? Is it known by other names?
• How effective has it been for other children who have a similar condition to the child?
• How will the medication help the child?  How long before I see improvement?
• Is this medication approved by the Food and Drug Administration (FDA) for the child’s condition?  If not, (i.e., it is being prescribed “off-label”), why is this medicine being recommended?
• What are the side effects that occur with this medication and how will I know if the child is experiencing any of these effects?
• What is the recommended dosage?  How often will the medication be taken?
• Does the child need laboratory tests (e.g. electrocardiograms, blood tests, etc.) before taking the medication?  Does the child need any tests while taking the medication?
• Will a child and adolescent psychiatrist monitor the child’s response to the medication and change the dose if necessary?  Who will check the child’s progress and how often?
• Does the child need to avoid other medications or foods while taking this medication?
• Does this medication interact with other medications (prescription and/or over-the-counter) the child is taking?

It is important to talk with the child about taking psychotropic medications. 

You should:

• Talk to the child in a way that the child can understand.
• Make sure the child understands why he or she is taking these medications.
• Tell the child what he or she can expect from any tests or treatment.

Help the child understand: WHAT ARE MY RIGHTS?

Youth in foster care have legal rights related to health care and medication.

You have the right to…

• Get a good assessment in which a doctor or specialist meets with you,listens to you, and discusses options.
• Know your diagnosis and understand the name and nature of what makes you feel and behave the way you do.
• Find out all of your options for treatment, including alternatives to medication. 
• Ask questions about the benefits and side effects of any medication adoctor suggests you take. 
• Receive support from a planning team to help you with medical decisions. 
• Know who has permission to make decisions about medications for you.
• Ask an adult you trust for help in understanding your rights to accept or refuse medication and to ask for changes in your treatment plan.

The Foster Parent Must:

• Continue to provide a stable environment and consistent behavior intervention and explore non-pharmacological (non-medication) interventions with healthcare providers. The child may also need behavior health therapy.
• Always read and keep the insert from the pharmacy that comes with each medication. The insert tells you important information on how to give the medication and on possible side effects.
• Store the medication in the original container that came from the pharmacy.  Medication must be sent in original container for respite Tip: ask the pharmacy for a second container so you can send two days worth of medication
• Medication must be locked away- behind two locks ie in a locked safe in a locked cupboard for safety purposes
• Give the medication exactly as prescribed and never more or less unless directed by the doctor.
• Never quit giving the medication to the child unless the doctor tells you to quit. Some psychotropic medications require weaning off gradually. Always follow the doctor’s instructions when stopping medications.
• Follow the doctor’s direction for giving the medication. For example, the doctor may tell you to give the medication at a certain time of day or to make sure the child does not eat certain foods.
• Watch to make sure the child takes the medication.
• Never give a child a medication that is prescribed for someone else.
• Keep a medication log for each child. Write down the date, time, and who gave the medication to the child. This must be given to the case manager each month
• Coordinate with the doctor to make sure you get refills on time

Coming Soon

If a child refuses to take a medication inform your Case Manager or On-Call (if it is After-Hours) right away. Please complete an Incident Report and forward to your Case Manager. It is deemed a Serious Occurrence if the child refuses medication multiple days/times.

To address the issue:

1. Call the Pharmacist and ask what the consequences of missing a dose are. Ask the Pharmacist to speak to the child on the phone or bring the child into the pharmacy to speak to the pharmacist. Create a plan with the child to continue to take the medication and you will call and make an appointment with the child’s doctor with respect to the child’s wishes to no longer be on the medication

2. Child won’t speak to the Pharmacist or is too young and the risk of missing a dose is not significant. Call the Case Manager and child’s worker for direction. Book an appointment to follow up with the child’s Physician as soon as possible

3. Missing a dose could cause significant issues. Report to your Case Manager and child’s worker and complete an Incident Report accordingly.

What Are Side Effects?

• These are uncomfortable effects such as stomach aches, drowsiness, dizziness, sleep problems, tremors, and weight gain that may occur when starting a new medication, increasing the dose, or stopping the medication.
• These may get better with healthy diet, rest and exercise.
• These may make the child feel very uncomfortable or the side effect may interfere with functioning, and the medical consenter should call the child’s doctor and seek advice if this happens.

What are Adverse Reactions?

• Are uncommon and unexpected.
• May be an allergic reaction.
• Are likely harmful if the child keeps taking the medication.
• May be life threatening.

Immediately talk to the child’s doctor and follow his or her directions if there is an adverse reaction.

• Always talk to the child’s doctor anytime you have a concern about how a medication is affecting a child.
• Always report adverse reactions to the doctor right away.
• Call 911 or immediately take the child to the emergency room if the child is having an adverse reaction that is life threatening.
• Remember to report this information to the case manager and child’s social worker immediately

A “high risk” situation involving psychotropic medications can be one of the following:

• psychotropic medications that are prescribed as needed or used as needed more than twice a day or for three or more consecutive days;
• a child is prescribed two or more psychotropic medications at the same time;
• a child under the age of seven is prescribed psychotropic medication;
• a psychotropic medication prescription that has not been reviewed by a health practitioner in more than six months;
• any psychotropic medication prescription that is stopped suddenly and abruptly by child without being supported by a health practitioner treatment plan; and
• any other situation which causes concern in the opinion of the licensee.

Let the child’s pediatrician or psychiatrist know that a child is considered high risk when the above criteria are met.

• The vast majority of children in care do not need psychotropic medications.
• Some children need psychotropic medications to get temporary relief from symptoms of trauma from abuse, neglect or separation to treat behavioral health disorders. 
• A single page double sided psychotropic medication administration form must be signed each time a medication is started, changed or stopped.  This is a Ministry requirement.
• Medication must be stored in a locked container in a locked cupboard- double locked.
• Medication must always be stored in original containers even for respite.
• Psychotropic medications alone are not the best treatment. They should always be used with non-pharmacological interventions, such as behavior interventions and behavioral health therapy, for long-lasting effects. 
• The foster parent has a responsibility to monitor the child to make sure the medication is helping, watch the child for side effects and adverse reactions, and let the doctor and CAS know how the child is doing. 
• The Foster Parent should consult their case manager, child’s social worker and physician if they believe the child is taking medications outside of regular prescribing norms or high risk.