Family care for children and youth

Family Care for Children and Youth, Inc. FOSTER PARENT TRAINING
PSYCHOTROPIC MEDICATIONS
INTRODUCTION A “psychotropic” or “psychoactive” medication is intended to act on the mind or brain affecting mental functioning and emotions. Psychotropic medications are used to treat what are commonly referred to as mental or emotional illnesses. Some children, including foster children, are put on these medications to treat anything from serious psychosis (literally “mental illness”) to mild depression and from epilepsy to hyperactivity. There is a huge list of possible mental illnesses and there are countless medications to treat them. All children who take powerful medications of any kind need the careful supervision of caring, informed adults. Psychotropic medications are powerful and potentially dangerous. All adult caregivers of children should be informed about the nature of and problems with these medications. Many of us, including social workers and foster parents, are not fully informed. Foster children are particularly vulnerable because their biological parents may not be actively supporting them, and the system, which supervises their care, can be quite complicated. Probably you would avoid letting your own children be labeled with a mental illness, and you would find other alternatives than medication to deal with behavior problems. But if no one intervenes for foster children under similar circumstances, they may be diagnosed as mentally ill and receive psychotropic medication. We do not want to allow children to be labeled as “mentally ill” as a result of their being in foster care. This training has three parts. First, we will look at what many medical and psychological professionals say about the so-called illnesses of mind and emotions. In this section we will look at who the people are in these professions and how they do their work. In the second section we will examine the drugs used and the side effects of these drugs. Finally we will consider our agency’s beliefs about these topics. In this third section, there will be a detailed description of what to do when a child is – or might be – diagnosed with a mental illness and how to deal with drug therapy when it is unavoidable. It is important to note that there are State regulations and agency policies within Family Care For Children and Youth (FCCY), which govern our work with children when it comes to the use of psychotropic medications. Therefore, we have FCCY forms designed specifically for this purpose. It is important that staff and foster parents be familiar with and use these forms appropriately. THE MEDICAL PERSPECTIVE ON MENTAL AND EMOTIONAL ILLNESS We live in a culture in which the medical model of illness and health governs most of the thinking about and treatment of problems involving the mind, emotions, and behavior. What is presented below is how this model works, what it considers to be mental and emotional illnesses, the causes of such illnesses from this perspective, and the roles of different people involved in this system. The Medical Model and the Mind We all are familiar with the “medical model” of treatment, and often it works fine. Some agent or “bug” from the outside invades me and I get sick. The doctor uses a different agent, such as an antibiotic, to fight the invader and I get well. This is called allopathic medicine, which means using something different from the illness to fight the illness. When we get sick, our friends may ask us, “What do you have?” This implies that I have something I should not have, and I will be better without it. It is the job of the doctor to remove it. That sounds ordinary enough, but let’s look more deeply at what it means. In the medical model, the cause of the illness is always separate from me, outside me. I would agree, surely, that when I catch cold, the virus was passed to me from someone else. If the cut on my finger gets infected, the bacterium came from outside my body and invaded me through the cut in my skin. I did not cause the illness, except that perhaps I could have been more careful around other sick people, or I could have kept the cut clean and protected. But what happens in the case of mental illness? Rarely is the cause an infection by some “bug.” More commonly today, many scientists believe that mental illnesses are caused by chemical imbalances in the brain or by genetic malfunctions. And, while most psychoactive drugs are designed to address such problems, we do not know enough about the brain to design any drugs to treat the problem the way a vaccine treats measles or penicillin treats an infection. The psychotropic medications attempt to restore imbalances or to correct for genetic problems by treating the symptoms that patients report. This model of illness can be called “deterministic,” which means that sick people do not choose to be ill, and also that they cannot simply choose to become well. If a child catches the measles, he did not choose to become sick, and neither he nor his parents can simply wish the measles away. If this model is applied to mental illness, then again the patient does not choose to be ill. Many counselors who work with such illnesses believe that an event in the outside world rather than a bug causes the illness. For example, a child is severely abused, which is the event. This event causes sadness, depression, anxiety, or perhaps acting-out behavior. The child did not choose to be abused, does not choose to be ill, and cannot choose to be healthy. Whether we are talking about a cold or depression, and whether it is a physician or a counselor who is treating the illness, from this perspective the patient has no control over his illness. That means that he needs a “doctor” or some kind to step in and provide a cure. Later in