A Closer Look: A Review of Psychotropic Medication Practices in Children's Residential Facilities in Ohio
A Publication of the Ohio Legal Rights Service
April 2002
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Copyright © 2002 Ohio Legal Rights Service. All rights reserved.
Dear Colleagues:
Ohio Legal Rights Service (OLRS) is Ohio's federally mandated and state designated Protection and Advocacy system. With increasing accountability being imposed on every front by Congress, state legislators and policymakers, the use of data to support policy decisions in the human service arena has become critical. Since the mission of OLRS is to protect and advocate the human, civil, and legal rights of people with disabilities, Major Unusual Incident (MUI) reports seemed an excellent place to begin this data collection.
Within the past two years, OLRS has created a data collection system to monitor MUI reports submitted by Licensed Children's Residential Facilities to the Ohio Department of Mental Health. This data system has enabled OLRS to develop a rich data base that provides us the ability to track statewide trends and patterns and fulfill our obligation to monitor health and safety, remedy systemic problems, and provide assistance.
This document, "A Closer Look: A Review of Psychotropic Medication Practices in Children's Residential Facilities in Ohio," is one of a series of publications based on the OLRS MUI data base. We are trying to portray an accurate and meaningful picture of activities and practices in facilities as reflected through an analysis of the MUI data. With our data base, OLRS is now able to recognize issues and concerns and validate those concerns with empirical data. We can also validate facility improvements and the best practices. Contrary to popular belief, OLRS recognizes how important it is to deliver positive information while we are documenting problems.
It is my hope that this document and the other "Closer Look" documents are helpful to you and the children in residential facilities.
Sincerely,
Carolyn S. Knight, Executive Director
Ohio Legal Rights Service
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A review of Ohio Legal Rights Service's (OLRS) Major Unusual Incident data base prompted OLRS to take a Closer Look at psychotropic medication practices at Ohio's Mental Health Children's Residential Facilities. During the year 2000, OLRS Staff visited four facilities to review medical records and gather baseline data. In addition to these baseline data, OLRS staff developed profiles on nine children living in the facilities. This information was forwarded to a consultant who reviewed the data and completed a written summary outlining findings and recommendations.
It is the intent of this publication to:
- Awaken the institutional culture so these medication and programmatic recommendations are addressed by providers;
- Make the target audience aware of the medication practices currently being implemented in Ohio's facilities;
- Challenge Ohio's mental health system to evaluate and improve its current treatment practices;
- Set a standard for Children's Mental Health Residential Facilities in Ohio that reflects an understanding of the impact of trauma on children;
- Advocate for treatment planning through a trauma-informed and trauma-sensitive perspective resulting in:
(1) decreased seclusion and restraint including chemical restraints,
(2) understanding that the use of psychotropic medications is only one of an array of tools in recovery, and
(3) increased recovery for kids because they are not being re-traumatized.
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Per the Ohio Administrative Code 5122-26-16(D)(2)(f), "Chemical Restraint" is defined by the Ohio Department of Mental Health as "a drug or medication that is used as a restraint to control behavior or restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition."
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The following are situations that are happening to children and need a closer look.
Situation #1: A 13 year old female was sexually assaulted between the ages of 3 and 7 by 4 different men. She is diagnosed with major depression. She has made several suicide attempts. During her 3 month stay at the facility, she was chemically restrained 13 times. The drugs used were:
- Haldol 5 mg
- Thorazine 25 mg
Currently her medication regime includes:
- Buspar 40 mg daily
- Haldol 5 mg daily
- Paxil 40 mg daily
- Benadryl 100 mg daily
Situation #2: A 12 year old female with diagnosis of bipolar II is prescribed:
- Zyprexa 40 mg daily
- Haldol 15 mg daily
- Depakote 2000 mg daily
On June 7, 8, 9, 11, 21, 22, 23, 24, 25, and 26 she received intramuscular shots, totaling:
- Haldol 90 mg
- Ativan 19 mg
- Benadryl 20 mg
Situation #3: A 13 year old male was restrained 7 times in July for a total of 400 minutes. Four of these restraints were chemical and mechanical. During one of these restraint episodes, within 5 hours, he received 3 emergency intramuscular shots of:
- Haldol 10 mg
- 3 intramuscular shots of Ativan 5 mg
Situation #4: A physician ordered a "stop all medication" for a 5 year old, who was lip smacking, grimacing, batting at the air, and complaining about being afraid because of all the "bugs" around him.
