Case Presentation:
You are seeing a 9-year-old male with preexisting ADHD, predominantly Inattentive Presentation who was recently removed from his biological mother and placed in a foster home. He has been stable on Concerta 27mg every morning for the last year with improvement in his symptoms in the school setting. His foster mother reports he has been having some trouble initiating sleep since being placed in the home. They have unsuccessfully tried various sleep hygiene ideas and foster mother is wondering if she can give him melatonin, which she finds helpful for her other foster children.
Most primary care providers are aware of the informed consent process related to prescribing psychotropic medications to patients, which involves a careful discussion about risks, benefits, alternatives, and potential side effects with patients and caregivers. The informed consent process for prescribing psychotropic medications for patients who are in foster care involves a more complex process, and this BHCS newsletter aims to provide background information as well as some practical guidelines for completing the required forms and processes.
Psychotropic medications are defined as those medications prescribed to affect mood or behavior and may include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants. By definition, this would include OTC medications and supplements like diphenhydramine and melatonin. 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. The oversight for prescribing medications intended for psychotropic use takes place through each county’s Juvenile Court. It involves prescribers submitting 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 several page document providing patient data focused on the presenting symptoms, presumptive diagnosis, physical health status, planned medication plan, and other clinical considerations (i.e., 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 child is prescribed a psychotropic medication (i.e., 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. Additionally, emergent applications may be submitted if a youth is already taking psychotropic medications when seeing a new prescriber, and stopping the medication could have negative effects in terms of the child’s emotional and behavioral well-being.
Locally, a team of board-certified child and adolescent psychiatrists (currently through the Vista Hill Foundation Center for Child and Youth Psychiatry clinic) reviews JV applications and informs the Court as to the appropriateness of provider requests. The psychiatric review focuses on assuring that the medication(s) proposed comport with the symptoms and diagnosis(es) reported, and that there are no major side effects or medical risk factors to consider. Reviewers consider the child’s age and developmental status and may want to see that ancillary psychotherapies and school supports (such as having an IEP or 504 Plan) are in place, where relevant. Most applications are approved on review but occasionally, a reviewer may ask for more information or justification for a specific regimen when there are concerns about the appropriateness of a treatment plan. These concerns might be related to number of medications being prescribed, maximum dose being proposed or type of medication being proposed for the target symptoms.
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, the JV-220 form can be completed by an ancillary clinical staff person (e.g., a nurse) but must be reviewed and signed by the prescribing physician. Nurse Practitioners or Physician Assistants submissions should be countersigned by their supervising physicians to ensure timely approval. JV-220 applications have to be renewed every 6 months or for any new medications, but if you are the same prescriber and the medications remain unchanged, a shorter application called the JV-220B can be completed: https://courts.ca.gov/sites/default/files/courts/default/2024-11/jv220b.pdf
A full description of the currently used guidelines for psychopharmacologic practice with children and adolescents under Juvenile Court jurisdiction in California is accessible at the website listed below (California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care 2024 Edition). The document is a good reference guide for dosing, indications, and clinical contraindications in general.
Back to our Case Presentation:
After a thorough history and physical does not reveal anything remarkable, you decide to continue Concerta, which has been helpful for his ADHD symptoms particularly in the school setting. You refer for school accommodations as well as behavioral therapy as ancillary services. The youth also mentions that he has previously found melatonin 3mg helpful for insomnia so you also decide that it would be appropriate to recommend melatonin 3mg in addition to Concerta. Because these are both being used to alter mood or behavior, a JV-220A application is required for both so you submit one with both medications listed on it. You put the maximum dose for Concerta at 54mg in case the dose needs to be adjusted in the future. You decide to submit it on an emergency basis so that he does not have to miss taking Concerta, which has been helpful, while waiting for the JV-220 application to be approved.
Quick Tips:
- Complete a JV-220A for any new patient who is a ward of court and needs psychotropic medications.
- If you add a new psychotropic medication or it has been six months since the last JV-220, complete an updated JV-220A. If you are the same prescriber and medications have not changed, you can complete a JV-220B instead.
References/Resources:
AUTHOR:
Charmi Patel Rao MD, DFAACAP
Medical Director, Vista Hill Foundation
Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry