Download YAR 2016 Prince Jefferson

Youth at Risk Conference, 2016
Understanding the “Gold Standard” of
Care for Youth with Symptoms of Trauma
&/or Major Mental Illness” Practical Tips
for Improving Legal Advocacy In and Out
of the Courtroom
Jefferson Prince, M.D.
Director, Child Psychiatry MassGeneral for Children at NSMC
Vice-Chair, Department of Psychiatry, NSMC
Staff, Child Psychiatry Massachusetts General Hospital
Instructor in Psychiatry, Harvard Medical School
Stages of the
Juvenile
Justice
Process
Landess, J. Civil and
Constitutional Rights of
Adjudicated Youth.
Child and Adolescent
Psychiatric Clinics of
North America, Volume
25, Issue 1, 2016, 19–26
KEY POINTS…
• Youth in the juvenile justice system have a high
prevalence of a diverse array of mental disorders
and severe psychosocial stressors.
• Trauma is common and trauma-informed care
should be considered a universal precaution in
working with justice-involved youth.
• Youth can benefit significantly from evidence-based
psychosocial and pharmacologic interventions.
• Although clinically ordered and supervised
seclusion may be appropriate in limited situations,
disciplinary or punitive use of isolation or solitary
confinement is categorically inappropriate.
Whitley, K and Rozel, JS. Mental Health Care of Detained Youth and Solitary Confinement
and Restraint Within Juvenile Detention Facilities. Child and Adolescent Psychiatric Clinics
of North America Volume 25, Issue 1, January 2016, Pages 71–80
2013 CDC Report on Mental Illness
in Youth
• 1 in 5 youth has a mental illness
• Estimated total cost $247 billion
• Because of their high prevalence, early onset,
their impact on the child, family, and
community, and its associated enormous cost
“…Mental and behavioral disorders of the
young represent a major public-health issue
in the US (and across the world)”
Problem: Limited Manpower
• About 6300 fully trained pediatric
psychiatrists currently practicing in the US
• Estimates that over 30,000 required to meet
current demand.
• Need for services projected to increase
100% by the year 2020.
• Increasing reliance on PCPs in the care of
children’s mental health problems
Center for Mental Health Services
Juvenile Screening Instruments
• MAYSI-2
• Youth Assessment & Screening Inventory
(YASI)
• Global Appraisal of Individual Needs-Short
Screener (GAIN-SS)
• Strengths and Difficulties Questionnaire (SDQ)
The Massachusetts Youth Screening
Instrument –Version 2 (MAYSI-2)
• Screening tool to be administered to all youth
(ages 12 through 17) by non-clinical personnel
within 1-3 hours after admission
• 52 questions about behaviors, thoughts or
feelings that young people answer “yes” or
“no” as being true for them in the “past few
months.”
• Not in Public Domain
Grisso, T et al., (2001). JAACAP 40(5), 541-548.
The Massachusetts Youth Screening
Instrument –Version 2 (MAYSI-2)
• ADU Alcohol/Drug Use 8 Frequency and pervasiveness of use
of substances
• AI Angry-Irritable 9 Feelings of preoccupying anger and
vengefulness, irritability and “touchiness”
• DA Depressed-Anxious 9 Depressed and/or anxious feelings
• SC Somatic Complaints 6 Bodily aches and pains often related
to depressed or anxious feelings
• SI Suicide Ideation 5 Thoughts and intentions about self-harm,
feelings of hopelessness
• TD Thought Disturbance 5 Altered perceptions of reality,
things not seeming “real”
• TE Traumatic Experiences 5 Self-reported exposure to events
that have potential traumatizing effects
Grisso, T et al., (2001). JAACAP 40(5), 541-548.
Components of Juvenile Screening
and Assessment
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Developmental and social history
General psychiatric history
Suicide risk
Violence risk
Trauma and child maltreatment
Substance use history
Special education history
Medical/dental
Sexual orientation/identity
Suicide Risk Screening
•
•
•
•
Past suicidal ideation or attempts
Current ideation, threat, or plan
Prior mental health treatment or hospitalization
Recent significant loss (relationship, death of family
member or close friend)
• History of suicidal behavior by family member or close
friend
• Suicidal ideation or behavior during prior confinement
• Initiation or discontinuation of psychotropic
medication(s)
Adapted from Penn JV, Thomas C. Practice parameters for the assessment and treatment
of youth in juvenile detention and correctional facilities. J Am Acad Child Adolesc
Psychiatry 2005;44:1085–98.
Violence Risk Assessment
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History of previous violent behavior
Weapons history
Exposure to violence and trauma
Child maltreatment
Conduct problems
Substance use
Psychiatric history
Gang involvement
Youth with violent histories should be referred for
further assessment and treatment.