Situation #5: A 12 year old female addicted to alcohol and crack/cocaine at birth. She was removed from her family at age 3 due to physical and sexual abuse. She has had 6 psychiatric admissions and multiple foster home placements. Her diagnoses include ADHD, PTSD, bipolar disorder, disruptive disorder, ODD and reactive attachment disorder. Medications include:
- Seroquel 900 mg daily
- Ritalin 10 mg daily
- Lithium 900 mg daily
- Depakote 2000 mg daily
During a 9 month admission she received 6 chemical restraints of Thorazine 100 mg IM. She was also in seclusion 23 times with an average time of 19.5 minutes. She was physically restrained by 2 or 3 men 31 times with an average restraint time of 20 minutes.
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OLRS Staff visited four facilities to review medical records including the cardex. OLRS recorded the diagnoses of children and the medications that were dispensed the day before OLRS' visit. A time sampling was conducted to determine the percentage of children in the facility who were on prescribed medication at the time of the visit. The name of the drug, dosage, and route were recorded.
- The four facilities housed a total of 96 children. Of these 96 children, 93 were on psychotropic medications.
- The average age across all facilities was 13.6 years.
- The children ranged from age 5 to 18 years.
- In one facility, nearly half of the children were diagnosed with a Bipolar Disorder while in another facility nearly half were diagnosed with an Explosive Disorder.
- Some children, as young as 10 years, were receiving 6 different psychotropic medications.
- In one facility, on the day OLRS selected to review, 3 Emergency Medication Interventions involving a Chemical Restraint were used.
- One child had 13 Chemical Restraints in 48 days.
Chemical Restraints within Facilities
|
Facility 1 |
Facility 2 |
Facility 3 |
Facility 4 |
| Children |
13 |
35 |
8 |
40 |
| Time Frame |
48 days |
48 days |
109 days |
102 days |
| Chemical Restraints |
13 |
16 |
5 |
4 |
Diagnoses within Facilities
|
Facility 1 |
Facility 2 |
Facility 3 |
Facility 4 |
| Number of Children |
13 |
35 |
8 |
40 |
| Bipolar |
6 |
17 |
1 |
0 |
| PTSD |
3 |
4 |
2 |
10 |
| Depression |
7 |
11 |
2 |
3 |
| Mood Disorder |
1 |
10 |
0 |
1 |
| ADHD |
3 |
7 |
5 |
2 |
| Conduct Disorder |
0 |
3 |
2 |
0 |
| Explosive Disorder |
0 |
1 |
0 |
18 |
| Impulse Disorder |
1 |
0 |
0 |
7 |
| Oppositional Defiant |
1 |
1 |
2 |
0 |
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OLRS compiled the data from the site visits and developed child specific profiles. The profiles and other information were given to a consultant for review. Summary information about the profiles:
- Profiles developed for nine children.
- Profiled children ranged in age from 8 years 8 months to almost 18 years old with an average age of 12.4 years.
- Many of the children were in custody of their home county's department of Job and Family Services.
- Almost all had histories of traumatic abuse occurring at an early stage in their development.
- Several had already been in multiple foster home placements.
- Most of the profiled children had long psychiatric histories that dated back to their early childhood and family of origin.
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The nine profiles were forwarded to Ellen L. Bassuk, M.D., Boston, Massachusetts. Dr. Bassuk is the President of The Better Homes Fund and Associate Professor of Psychiatry at Harvard Medical School. In 1997 she was co-editor of "The Practitioner's Guide to Psychoactive Drugs." Dr. Bassuk reviewed the files, and wrote general impressions of the children and specific recommendations for the Mental Health services delivery system in Ohio.
