Mental Health Consultation within State Child Agency

1. Mental Health Consultation within State Child Agency Patricia K. Leebens, MD Clinical Assistant Professor Yale Child Study Center Former Director of Psychiatry Department of Children & Families State of Connecticut P.K. Leebens, 2012

2. Conflict of Interest None P.K. Leebens, 2012

3. Overview of Presentation • Background Information of Connecticut Department of Children & Families • Behavioral Health Resources within DCF • Evolution of Psychotropic Medication Oversight and Mental Health Consultation with Foster Children • Pros and Cons of Role of Child Psychiatry Chief Within State Child Agency P.K. Leebens, 2012

4. Educational Objectives • Increase awareness of policy issues unique to psychiatric consultation with children in state care • Become familiar with AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline P.K. Leebens, 2012

5. Educational Objectives • Increase understanding of process to establish a centralized psychotropic medication consent process and psychiatric consultation and medication oversight process within a state children’s agency • Increase knowledge of role of child psychiatrist working within a state agency, including pros and cons P.K. Leebens, 2012

6. Connecticut Department of Children & Families (DCF) • Consolidated State Agency for Children’s Services with Four Mandated Areas: Child Welfare, Juvenile Justice, Behavioral Health, Prevention Services • Operated under Federal Consent Decrees (“Juan F” and “Emily J” ) since 1991 after suits by ACLU • 93,000 Hotline calls/year; 6800 substantiated • DCF provides services for 36,000 children/yr • DCF legal guardian for 5000 children/youth P.K. Leebens, 2012

7. Behavioral Health Resources: Important Focus at DCF • Centralized Administration---Directors of Psychiatry (child psychiatrist), Medicine (pediatrician), Behavioral Health (PhD), Licensing of Mental Health Services (LCSW), Substance Abuse (LCSW), Juvenile Services (PhD), Child Welfare (LCSW), Prevention (PhD) • Regional Support---Regional Medical Director (child psychiatrist), LCSW, Mental Health Program Director • Juvenile Services--- Connecticut Juvenile Training School (child psychiatrist and pediatrician full-time) • Psychiatric Hospital---Albert J. Solnit Psychiatric Center (8 child psychiatrists; Yale Child Study Center Training Site) P.K. Leebens, 2012

8. DCF Director of Psychiatry • Not a political appointment -- Manager (DCF MD’s unionized -- Local #1199) • Consultant -- Child Fatality Review; Foster Parent “Exception” Committee; individual case consultation; Training Academy; Medical Review Board & Institutional Review Board; CJTS & Al Solnit Center; inservices with regional nurses; leadership meetings • Mental Health Liaison -- “I’ll do that.” • Oversees---Centralized Medication Consent Unit (CMCU), Psychotropic Medication Advisory Committee (PMAC), and Regional Medical Directors P.K. Leebens, 2012

9. Evolution of Increased Mental Health Consultation and Psychotropic Medication Oversight • October, 1999 -- Dr. Leebens hired as DCF Director of Psychiatry – an “empty” position from 1992 to 1999. Quickly apparent that : • Oversight of mental health needs of children in state care was inadequate. • Psychotropic medication use for children in state care was excessive with little medical oversight. • Medication permission process was lengthy, confusing, and not medically informed. P.K. Leebens, 2012

10. Evolution of Increased Mental Health Consultation and Psychotropic Medication Oversight • 2000 – Statewide Advisory Committee • Psychotropic Medication Advisory Committee (PMAC) meets monthly; minutes public • Volunteer members, public and private sector: APRN’s, child psychiatrists, pediatricians, clinical pharmacists, parents, Medicaid and policy wonks • Headed by DCF Director of Psychiatry • Review “best practices” for evaluation and treatment of foster care children, and psychotropic medication monitoring and consent process P.K. Leebens, 2012

11. Evolution of Increased Mental Health Consultation and Psychotropic Medication Oversight • 2001-2002 DCF Director of Psychiatry participated in the development of AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody. • Main goal of position paper to improve psychiatric consultation and mental health care of children in state care, as well as medication oversight. http://www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf P.K. Leebens, 2012