Standardized Violence Risk Instruments
• Structured Assessment of Violence Risk in
Youth (SAVRY)
– youth between ages 12 and 18
– reviews risk factors
– Strong predictive value of recidivism
• Youth Level of Service/Case Management
Inventory (YLS/CMI)
• Hare Psychopathy Checklist: Youth Version
Frequency of Exposure to Trauma
Among Detained Youth is Staggering
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•
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Sample of 898 detained youth age 10 to 18
Northwestern Juvenile Project
92.5% of youth experienced ≥1 traumas
Mean traumatic incidents experienced 14.6
11.2% of the sample population met criteria
for PTSD within the preceding 12 months
• ≥50% reporting witnessing violence as the
instigating trauma
Abram, KM et al., Posttraumatic stress disorder and trauma in youth in juvenile
detention. Arch Gen Psychiatry, 61 (2004), pp. 403–410
Trauma Work in Juvenile Justice Settings
• Traumatic experiences of youth in juvenile justice
systems may differ qualitatively and quantitatively
from the experiences of other youth
• Violent bereavement & victimization
• Sexual trauma in particular is seen as a
– major risk factor for justice involvement for young female
youth in general and female youth of color in particular.
• Trauma-focused treatment is generally recognized to
be most effective when it occurs in a stable, safe
therapeutic setting in which the youth feels
comfortable beginning to discuss the traumatic
experiences
Trauma Work in Juvenile Justice Settings
• Trauma-focused treatment most effective when it
occurs in a stable, safe therapeutic setting in
which the youth feels comfortable beginning to
discuss the traumatic experiences
• May involve
– Medications and psychotherapy
• Should occur in the context of a therapeutic
relationship that is stable and experienced as safe
• Context is not possible in many juvenile justice
settings
Trauma Work in Juvenile Justice Settings
• Consider the axiom that a clinician should ‘screen
for symptoms, not dive for details’.
• A ‘good-enough’ interview may detail severity and
frequency of PTSD symptoms without delving into
the especially painful details.
• Give permission for the youth to end the line of
questioning at any time.
• Clinicians may consider trauma-informed care as a
universal precaution: trauma is so prevalent in this
population that it is prudent to assume that any
youth may have an undisclosed trauma history.
Fallot, RD & Harris, M. A trauma-informed approach to screening and
assessment. New Dir Ment Health Serv, 2001 (89) (2001), pp. 23–31
Challenges to Trauma Work in
Juvenile Justice Settings
• Lack of clinical control over
– Length of treatment
– Environment of care or custody
– Potential conflicts of interest (e.g., when
details of traumatic experiences reveal
details about criminal conduct of the youth
or others that may be reportable or the
subject of an ongoing criminal case)
Conference of
Behavior Control
through Drugs
Psychotropic
Hedonism
vs.
Pharmacological
Calvinism
Gerald Klerman,MD
September 1972
Context in Which to Provide/Receive/Decide
FDA-Approved Indications/Dosing
• Off-label use represents 50-75 % of pediatric medication
use (Zito, JCAP 2008)
• Product information is developed cooperatively by the
pharmaceutical manufacturer and FDA, generally reflecting
evidence from manufacturer sponsored studies.
• Does not necessarily reflect the evolving evidence base
that may include NIH-funded or investigator-initiated
studies.
• Thus, prescribers need to be aware of randomized
controlled trials in the literature, consensus guidelines,
practice parameters as well as product information.
Practice Parameters on Use of Psychotropic Medications in Children &
Adolescents, Journal American Academy of Child and Adolescent
Psychiatry, 2009
Note on Off-Label Use of Drugs in Children
• FDA approval requires “substantial evidence”, resulting from
“adequate & well-controlled investigations” that when combined
with the pace of medical discovery does not reflect all possible
uses of a medication.
• Off-label medication use in children & adolescents is neither
incorrect nor investigational if based on published scientific
evidence &/or expert medical opinion.
• MCPAP consultants are committed to therapeutic decisionmaking guided by the best available evidence regarding the
balance between benefits and harms for the individual patient.
•Adapted from AAP Policy statement, March 2014
•http://pediatrics.aappublications.org/content/133/3/563
FDA Approved Indications for
Antipsychotic Medications
• In Adults
– Schizophrenia, Schizoaffective & Psychotic Disorders
– Bipolar Disorder
– Adjunctive treatment for Major Depression.