- "The reality of their lives was bleak. Their presentations were characterized by severe behavioral difficulties, multiple symptoms, inadequate coping skills, poor adjustment in school, and compromised interpersonal relationships. Not surprisingly, many were noncompliant with authority figures and sometimes oppositional and defiant. Most important, they generally had inadequate parenting, felt unloved and unwanted, had poor self-concepts, and consequently, suffered from many developmental problems."
- "At the least, it is imperative that providers try to understand the reality of these children's lives and their past experiences as well as the nature of their psychiatric/neurological difficulties. Once providers understand the complexity of their presenting problems and how their behaviors/disorders reflect a response to their circumstances, providers must chart a course that will ultimately help them adjust to their difficult external and internal reality."
- "The challenge for mental health providers is how to help children mature and develop when their life experience has been marked by neglect and abuse, inconsistent or inadequate parenting, unstable living situations, and involvement with complex bureaucratic systems."
- "As part of a comprehensive understanding of these children, providers should gather information about their past experiences in the system, rigorously assess the child, meet with their parents or caretakers, get information from the schools, and then do a complete assessment that will lead to a diagnosis that is based on DSM-IV criteria. In addition to the diagnosis, the child's strengths should be emphasized. This strategy is important since a full assessment will help providers make appropriate choices about medication and treatment approaches."
Additional comment from Dr. Bassuk: "Without a comprehensive understanding of the child that is more than symptom based, the treatment that follows is likely to be inadequate."
Findings and Recommendations
Dr. Bassuk's findings and recommendations are framed by her clinical view of psychiatric care.
Diagnoses
- Diagnoses should include specific symptom profiles as well as inclusion and exclusion criteria (see DSM-IV).
- If there is a change in diagnosis, it should be explained. "Since diagnoses often drive some of the medication/treatment choices, this is an important issue."
- Neurological and medical diagnoses should be included as well.
- Learning challenges should be specified.
- All children with significant developmental problems (e.g., Pervasive Developmental Disorder, PDD) should be evaluated by a neurologist and have an EEG.
Trauma
- Trauma training should be required of all providers working in these settings.
- All service delivery strategies should be trauma-informed.
- Specific trauma treatment should be provided to selected children.
- Because trauma is a major aspect of the unrelenting negative course of many of these children, each child with a trauma history should be assessed by a skilled trauma specialist.
Additional comment from Dr. Bassuk: "Given the pervasive histories of early trauma in these children, it is imperative that the facilities where they are treated are safe and that these children are given the opportunity to form trusting, anchoring relationships with providers who are themselves safe."
Treatment Plans
- The treatment plan should be developed on the basis of the assessment, formulation, diagnoses, and symptom presentation of the child.
- The treatment should pay particular attention to ensuring safety both environmentally and interpersonally.
- Whenever possible, each child should be assigned a provider that has the ability to follow the child over time and serve as a safe, anchoring, containing relationship.
Additional comment from Dr. Bassuk: "Treatment planning flows from a conceptualization of all aspects of the child's problems (e.g., psychosocial, biological) and addresses the question of the reasons for the child's deterioration."
Medication
- Since most children enter the hospital on multiple medications and are doing poorly, the hospitalization provides an opportunity to do a medication washout and discontinue all medications (as indicated). This would give the provider the opportunity to observe the patient without medication, complete a full assessment, and conduct adequate medication trials. This strategy would probably help to minimize polypharmacy.
- Minimize the amount of medication and the use of multiple medications.
- When adding a new medication, conduct a rigorous medication trial with markers that include responsiveness. Dr. Bassuk states, "A critical principle of psychopharmacology is to avoid polypharmacy."
- Document all new medications and changes in dosages; include the patient's response.
- Before beginning a medication, weigh the risk/benefit ratio.
