AACAP Guidelines and Advocacy for Community-Based Systems of Care

first posted November 28, 2012 updated August 9, 2013
The AACAP is intentionally undermining the FDA 
black box warning on SSRIs:

via American Academy of Child and Adolescent Psychiatry:
Guide for Community Child Serving Agencies on Psychotropic Drugs for Children and Adolescents

"Some psychotropic medications have FDA Black Box Warnings. Medicines with black box warnings are still FDA approved, but their use requires particular attention and caution regarding potentially dangerous or life threatening side effects. Selective Serotonin Reuptake Inhibitors (SSRI’s) carry a black box warning that they may cause suicidal ideation or behavior, although the most recent review of the evidence is not  conclusive that SSRIs increase suicidal behavior. Families should work in consultation with their child's physician or other mental health professional to develop an emergency action plan, called a “safety plan”. This is a planned set of actions for the family, youth and doctor to take if and when the youth has increased suicidal thinking. This should include access to a 24-hour hotline available to deal with crises. AACAP recommends that family members discuss this with the provider if they are uncertain about a black box warning.7"(emphasis mine)

Community-Based Systems of Care

Clinicians who serve children and adolescents with complex mental health needs generally find themselves interfacing with multiple child-serving systems and community programs, including juvenile justice, child welfare, substance abuse, developmental disabilities, and schools. AACAP advocates for the improvement of services in each of the systems to ensure children have access to a full array of prevention, early intervention, and treatment options.

To learn more about AACAP's clinical practice resources for community-based systems of care, click here.

Funding for Community-Based Systems of Care
Through the annual federal appropriations process, AACAP advocates for increased funding for federal agencies and laws that support state and community mental health treatment and services.
AACAP Policy Summary on FY 2013 Appropriations

Foster Care
A December 2011 report from the Government Accountability Office report discusses the use of psychotropic medications with children in foster care. The report highlights AACAP's Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline as the basis to assess states psychotropic drug monitoring programs for children in foster care. As a result, many states are adopting AACAP guidelines as they develop oversight systems.

Government Accountability Office Report:
Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions 

AACAP Position Statement on Oversight of Psychotropic Medication Use 

for Children in State Custody: A Best Principles Guideline 

Background 

Children in state custody (definition of state custody: the state has assumed all parental responsibilities and decision-making for the child) often have biological, psychological, and social risk factors that predispose them to emotional and behavioral disturbances.  These risk factors can include genetic predisposition, in utero exposure to substances of abuse, medical illnesses, cognitive deficits, a history of abuse and neglect, disrupted attachments, and multiple placements.

Resources for assessing and treating these children are often lacking.  Due to multiple placements, medical and psychiatric care is frequently fragmented.  These factors present profound challenges to providing high quality mental health care to this unique population.  Unlike mentally ill children from intact families, these children often have no consistent interested party to provide informed consent for their treatment, to coordinate treatment planning and clinical care, or to provide longitudinal oversight of their treatment.  The
state has a duty to perform this protective role for children in state custody.  However, the state must also take care not to reduce access to needed and appropriate services.

Many children in state custody benefit from psychotropic medications as part of a comprehensive mental health treatment plan. However, as a result of several highly publicized cases of questionable inappropriate prescribing, treating youth in state custody with psychopharmacological agents has come under increasingly intense scrutiny.  Consequently, many states have implemented consent, authorization, and monitoring procedures for the use of psychotropic medications for children in state custody.  These policies often have unintended consequences such as delaying provision of or reducing access to necessary medical care.

Basic Principles 

 The AACAP is the organization representing professionals most skilled in the art and science of child psychopharmacology.  Accordingly, the AACAP has developed the following basic principles regarding the psychiatric and pharmacologic treatment of children in state custody:
1. Every youth in state custody should be screened and monitored for emotional and/or behavioral disorders.  Youth with apparent emotional disturbances should have a comprehensive psychiatric evaluation.  If indicated, a biopsychosocial treatment plan should be developed.
2. Youth in state custody who require mental health services are entitled to continuity of care, effective case management, and longitudinal treatment planning.
3. Youth in state custody should have access to effective psychosocial, psychotherapeutic, and behavioral treatments, and, when indicated, pharmacotherapy.
4. Psychiatric treatment of children and adolescents requires a rational consent procedure. This is a two-staged process involving informed consent provided by a person or agency authorized by the state to act in loco parentis and assent from the youth.
5. Effective medication management requires careful identification of target symptoms at baseline, monitoring response to treatment, and screening for adverse effects.
6. States developing authorization and monitoring procedures for the use of psychotropic medications for youth in state custody should use the principles in this document as a guide and should assure that children and adolescents in state custody get the pharmacological treatment they need in a timely manner.