• In Children and Adolescents
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–
–
–
–
Irritability associated with Autism (5-16 year olds)
Tics and Vocal Utterances of Tourette syndrome
Bipolar Mania (10-17 year olds)
Schizophrenia (13-17 year olds)
Severe behavioral problems marked by combativeness
and/or explosive hyperexcitable behavior (Thorazine,
Mellaril and Haldol; as young as 2 years old)
First Generation Antipsychotic
Medications
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Chlorpromazine (Largactil, Thorazine)
Fluphenazine (Moditen, Prolixin, Modecate)
Haolperidol (Haldol)
Loxapine (Loxapac, Loxitane)
Methotrimeprazine (Nosinan, Nizinan, Levoprome)
Molindone (Moban)
Pericyazine (Neuleptil)
Perphenazine (Trilafon)
Pimozide (Orap)
Thioridazine (Mellaril)
“Atypical” or 2nd/3rd Generation
Antipsychotic Medications
Generic Name
Trade name
Iloperidone
Fanapt
Paliperidone
Invega; Invega Sustenna
Risperidone
Risperdal; Risperdal M-tab; Risperdal Consta
Lurasidone
Latuda
Ziprasidone
Geodon; Zeldox
Clozapine
Clozaril; FazaClo ODT
Asenapine
Saphris
Quetiapine
Seroquel; Seroquel XR
Olanzapine
Zyprexa; Zyprexa Zydis; Zyprexa Intramuscular; Zyprexa
Relprevv; Symbyax (combined with Fluoxetine (Prozac))
Aripiprazole
Abilify; Abilify Discmelt
Second-Generation Antipsychotic Medication
Medication (Brand Name)
Dose Range
FDA indications
Risperidone (Risperdal)
0.5- 3 mg/d oral; divided
BID-TID (max 6 mg/d)
>13 y for schizophrenia &
bipolar; >6 y irritability in ASD
Olanzapine (Zyprexa)
2.5-10 mg/d; oral; divided 13-17 y as second-line
BID-TID
treatment of schizophrenia
Quetiapine (Seroquel)
25-800 mg/d; oral;
divided BID-TID
>13 y for schizophrenia and
bipolar
Aripiprazole (Abilify)
2-30 mg/d by mouth
divided BID-TID
13-17 y for schizophrenia and
bipolar; >6 y irritability in ASD
Ziprasidone (Geodon)
20-160 mg/d; oral with
food; divided BID
For Schizophrenia and Bipolar in
Adults
Asenapine (Saphris)
5-20 mg/d; sub-lingual,
BID
For Schizophrenia and Bipolar in
Adults
Lurasidone (Latuda)
20-160 mg/d; oral with
food, QD
For Schizophrenia in Adults
Iloperidone (Fanapt,
Zomaril)
1-6 mg/d; oral; BID
For Schizophrenia in Adults
Between 1995-1998 and 2007-2010
• Psychiatrist visits
– Increased significantly faster for youths (2.86 to 5.71 visits)
than for adults (10.22 to 10.87 visits) (interaction: P < .001).
• Psychotropic medication visits
– Increased for youths (from 8.35 to 17.12 visits) and adults
(from 30.76 to 65.90 visits) (interaction: P = .13).
• Psychotherapy visits
– Increased from 2.25 to 3.17 per 100 population for youths,
decreased from 8.37 to 6.36 for adults (interaction: P < .001).
• 27.4% of child visits, 47.9% of adolescent visits, and
36.6% of adult visits resulting in a mental disorder
diagnosis were to a psychiatrist.
Olfson M et al., JAMA Psychiatry. 2014 Jan;71(1):81-90.
Increasing Numbers of Youth Are Treated
with Antipsychotic Medications
• Between 1993-1998 and 2005-2009, visits with a
prescription of antipsychotic medications per 100
persons increased from
– 0.24 to 1.83 for Children
– 0.78 to 3.76 for Adolescents
• From 2005 to 2009, disruptive behavior disorders
were the most common diagnosis in Youth
prescribed antipsychotic medication
– 63.0% for Children
– 33.7% for Adolescents
Olfson M et al., JAMA Psychiatry. 2014 Jan;71(1):81-90.
The ‘gold standard’ of diagnosis
• Gathering data (ideally from multiple sources)
about…
– Symptoms (present manifestations, longitudinal
course, contribution(s) from biological, psychological,
social and behavioral realms) and their
– Impact on development (i.e., social, emotional,
physical, psychological and educational)
• …using current diagnostic criteria (DSM-5) in
combination with clinical judgment.
Determining whether atypical
antipsychotic treatment is needed
• Assess meaning, origin, and impact of the Tx target
• Assess potential medical (ie, pain), psychiatric (ie,
anxiety), and situational factors/triggers contributing to
target symptom expression.
• Understanding the function of behavior (eg, escape,
avoidance, attention), evaluating
antecedents, behaviors, and consequences (“ABCs”).
