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    Child Welfare and Psychotropic Drug Monitoring: The Role for Social Workers

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    Psychotropic treatments for children in foster care can be appropriate, but this form of therapy requires considerable oversight and advocacy from social workers and caregivers. Children do not respond to medications in the same way that an adult may respond because they are constantly growing, their response to medication can be developmentally dependent.

    There is a greater risk for a toxic buildup and significant health events can occur without careful monitoring. Social workers should be aware of prescribing guidelines and steps for advocacy and monitoring, but can often feel that becoming involved is beyond their scope or even that medications should be avoided completely in favor of psychosocial care.

    Caregivers are often desperate to get psychosocial services, but they may lack accessibility and availability leading to the perception of pharmacotherapy as the only option. Unfortunately, this can also lead to higher rates of prescribing in the effort to help a child.

    Although the Trauma-Focused Movement in Child Welfare also seeks a reduction in psychotropic use, it should not be solely aligned with psychosocial services. Children in care are more likely to present with developmental, emotional and behavioral health issues. Responsible and appropriate psychotropic use has a place in caring for them too along with supportive and empathetic caregiving which is always required. Caregivers may need additional training to assist children who have intensive needs.

    Psychosocial therapies should be tried first, whenever possible, and then with medication. Social workers can be instrumental in this process. Social Workers can assess the supports and stability in the home, understanding the recommended guidelines for prescribing, providing comprehensive history to prescribing providers and by monitoring so that medication is prescribed and utilized responsibly. Social workers do not need to be doctors in order to participate in decisions for care. Social workers just need the ability to ask good questions, pay attention and advocate effectively – which is basically routine social work practice.

    Keep in mind there are always exceptions to the rule, and all assessments should be assessed on a case by case basis. Here are some basic guidelines to begin effective advocacy and monitoring:

    1. Provide a comprehensive medical, family and social history, as well as a list of any over the counter or non-psychotropic medications the child may be receiving. Failure to do so could lead to serious adverse effects.
    2. Use tools to gather evidence to assess for trauma or current triggers in the home or school and provide this as well. Is a developmental assessment needed?
    3. Weigh risk versus benefit to the child. All medications have the potential to help, hurt or do nothing at all. If the benefit does not outweigh the risk, then it should not be tried.
    4. Prescribers should also use tools and gather evidence – medical history, academic performance, labs – and make referrals for needed assessments before recommending a treatment path (ex., psychological evaluation, psychosocial therapy is in place) prior to prescribing.
    5. Request that only one medication be added or subtracted at a time. By only making one change at a time, the response can be more easily determined.
    6. Go low and go slow – start with the lowest dose and move up. FDA approved medications are typically the first line of treatment, but well-evidenced medications may also be used. Ask the physician for evidence and rationale. Seek a second opinion if needed.
    7. If it is not working, then it should be discontinued, but never stop a medication without a physician’s direction to do so. Instead return as needed to ensure the physician understands what is happening.
    8. Ensure assent and consent from the child as much as possible and be mindful of legal age of consent laws in your state. By involving a child and caregivers in psychoeducation and treatment options, you will strengthen your alliance, empower the child and increase the likelihood that the child will trust and be willing to seek care in the future should it become necessary.
    9. A child should typically see the prescriber within 2-4 weeks of a new or discontinued medication and every three months, if things are going well.
    10. Every six months to one year, earlier if planned, discuss the reduction and discontinuation of a medication. Every treatment plan designed with a physician should also include a plan to halt a medication in the future and how to do that.

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    Heather Williamson, LMSW, is a clinical specialist for a state agency. She has worked in the private sector as a neuropsychometrician, as well as previous work experience in psychiatric settings. These have provided a unique perspective as a social work practitioner now working in a public agency, particularly with regard to prescription monitoring and oversight.

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