Today’s e-Weekly provides an overview of the JV-220 process as it applies to a general pediatric primary care practice and provides references to relevant forms and protocols to assist in compliance with informed consent regulations for youth in foster care in San Diego County.
Prescribing psychotropic medications to children and adolescents who are in foster care or in a court authorized group home or residential placement is and has been subject to governmental oversight and regulation in the State of California for many years.
This oversight takes place through each County’s Juvenile Court requiring prescribers to submit applications, known in the trade as “JVs” or “JV-220s”, in order to obtain the Court’s authorization for the prescriptions for psychotropic medications to treat a behavioral health condition.
The JV-220 application itself is a 6 page document providing patient data focused on the presenting symptoms, presumptive diagnosis, physical health status, planned medication plan, and other clinical considerations (labs, past history, prior meds, past and current psychotherapies, family status, trauma exposure and other support services, etc.). This form is sent to the child’s County social worker who forwards it to the Court for further processing. You can access and download the JV-220a form here: https://www.courts.ca.gov/documents/jv220a.pdf
Given the multiple parties with interests when a foster children is prescribed a psychotropic medication (the child, biological parent(s), child protective worker, foster parents, public health nurses, the psychiatrist reviewer, a CASA Worker, lawyers for the child and family and, not the least, the Court itself) JV submissions to initiate a treatment can take up to several weeks to be processed. Because of this timeline, JV-220 applications can be submitted as emergent requests with review and authorization (or, rarely, denial of authorization) occurring after a psychotropic medication is actually prescribed. Emergent applications may be submitted when a delay in initiating treatment to protect the child or others from serious harm or significant suffering.
Locally, a team of psychiatrists reviews JV applications and informs the Court as to the appropriateness of provider requests. Most applications are approved on review but occasionally, a prescriber may be asked for more information or justification for a specific regimen when there are concerns about the appropriateness of a treatment plan.
The psychiatric review is conducted by the board-certified child and adolescent psychiatrists at the Juvenile Court Clinic who focus on assuring that the medication(s) proposed comport with the symptoms and diagnosis(es) reported, and that there are no side effects or medical risk factors not being appropriately considered. Reviewers consider, the child’s age, developmental status and may want to see that ancillary psychotherapies and supports (such as having an IEP or 504 Plan) are in place, where relevant.
For most primary care providers, providing care for a foster child with a commonplace behavioral health condition, such as ADHD or uncomplicated Anxiety or Depression, the JV-220 application is an uncomplicated, albeit somewhat time-intensive process. Appropriate medication regimens are typically approved and it is only with more complex clinical situations that the court will request either further information or other measures. Pragmatically, it should be noted that the JV-220 form can be completed by an ancillary clinical staff person (e.g., a nurse) but must be signed by the prescribing physician. Nurse Practitioners or Physician Assistants submissions should be countersigned by their supervising physicians.
Child psychiatrists working with foster children and adolescents with more complex and severe illness, may have to justify poly-pharmacy, dosing outside of FDA approved guidelines, concerns about side, or objection by a biological parent, among other issues.
A full description of the currently used guidelines for psychopharmacolgic practice with children and adolescents under Juvenile Court jurisdiction in California is accessible at the website listed below. The document is a good reference guide for dosing, indications, and clinical contraindications in general. If you prescribe or want to learn how to prescribe it will be a go-to resource in the future that will amply reward your efforts in saving the file on your laptop.
http://file.lacounty.gov/SDSInter/dmh/1071988_Paremeters3.8ForUseOfPsychotropicMedicationInChildrenAndAdolescents.pdf (July 15, 2020)
SmartCare will be working with the Juvenile Court Clinic to schedule a televideo training session for interested pediatric providers in the coming months. In the interim, if you have questions or wish to learn more about the JV-220 process, feel free to contact the Juvenile Court Clinic’s Program Manager, Maria Sanchez at 858 571-1964
- Parameters 3.8 for Use of Psychotropic Medication in Children and Adolescents, July 15, 2020
- Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents, American Academy of Child & Adolescent Psychiatry, 2012. https://www.aacap.org/App_Themes/AACAP/docs/press/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and_adolescents_2012.pdf
- JV 220 Protocols and Forms
- JV 217 Guide to Psychotropic Medication Forms & Protocol: https://www.courts.ca.gov/documents/jv217info.pdf
- JV-220 Cover page completed by County Social Worker or Probation Officer
- JV-220a Prescriber Submission for a new medication trial
- JV-220b Prescriber re-Submission to continue a current med trial (@ 6 month intervals)