this training, you will see why our agency does not believe in this model. Illnesses of the Mind and Emotions There is a published catalog of different types of mental or emotional illnesses. It the fourth edition of the Diagnostic and Statistical Manual (DSM-IV-TR). It is used by psychiatrists, psychologists, and sometimes by physicians and social workers to diagnose patients’ or clients’ problems. There is at least one reference copy in Administrative Offices of FCCY. However, we in our agency do not perform diagnoses. Some of these disorders are what we usually think of when we hear about “crazy” behavior: hallucinations, being out of touch with reality, going through extremes of emotion, and so forth. There are names such as schizophrenia and bipolar disorder (manic depression) to refer to the “big” illnesses. There are many other kinds of diagnoses, however, such as depression, anxiety, ADHD (attention-deficit hyperactivity disorder – sometimes just ADD), and alcoholism. For most of the illnesses catalogued in the DSM-IV, there is no known cause, unlike illnesses such as measles or AIDS. Instead, a mental health diagnosis most often is a list of symptoms. In other words, while a physician uses symptoms like a rash to diagnose measles in order to treat the virus, in the case of a mental illness the symptoms are the illness. How does someone know when a person really has the illness? If he has enough of the symptoms, then he has it, maybe. However, there is usually no laboratory test which can be done to prove it and quite often different users of the DSM-IV disagree on the diagnosis. Doctors: Psychiatrists, Psychologists, and Physicians In dealing with these matters, it is important to distinguish between psychiatrists and psychologists. A psychiatrist always is a “doctor.” A psychologist may be one also. The difference is that only a psychiatrist is a physician (M.D.) that has both a medical degree and a degree in psychology, the study of the mind, emotions, and behavior. A psychologist who is a “doctor” (Ph.D.) is not a physician. Of the two, only a psychiatrist can prescribe medications because only they have the necessary medical training. Normally, but not always, psychiatrists are trained only in the medical model of treatment. Most often psychologists are trained primarily in some sort of counseling – “talk therapy”- behavior modification. Psychiatrists and psychologists do different jobs and have different qualifications. A psychiatrist is not the only person who can prescribe a psychotropic medication. Your family physician can do so because they are medically trained doctors. Many lay people assume that if a family doctor prescribes a medication, the drug is not psychotropic. This is not true. In fact, many physicians do prescribe many of the possible psychotropic drugs upon request of their patients, without a psychiatric referral. PSYCHOTROPIC MEDICATIONS AND THEIR SIDE EFFECTS There are essentially four classes of psychoactive medications: 1. Anti-psychotic or neuroleptic drugs, including Thorazine, Haldol, and Mellaril. 2. Anti-depressants, including Lithium, Elavil, Prozac, and Paxil. 3. Anti-anxiety drugs, the so-called minor tranquilizers, including Valium, Xanax, 4. Psycho stimulants, including Ritalin. All of these drugs are used to treat symptoms by applying an external control on thoughts and feelings. Rarely do biological tests exist that could confirm a diagnosis. In any case these drugs do not cure the illness. Extensive descriptions of the drugs, along with indications for use and potential side effects, can be found in the Physician’s Desk Reference (PDR), which also is available at FCCY’s administrative office. Most of these drugs have a list of potentially serious side effects. While such side effects can include rashes, loss of appetite, blurred vision, dry mouth, sleep disorders, or irritability, often these are temporary. Many of the drugs, however, can become toxic if taken over prolonged periods of time. Other significant side effects fall into four categories: A. Addiction: Many of the drugs are addictive (some highly so). Some researchers worry that addiction to prescription drugs can lead people into the use of illegal street drugs such as cocaine or heroin. B. Tardive dyskinesia, a gradual erosion of muscle control caused by nerve damage. Patients with tardive dyskinesia may develop tics in facial or other muscles, loss of muscle control, and difficulty with gross motor skills. C. Tardive akathisia, the development of a nervous irritability making it difficult or impossible for the patient to remain still. D. Tardive dementia, the deterioration of mental ability. The word “tardive” here means a slow or delayed onset of the side effects. Often when the symptom – loss of muscle control, constant movement, dementia – is noticed there already has been some damage. This is because the action of the drug masks or hides the onset of the problem. Such side effects are, for the most part, irreversible – the damage cannot be repaired once it happens. The likelihood that any of these conditions will develop increases with the length of time that the patient is on the drug. That makes all these drugs potentially very dangerous. Unfortunately, the onset of the side effects is relatively unpredictable, varying widely from one person to another, so that it is virtually impossible to predict the damage, if any, in advance. Recently, serious questions have been raised about the use and value of many of these medications. As reported in the 8/24/96 issue of Science News (p. 123), “… the lion’s share of (anti-depressants’) effectiveness stems from the placebo effect… A placebo is a “sugar pill,” a prescription which has no known medical or harmful effects”. In other words, people improved more because they believed they would than because of the medication. Science News reports further: The placebo effect is twice as strong as either the pharmacological effects of antidepressants or “nonspecific” factors, such as the passage of time… antidepressant researchers typically do a pretest to weed out volunteers who respond strongly to a single placebo pill. Moreover, an unknown number of studies in which antidepressants fail to outperform placebos are either not submitted or not accepted for publication. This means that we really do not know, for the major class of antidepressants at least, that the drug, with its potentially harmful side effects, is any more effective than therapy without a drug. Peter Breggin, a psychiatrist, in his book Toxic Psychiatry, worries that such problems – including poor-quality research by pharmaceutical companies – apply to many drugs other than just the antidepressants. And to make matters worse, it has been reported recently that there is a drug culture selling and abusing such widely prescribed drugs as the stimulant Ritalin. AGENCY BELIEF AND POLICY REGARDING PSYCHOTROPICS Being Informed About Psychotropic Medications It should be obvious by now that psychotropic medications can be very dangerous, that they do not cure the conditions for which they are prescribed, and that their use could interfere with a person’s ability to choose alternatives. There also is a great deal of uncertainty in the diagnosis and treatment of mental illnesses. As was stated on the first page, children, and particularly foster children, are vulnerable to the misuse of these medications. It is especially important, then, that everyone who is directly or indirectly responsible for foster children become as informed as possible regarding all of these issues. It is important to remember that physicians as well as psychiatrists might prescribe these medications. We do not allow foster children to accept prescriptions for psychotropics from physicians – we will see below that all such prescriptions must come from psychiatrists. But how does one know if a particular prescription is for a psychotropic? A good rule of thumb concerns the purpose of the medication: If it is to change moods or feelings, if it is to change thought patterns, or if it is to change behavior, then probably it is psychotropic. If there is a question, however, check with your program office supervisor. We can look in the PDR or even call a psychiatrist if the supervisor does not know. Appropriate Use of Psychotropic Medications We do not believe that it is appropriate for anyone to use psychotropic medications for extended periods of time, and certainly not all of one’s life, as is prescribed in some cases. Such a use probably would be a substitute for the person’s choosing her own direction in life, and it might lead to permanent physical as well as mental damage. The guiding philosophy of our agency is that each person should have as much freedom of choice and internal control over his or her life as possible. Therefore, we need to balance any psychotropic medical treatment with the Family Based Services, based on Choice Theory, which we offer. In addition, we must protect the children in our care from the kinds of damage that unrestrained use of psychotropic drugs could cause. We may from time to time encounter a child who simply must be on a powerful psychotropic drug for the indefinite future. Probably such a child is not appropriate for foster care placement, however much we might like to help. Choice Theory and Reality Therapy There is no denying that children are hurt by abuse, neglect, and the other reasons that may bring them into foster care. They may have emotional scars that affect their behavior. It is likely that they will behave worse than children who have not been abused and do not need to be placed in foster care. Some of our children behave in some pretty upsetting ways in order to meet their needs, and most of the time such behavior does not, in fact, meet anyone’s needs in foster homes. Most of the time, these children can learn different and more effective ways to meet their needs. It is our job to help them realize that, even if they have been hurt seriously, they choose their behavior and still they can change. If we can help them choose more effective ways to live, this will be help that has a lasting impact in their lives. In our agency, we all should know how to apply the tools found in Reality Therapy and Choice Theory. If a foster child is placed on some form of psychotropic medication, we can be using these tools to help him learn better ways of meeting his needs while he is in drug therapy. Then, when the drug is withdrawn, he can manage more effectively through his own choices. This work we do while the child is in drug therapy can both shorten the length of such therapy and help ensure that it will not be needed again in the future. Nevertheless, there are dangers to any drug therapy. The dangers are multiplied if there are no plans for change while the person is on the drug and no plans for what will happen when the drug is withdrawn. Sometimes without such goals, no one plans to remove the drug. We have seen what can happen if such drugs are used for longer and longer periods of time. In Reality Therapy there must be a plan to achieve what is wanted. In this instance, there needs to be a plan to help children on drug therapy choose different behaviors, and there needs to be a medical plan, that will become part of the Individual Service Plan, to remove the drug at a specific time. To put all this together, our agency believes that it is in the best interests of your foster children not to take psychotropic medications if possible, to take only those drugs that are deemed necessary, to remain on the drugs for the shortest time