Transcript Clinical Perspective:

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
Conflict of Interest
None
P.K. Leebens, 2012
Overview of Presentation
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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
Educational Objectives
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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
Educational Objectives
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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
Connecticut Department of
Children & Families (DCF)
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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
Behavioral Health Resources:
Important Focus at DCF
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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
DCF Director of Psychiatry
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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
Evolution of Increased Mental Health
Consultation and Psychotropic
Medication Oversight
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October, 1999 -- Dr. Leebens hired as DCF
Director of Psychiatry – an “empty” position
from 1992 to 1999. Quickly apparent that :
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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
Evolution of Increased Mental Health
Consultation and Psychotropic
Medication Oversight
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2000 – Statewide Advisory Committee
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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
Evolution of Increased Mental Health
Consultation and Psychotropic
Medication Oversight
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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/Fos
terCare_BestPrinciples_FINAL.pdf
P.K. Leebens, 2012
Evolution of Psychotropic Medication
Oversight via Consultation
with Legislature
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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
Mental Health Consultation with
Legislature – Impact on Public Policy
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2004 – Passage of Public Act No. 04-238
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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
Evolution of Increased Mental Health
Consultation and Psychotropic
Medication Oversight
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2005 PMAC drafts practice guidelines,
medication monitoring protocol, and
medication permission process
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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
Evolution of Increased Mental Health
Consultation and Psychotropic
Medication Oversight
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2007 – Under DCF Medical Director Janet
Williams, statewide implementation of new
Centralized Medication Consent Unit
(CMCU)
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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
DCF Psychotropic Medication
Oversight Materials
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Available at www.dcf.ct.gov
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Psychotropic Medication Treatment Guidelines
for children in state care
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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
Additional Helpful Guidelines
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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
Pros of Work as Child Psychiatrist
Within State Agency
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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
Cons of Work as Child Psychiatrist
Within State Agency
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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
Suggestions for Improved
Effectiveness as State Administrator
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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
Special Thanks:
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Lesley Siegel, MD, current DCF Director of
Psychiatry
Janet Williams, MD, now deceased, former
DCF Director of Psychiatry
Aurele Kamm, APRN, retired, tireless
developer of Central Med Consent Unit
Mike Naylor, MD – mentor and guide
P.K. Leebens, 2012
Contact Information
Patricia K. Leebens, MD
Consulting Child and Adolescent
Psychiatrist
Family & Children’s Aid, Inc.
80 West Street
Danbury, CT 06810
[email protected]
203-748-5689 x104
P.K. Leebens, 2012