Introduction
Child psychiatrists working in residential treatment settings are serving
the most seriously disturbed children and adolescents in the State of California.
Most of these children have been hospitalized in acute psychiatric facilities
on many occasions with symptoms of depression to the point of suicidal action,
psychosis, and/or behavioral disturbances which are so severe that they
cannot be maintained in home settings. These are the children in past decades
who were maintained in state hospital programs. The Child, Adolescent and
Family Committee of the California Psychiatric Association (CPA) has been
working on the preparation of "Practice Parameters" for Child
Psychiatric Practice in Residential Treatment Centers (RTCs) to address
their needs. Our members are deeply troubled by pressures on quality and
quantity of care which are occasioned by the emergence of "managed
" care and other models which emphasize cost containment at the expense
of the clinical needs of these emotionally disturbed young people.
We hope that these parameters will assist members who work in such settings,
as a clinical instrument, backed by the professional authority of the CPA,
for the establishment of minimally acceptable child/adolescent practices
in residential treatment centers from administrative as well as clinical
perspectives. We recognize that "minimal " may become interpreted
as being "optimal " but given the current state of affairs, that
risk seemed more than offset by the urgent need to establish a clinical
"safety net."
The following are parameters and not meant to supersede clinical judgment
in individual cases. The California Psychiatric Association envisions their
being used as a framework to assure quality child and adolescent psychiatric
practice in residential treatment settings.
Each consultation has its unique features. We urge psychiatrists consulting
to residential treatment facilities to define their roles broadly. Our training
in medicine, child development, psychopathology, psychotherapy, family and
organizational dynamics, and the impact of social and cultural forces on
the child, places us in a position to provide essential input into every
phase of residential treatment. It is not in the best interests of the children
for child psychiatrists to be utilized exclusively as medication managers.
Parameters
1. Every child in a residential treatment setting needs a comprehensive,
written psychiatric evaluation upon admission. This must include a history
and a review of all pertinent past and current records. A mental status
examination is mandatory, as are interviews with collateral parties as deemed
necessary.
Rationale: A complete evaluation on admission saves time and money
by protecting against unnecessary procedures which may have already been
done in other settings. It produces a timely, more accurate treatment
plan based on a fresh professional evaluation integrated with what has been
helpful in the past.
2. The psychiatrist must be in communication with the treatment staff.
There must be provision for face to face communication with an individual
or individuals having direct responsibility for the child's day-to-day management
each time the child is seen.
Rational: Psychiatric consultation is only as good as the accuracy
of the observations communicated. Continuing feedback concerning the effectiveness
of interventions is crucial in modifying and refining treatment.
3. The psychiatrist must have easy access to persons responsible for
the administration, planning, and clinical operations of the treatment center.
It's imperative that a system be in place to communicate to the program
director dangerous or anti-therapeutic practices which may come to the psychiatrist's
attention.
Rationale: The overall treatment philosophy and the implementation
of that philosophy is the responsibility of the administration of each Residential
Treatment Center. The child psychiatrist meeting on a regular basis with
children and staff is in a position based on his/her professional training
to know how that philosophy is being carried out. If things are happening
which are not in the best interest of the children the leadership needs
to know this quickly both to improve the program and to protect against
possible injury.
4. With regard to use and management of psychoactive medication: There
needs to be a physical examination or access to a current report of a physical
examination by another physician. Any child being started on psychotropic
medication needs to be seen as often as necessary to determine effectiveness,
monitor side effects and to adjust dosage levels. Specialized laboratory
testing needs to be done in accordance with accepted standards of care and
in keeping with the clinical judgment of the psychiatrist. Children must
be seen as frequently as necessary according to the medical judgment of
the psychiatrist. A medication record must be established which indicates
name, date, medications ordered, dosage, frequency, number of refills of
medication, allergies, and compliance. Each time the child is seen by the
child psychiatrist, he or she must write a note indicating treatment responses,
compliance, side effects and testing results.
A quiet private place is necessary for psychiatric interviewing.