• Compare “ABCs” across settings
• Behavioral interventions to help youth & adults identify
alternative/more rewarding ways to communicate &
achieve needs
Identifying and tracking target
symptoms
• Use objective measures at baseline to
establish target symptom frequency, intensity,
and duration across settings
(home/school/community). “Weather and
Climate”
• Establish treatment response expectations in
advance and review regularly
• Consider using brief objective rating scales in
to monitor symptom severity and frequency
Monitoring Antipsychotic Use in Youth:
Baseline & Annually
• Assess personal/family history
(cardiovascular/metabolic illness, seizures/other
neurologic disorder, past treatment
response/adverse effects, lifestyle factors
[diet/exercise])
• Current treatments/potential interactions with
antipsychotics (eg, fluoxetine and paroxetine may
inhibit hepatic metabolism of aripiprazole and
risperidone, resulting in increased blood levels of
atypical antipsychotic)
Monitoring Antipsychotic Use in
Youth: Every Visit
• Treatment efficacy/effectiveness
• Basic clinical measures (height, weight, body mass
index, pulse, blood pressure)
• Lifestyle factors
• Somnolence/sedation
• Prolactin-related adverse effects (eg, galactorrhea,
gynecomastia, oligorrhea/amenorrhea; measure
blood prolactin levels if adverse effects are present)
• New medications/interactions with antipsychotics
Baseline, 3 and 6 Months on Treatment,
and Every 6 Months Thereafter…
• Blood work to monitor liver function, fasting
glucose, glycosylated hemoglobin, and lipids.
• Use clinical judgment to assess whether lessfrequent monitoring (ie, baseline, 6 months,
annually) is appropriate in patients with low
adverse effect risk or when significant barriers
to more-frequent blood draws are present.
Baseline, During Titration, and Every 3
Months Thereafter…
• Monitor for movement disorders with
objective rating scales (eg, Abnormal
Involuntary Movement Scale or SimpsonAngus Rating Scale).
Concurrent use of Multiple
Antipsychotic Medications?
Use of Atypical Antipsychotic Medications
in Children and Adolescents states, “the
use of multiple AAAs [atypical
antipsychotics] has not been studied
rigorously and generally should be
avoided” (AACAP, 2012).
Ethical Considerations
• Autonomy Principle
– Clear informed consent with parents
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•
•
•
FDA Status
Level of Evidence
Potential Risks and Benefits
Alternative interventions
• Beneficence vs. Nonmaleficence
– Providing benefit vs. not causing harm
• Justice, Equity
– Incentives to encourage research to improve safety,
tolerability and efficacy
Before initiating medication in
adjudicated youth, please Consider…
• How certain is the diagnosis?
• How good is the evidence for a given medication for
this person, with that diagnosis, at this time?
• Is the youth willing to continue to take the medication,
across placements?
• Are the parents or legal guardians in agreement with
medication?
• What are the legal parameters for consent given the
age of the patient and the patient’s legal status?
• In short, what are the risks of treatment and nontreatment in either a correct-diagnosis or incorrectdiagnosis scenario?
Seclusion, Isolation, and Solitary
Confinement
• Seclusion and restraint are clinical
interventions; isolation and solitary
confinement are disciplinary measures.
• The National Commission on Correctional
Health Care permits clinically indicated
seclusion or restraint within narrow
parameters but no longer allows isolation or
solitary confinement.
Standards for health services in juvenile detention and confinement facilities,
National Commission on Correctional Health Care, Chicago (2011)
Seclusion, Isolation, and Solitary
Confinement
• Any use of should occur in accordance with written
and reviewed policies maintained by the facility and
that are in alignment with relevant federal and state
regulations, laws, and ethical standards.
• Guidance on prohibited practices relating to isolation
and solitary confinement for juveniles is an ongoing
project of the American Civil Liberties Union
(extensive resources available at
https://www.aclu.org/report/alone-afraid
Seclusion
• A therapeutic intervention that occurs at the direction
of a physician in response to psychiatric symptoms
creating imminent danger to a patient or to others.
• The purpose is management of agitation and prevention
of harm.
• Time limited, monitored, initiated, and ended based on
clinical criteria and real-time assessment.
• Seclusion and therapeutic physical holds may be
clinically and ethically appropriate in some limited
situations in juvenile justice settings.
Supports for Clinicians & Families of Children with
Questions About Psychiatric Medications
• American Academy of Child and Adolescent Psychiatry www.aacap.org
• American Academy of Pediatrics www.aap.org
• Handouts/Guidelines/Warnings about Depression and use of
antidepressants in children and adolescents available at
www.parentsmedguide.org
• Screening Tools available at www.schoolpsychiatry.org
• Innovative Collaboration between Psychiatry and Pediatrics
Massachusetts Child Psychiatry Access Project (MCPAP) www.MCPAP.org
• Medline Plus (A service of the U.S. National Library of Medicine and the
National Institute of Health)
www.nlm.nih.gov/medlineplus/druginformation.html
Never Worry Alone!