possible, and to have plans created with the help of adult caregivers to provide better alternatives to such drug therapies. Informed Consent and Consent Forms Department of Public Welfare regulations distinguish children who are fourteen years old or older from those who are younger. Younger children must have parental consent before psychotropic medications can be administered. Children who are fourteen and older must consent to their own treatment – no one can consent for them – or the medications cannot be used. (While there may be exceptions, normally they will involve hospitalization and need not concern us here.) This would imply that children who are fourteen or older will be able to consent in a knowledgeable way to their own treatment based on information the psychiatrists and we supply. However, it is difficult enough for an educated adult to understand fully the nature of medical treatment of any sort, not to mention psychiatric treatment. We really cannot expect that children of any age will understand very well. It is fine that a fourteen-year-old consent to her own treatment, but what if she is consenting only because she thinks we want her to do so, or to please her parents, or for fear that the judge will not send her home otherwise? We should not try to make up her mind for her. It is her consent that is required, and her choice. What we should do is become as informed ourselves as we can. Our being informed will help our foster child with information she needs. More importantly, it will help all of us – child, parents, foster parents, case manager, county caseworker, psychiatrist – work toward a common, mutual decision as to what is best. If we are asking the right questions, then probably a better, more detailed, safer plan will be created. Psychiatrists are very busy people, but they also are caring people. Most of the time, they will be grateful if we are raising appropriate treatment questions. In the last section, we will discuss how to do this. Policy and Procedures Our agency has a Psychotropic Medication Consent form to be used to obtain the consent of a child who is fourteen or older, and we also have a letter to inform the biological parents. The Psychotropic Medication Information Sheet is for foster parents and staff to list instructions for the use of medications, their side effects, and plans for each psychotropic prescribed. We also have a Counseling/Psychiatric Referral form for use when a child is referred for counseling or psychiatric evaluations. There is an agency policy, titled “Psychotropic medications Update,” which discusses psychotropic medications and what to do when a child is given a prescription. It instructs as follows: 1. A psychiatrist (not a general physician) must prescribe all psychotropic 2. Case management staff is to ensure that the psychiatrist is informed concerning 3. The appropriate consent forms are to be used. 4. Medications are to be listed on the face sheet of the child’s file. No child may be placed on a psychotropic medication without following these procedures, which means that foster parents must discuss a referral or prescription with the case manager before the child can receive the medication. Note: Many common medications such as Ritalin are psychotropic. Again, any drug that is intended to alter moods or feelings, to change thought patterns, or to control behavior is almost certainly psychotropic. We all are responsible to ensure that the children in our care are given proper treatment and protection. As mentioned in this policy, we all should assist in the effort to avoid allowing a child to be diagnosed as suffering from a mental illness. As we have seen, such illnesses are actually lists of symptoms. Probably virtually anyone could be diagnosed with something. The diagnosis is a label, and often the label will remain in the child’s record for life. Even children who change and choose to behave in ways that everyone recognizes as healthy often have great difficulty dropping an earlier diagnosis. This is partly because there is prejudice connected with such labels. For children, this may mean being denied an ordinary school classroom with peers. For an adult who was diagnosed as a child with a mental illness, it may mean being turned away by a military recruiter, being denied health insurance, and so forth. Our policy also instructs us to consider the use of psychotropic medications as a last resort. While such medications may be useful in some instances, there are many other tools that do work and are preferable in helping children choose responsible, effective, need-fulfilling behaviors. What this means then, is that we who provide daily care for foster children must be very careful to watch what is happening with children’s behavior, moods, and thinking. Our system of care must ensure that a responsible treatment plan is in place in the event that psychotropic medications cannot be avoided. Such a plan, developed with the psychiatrist, should include: A. A therapeutic or recommended dosage (often related to age and body weight). B. Recommended length of time a person should be on the medication. C. Recommended evaluation procedure while drug therapy is in process, such as E. Symptoms of developing side effects – what to watch for. F. Other drugs to avoid in combination with the proposed medication. G. A plan for the learning of new behaviors while the drug is being used. H. A plan for continuing this new way of coping after the drug is withdrawn. If foster parents and case managers communicate well, if the agency Psychotropic Medication Information sheet is used carefully, and if the tools found in Reality Therapy and Choice Theory are implemented, all these areas should be addressed.

Source: http://fccy.org/FPR%20Files/31%20Psychotropic%20Medications.pdf