- Since many medications have not been approved for use in children, get adequate informed consent and include this in the chart.
- Any change in medication or medication trial should be documented including the child's response. Adverse reactions should be carefully noted.
Seclusion and Restraint
- Avoid the use of seclusion and restraint.
- A policy for avoiding the use of seclusion/restraint should be developed.
- Avoid stripping children.
Additional comment from Dr. Bassuk: "Seclusion and restraint are almost always harmful to children and especially to those with histories of trauma."
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Furthermore, the use of medications seems to be primarily aimed at behavioral/symptomatic control that at times was clearly necessary. However, the combination of meds (Adderall, Depakote, Risperdol, and Clonidine — other combinations included Serzone, Adderall, Depakote, Lithium, Seroquel, and Clonidine) in a child this age (10) may have had little positive impact, especially given the need for repeated and constant seclusion and restraint (69 restraint episodes). Since this child did not improve, the medication should have been reviewed again and a new strategy developed. Instead, the strategy seemed to be to include a medication from each class of drugs — clear-cut medication trials were not carried out nor was it evident what drugs worked for what symptoms or disorders.
An 8 year old girl was treated at various points with a combination of Adderall, Clonidine, Seroquel, Trazodone, Zoloft, Prozac, Zyprexa, and Remeron. It is unclear about the risks and benefits of the array of medications that have been prescribed for this child. Most of the medications have not been approved for use in children. Furthermore, most of them have serious adverse effects. Since these drugs were not provided sequentially or in careful medication trials, it is difficult to assess the patient's response. Thus, both their short-term and long-term positive and negative effects are unknown.
A 13 year old girl has a history of severe physical abuse by her parents and sexual abuse by family members since the age of 7. The child has complex PTSD with recurrent depression and an eating disorder secondary to her severe abuse history. Stripping the patient, repeated mechanical and then physical restraints, and intramuscular medication indicate a unit that is not trauma sensitive.
The choices of medication do not seem specific for her disorder and instead, seem to have been chosen to contain symptoms. The medications seem to be another form of behavioral control that for a trauma patient could be retraumatizing.
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In an effort to better serve children in facilities throughout Ohio and to follow Dr. Bassuk's recommendations, Ohio Legal Rights Service suggests the following steps be taken:
Statewide
- Establish a statewide Task Force to develop policy guidelines that address (1) psychopharmacological treatment of children and (2) Trauma sensitive programming.
- Develop and establish a Training and Technical Assistance Initiative to improve medication practices and trauma sensitive programming for children. Include web based training and information.
- Train State Department licensure staff to increase the awareness of trauma sensitive programming.
- Sponsor statewide training and disseminate information on medication practices and trauma sensitive programming for children.
Local Providers
- Review appropriate use of medication based on comprehensive, systematic assessments.
- Monitor and track medication patterns and practices through the Quality Improvement mechanism.
- Develop an institutional culture that focuses on developing effective treatment strategies for children who have been victims of trauma.
- Hire or contract trauma specialists to evaluate needs and develop appropriate treatment plans and train staff in trauma sensitive programming.
- Develop guidelines to ensure that all services are trauma-informed.
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The following quote is from J. L. Herman, (1992), from the book "Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror." Basic Books, New York, New York (page 96).
"Repeated trauma in childhood forms and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks of adaptation. She must find a way to preserve a sense of trust of people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness. Unable to care for or protect herself, she must compensate for the failures of adult care and protection with the only means at her disposal, an immature system of psychological defenses."
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This publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov
Ohio Legal Rights Service and this publication are funded in part by grants under the following federal laws:
- Developmental Disabilities Assistance (DD) Act, administered by the Administration for Children and Families;
- Protection and Advocacy for Mentally Ill Individuals Act (PAIMI), administered by the Center for Mental Health Services of the U.S. Department of Human Services; and the
- Rehabilitation Act of 1973 as amended, administered by the Office of Education Services and the Rehabilitation Services Administration of the U.S. Department of Education.
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