It is important for the psychiatrist to communicate directly with the
parent or parent surrogate as circumstances will allow. In residential treatment
settings, parents are often not available; however, when they are, access
to the psychiatrist helps with the treatment planning at all levels.
When children are wards and dependents of the Juvenile Court, the court,
through the court officers, must take responsibility for information exchange.
This needs to include treatment summaries, psychological testing, and any
available past information on medication management.
The administration of the residential facility needs to insist on basic
information coming with the child prior to admission. This needs to include
all available psychiatric hospitalization summaries. A referral packet on
a new patient should include all treatment summaries, including reports
from the previous treating psychiatrist. The name and phone number of the
previous treating psychiatrist needs to be included. All psychological and
educational testing should also be in a referral packet. A list of current
psychotropic medications, dosages, length of time on each medication, and
a sufficient supply of medication until the child can be seen is mandatory.
Rationale: There are minimal standards for the management of children
and adolescents on psychotropic medication. These medications must be managed
according to the standards of practice for the community in which the treatment
center is located. The goal is to maximize effectiveness and minimize
risks guided by the medical judgment of the psychiatrist.
5. Communication from referring facilities and communication when a child
is discharged from a residential treatment center is crucial. When a child
comes from a referring facility, there must be reports of significant clinical
interventions which come with the child. In the case of psychiatric hospitalizations,
there needs to be a clinical summary from the treating psychiatrist indicating
the clinical course in the hospital, particularly the results of trials
on different psychotropic medication. When a child is being transferred
from a residential treatment facility to another residential facility, it
is the referring psychiatrist's responsibility to make sure a summary is
included with diagnoses, remaining symptoms, test results, other thoughts
and observations and medication management information.
Rationale: Psychiatrists in all settings need to take joint
responsibility with the facility for communicating with colleagues when
a child or adolescent is transferred. Necessary releases need to be obtained
and information sent as part of on-going responsibility for patient care.
Conclusion
The Child Adolescent and Family Committee of the California Psychiatric
Association is committed to advocating for quality treatment in the face
of tremendous pressure, often blindly applied to the individual psychiatrist
and his or her patient. We need ways to educate health policy leadership
that short-term financial gains lead to long-term losses unless quality
issues are supported. We also need to educate our patients, their parents
and guardians, to advocate for themselves and to demand quality services.
We are hopeful that these parameters will help all of us to better serve
children and families.
References
American Academy of Child & Adolescent Psychiatry: Practice Parameters
for the Psychiatric Assessment of Children and Adolescents, Journal of
the American Academy of Child Adolescent Psychiatry, 34 (10), 1995:
1386-402.
Raider, MC, A Service Delivery-Focused Approach to Evaluation of Group Work
Intervention in Residential Agencies, Residential Treatment for Children
and Youth, 4 (4),1987: 83-92.
Shostak, AL, Group Homes for Teenagers, New York: Human Services Press,
1987.
Grigsby, KR, Consultation with youth shelters, group homes, foster homes,
and Big Brothers/Big Sisters programs, in (ED) Lewes,. M, Child and Adolescent
Psychiatry: A Comprehensive Textbook, Baltimore: Williams and Wilkins,
1991: 909-914.
Walkup,, JT, Clinical decision making in child and adolescent psychopharmacology,
Child and Adolescent Clinics of North America, 4 (1),1995: 23-40.
THESE PARAMETERS WERE DEVELOPED BY THE CHILD, ADOLESCENT AND FAMILY COMMITTEE
OF THE CALIFORNIA PSYCHIATRIC ASSOCIATION (CHAIR, STEWART TEAL, M.D., DAVIS,
CA) AND THE CALIFORNIA ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY (PRESIDENT,
JOSEPH GREENE, M.D., MONTEREY, CA), OCTOBER 1995
California Psychiatric Association
1029 K Street, Suite 28
Sacramento, CA 95814
916-442-5196
This document may be reprinted with permission from the California
Psychiatric Association when published in its entirety.
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