12. Evolution of Psychotropic Medication Oversight via Consultation with Legislature • 2003 DCF Legislative Liaison contacts Dr. Leebens regarding proposed legislation to appoint a committee of legislators to oversee use of psychotropic medications with DCF children in state custody. (Yikes!) • Dr. Leebens and legislative liaison consulted with legislator to inform her about PMAC’s work and AACAP Guidelines. • Dr. Leebens and legislator propose new statute. P.K. Leebens, 2012

13. Mental Health Consultation with Legislature – Impact on Public Policy • 2004 – Passage of Public Act No. 04-238 • DCF shall within available resources and with the assistance of the University of CT Health Center: • Establish guidelines for the use and management of psychotropic medications with children and youth in the care of DCF, and • Establish and maintain a database to track the use of psychotropic medications with children and youth committed to the care of DCF P.K. Leebens, 2012

14. Evolution of Increased Mental Health Consultation and Psychotropic Medication Oversight • 2005 PMAC drafts practice guidelines, medication monitoring protocol, and medication permission process • DCF Chief of Behavioral Health gets commitment from legislature for $1.2 million to set up psychotropic consultation and oversight process • Request for Proposals process results in 2 unacceptable submissions • Behavioral Health drafts internal proposal P.K. Leebens, 2012

15. Evolution of Increased Mental Health Consultation and Psychotropic Medication Oversight • 2007 – Under DCF Medical Director Janet Williams, statewide implementation of new Centralized Medication Consent Unit (CMCU) • Centralized to handle all state-wide requests by fax, phone, or email; manned by MD’s and APRN’s • Phone consultation often centerpiece of process • Response within 12 to 24 hours • Provider education and child safety paramount • Med link data collected and aggregated P.K. Leebens, 2012

16. DCF Psychotropic Medication Oversight Materials • Available at www.dcf.ct.gov • Psychotropic Medication Treatment Guidelines for children in state care • Psychotropic Medication Protocol for Laboratory Studies and Maximum Dosing • DCF Approved Medication List • DCF 465 – Request for Psychotropic Medication Consent Form . . . And more P.K. Leebens, 2012

17. Additional Helpful Guidelines • A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents found on the AACAP website: www.aacap.org/galleries/PracticeInformation /Psychopharm_in_SOC_Feb_2012.pdf P.K. Leebens, 2012

18. Pros of Work as Child Psychiatrist Within State Agency • Statewide mandate to serve the needs of children increases power of advocacy • Access to expertise within and outside of agency (statewide and nationally) • Work is varied, challenging, with opportunities to have positive impact on many children and families in need • Our training well-suited for complex “family” system issues in state government P.K. Leebens, 2012

19. Cons of Work as Child Psychiatrist Within State Agency • Can be co-opted by political forces which demand your sole allegiance to the state agency rather than to children and families that we serve • Commissioner political appointment – new governor may mean new direction to state agency • Can be professionally “contaminated” by ill-will against state agency • May have budgetary limitations which compromise your effectiveness and/or your professional standards P.K. Leebens, 2012

20. Suggestions for Improved Effectiveness as State Administrator • Keep your eye on the prize: Improved care for children and families that you serve. • Practice transparency in what you do and advocate. • Be collegial and respectful of other disciplines. • Know your field and stay connected to colleagues in other states, the private sector, med schools, and professional societies. • Slow and steady wins the race. P.K. Leebens, 2012

21. Special Thanks: • Lesley Siegel, MD, current DCF Director of Psychiatry • Janet Williams, MD, now deceased, former DCF Director of Psychiatry • AureleKamm, APRN, retired, tireless developer of Central Med Consent Unit • Mike Naylor, MD – mentor and guide P.K. Leebens, 2012

22. Contact Information Patricia K. Leebens, MD Consulting Child and Adolescent Psychiatrist Family & Children’s Aid, Inc. 80 West Street Danbury, CT 06810 patricia.leebens@fcaweb.org 203-748-5689 x104 P.K. Leebens, 2012