Best Principles Guideline 

 For states planning to develop programs for monitoring pharmacotherapy for youth in state custody with severe emotional disturbances, the AACAP proposes the following guidelines. Guidelines are categorized into minimal, recommended, and ideal standards.

1. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, in consultation with child and adolescent psychiatrists, should establish policies and procedures to guide the psychotropic medication management of youth in state custody.
States should:
a) Identify the parties empowered to consent for treatment for youth in state custody in a timely fashion [minimal].
b) Establish a mechanism to obtain assent for psychotropic medication management from minors when possible [minimal].
c) Obtain simply written psychoeducational materials and medication information sheets to facilitate the consent process [recommended].
d) Establish training requirements for child welfare, court personnel and/or foster parents to help them become more effective advocates for children and adolescents in their custody [ideal]. This training should include the names and indications for use of commonly prescribed psychotropic medications, monitoring for medication effectiveness and side effects, and maintaining medication logs.

Materials for this training should include a written “Guide to Psychotropic Medications” that includes many of the basic guidelines reviewed in the psychotropic medication training curriculum.

2. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, in consultation with child and adolescent psychiatrist, should design and implement effective oversight procedures that:
a) Establish guidelines for the use of psychotropic medications for youth in state custody [minimal].
b) Establish a program, administered by child and adolescent psychiatrists, to oversee the utilization of medications for youth in state custody [ideal].

This program would: 

i. Establish an advisory committee (composed of agency and community child and adolescent psychiatrists, pediatricians, other mental health providers, consulting clinical pharmacists, family advocates or parents,
and state child advocates) to oversee a medication formulary and provide medication monitoring guidelines to practitioners who treat children in the child welfare system.
ii. Monitor the rate and types of psychotropic medication usage and the rate of adverse reactions among youth in state custody.
iii. Establish a process to review non-standard, unusual, and/or experimental psychiatric interventions with children who are in state custody.
iv. Collect and analyze data and make quarterly reports to the state or county child welfare agency regarding the rates and types of psychotropic medication use.  Make this data available to clinicians in the state to improve the quality of care provided.
c) Maintain an ongoing record of diagnoses, height and weight, allergies, medical history, ongoing medical problem list, psychotropic medications, and adverse medication reactions that are easily available to treating clinicians 24 hours a day [recommended].

3. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should design a consultation program administered by child and adolescent psychiatrists [recommended].

The consultation program:

a) Provides consultation by child and adolescent psychiatrists to the persons or agency that is responsible for consenting for treatment with psychotropic medications.
b) Provides consultations by child and adolescent psychiatrists to, and at the request of, physicians treating this difficult patient population.
c) Conducts face-to-face evaluations of youth by child and adolescent psychiatrists at the request of the child welfare agency, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications when concerns have been raised about the pharmacological regimen.
4. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should create a website to provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psychoeducational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications [ideal]  (emphasis mine)

AACAP "plan" is not in children's best interest

My primary problem with how the Academy is addressing the off label drugging of vulnerable children, is the lack of individual and collective responsibility and the lack of ethical integrity the AACAP demonstrates by failing to hold it's members accountable. There is no acknowledgement, or even a mention of the corrupt psychiatrists, the academic researchers, and "Key Opinion Leaders" whose corrupt work products laid the foundation to market psychiatric diagnoses and teratogenic drugs as effective "medical treatment" for children and adolescents with emotional and behavioral difficulties without evidence the drugs were safe or effective for children and adolescents.

It's as if we are supposed to pretend there is no connection between psychiatrists collaborating with the pharmaceutical industry on research, CME, symposiums and the AACAP's annual convention and the proliferation of off label prescriptions of psychotropic drugs to children? Exaggerated claims about safety, efficacy and effectiveness of psychotropic drugs were made by psychiatrists who were never censured or discredited for making fraudulent claims; nor has any of their corrupt work product been removed from the evidence base, or retracted from professional journals.  No psychiatrist has ever been held accountable for functioning as a marketeer for the pharmaceutical industry. What kind of distorted "medical judgement" causes a professional to use corrupt information to formulate treatment guidelines for using teratogenic drugs on children with emotional and behavioral problems without evidence of safety and effectiveness? It's unethical to recommend the use of dangerous drugs with serious and even fatal risks as a "safe and effective" way to "treat" the emotional and behavioral problems of vulnerable children. 

It is a relatively small number of individual psychiatrists whose unethical behavior propelled this criminal enterprise while the majority were merely complicit in their silence. Unethical  professionals were aided and abetted by their colleagues who continue to refuse to repudiate blatantly unethical conduct and unsafe treatment standards based on marketing strategies.

In all reality, a pharmaceutical marketing agenda permeates psychiatry's consensus based diagnostic criteria and standard treatment proocolss. Many psychiatrists are willfully blind to the iatrogenic injuries they inflict upon patients. Akisthesia, Tardive Dyskinesia, diabetes, obesity, high cholesterol, heart disease, and brain damage are characterized as  "acceptable risks," "tolerable side-effects," or worse, attributed to the psychiatric diagnosis the patient was given, if even recognized at all. The primary beneficiaries of this standard of care are the pharmaceutical companies and their stockholders. It's criminal; it violates the Human Rights of their minor patients and their parents.

Professionals with ethical integrity, critical thinking skills and without conflicts of interest would not be "monitoring" the use of fraudulent consensus based treatment algorithms/marketing agenda, but would rely on ethical medical research data and use ethical medical standards.

Why would any reasonable person believe that a group with a history of dishonest, unethical behavior can critically assess and correct long-term ethical failures? To date, there has not been a good faith effort to stop using corrupt research data, or retract phony 'peer-reviewed' journal articles; let alone stop using stop using unethical standards of care derived from corrupt research, or entirely based on consensus...There is no way the medical malfeasance will be stopped by the same psychiatric professional groups that have implemented, condoned and supported it--- It is insulting all things considered, are we are seriously expected to believe that monitoring the ongoing off label use of dangerous teratogenic drugs on vulnerable children is a good faith effort to first do no harm, much less, in any child's "best interest?!" Forgive me, but since when have we, as a society, entrusted criminals to stop their criminal behaviors and to police themselves?

The AACAP recommends that "State child welfare agencies, the juvenile court, or other state or county agencies...create a website" with links to "helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications" is in effect, recommending that other child serving agencies to do what the AACAP has utterly failed to do. What is truly needed is for these professionals to make actual, meaningful amends for their own egregious ethical failures.

It is time for psychiatrists to demonstrate to the world they are professionals worthy of being granted an opportunity to regain the trust they have shattered. Denying responsibility and failing to be accountable for what individual psychiatrists and professional groups have done to lose the public's trust only further undermines the potential for regaining it! Psychiatric professional groups must find the courage to hold individual psychiatrists who violate ethical research standards and who fail to obtain informed consent for treatment, and use unethical medical practices, accountable; instead of remaining silently complicit. 

I doubt the writers of this Best Principles guideline stopped to consider that one of their suggestions would require that referrals for information to the National Institutes of Mental Health, National Alliance on Mental Illness,  the American Psychiatric Association, and the American Academy of Child and Adolescent Psychiatry would need to stop since all of their websites have biased, inaccurate information about psychiatric diagnoses and psychotropic drugs for the general public.  It would be a meaningful gesture for the AACAP to lead the way and remove the biased and inaccurate information from it's own website replacing it with accurate, and ethical information as this Position Statement and Best Principles Guideline recommends...

Doctors who value integrity and honor their primary ethical duty, i.e. serving the "best interests" of their patients, would not turn a blind eye to unethical conduct; or continue to use standards developed from tainted research.

It takes humility and fortitude to be accountable. Trust is earned; it's not issued with a medical license!

Antipsychotic Medication Use in Medicaid Children and Adolescents: Report and Resource Guide From a 16-State Study 


photo from Just Ducks