asthma medications are safe for children

*music playing >> hi everyone. and thank youfor joining us today during ourfirst-ever live broadcast of ksoc-tv, which stands forknowledge network for systems ofcare. i'm gary blau, chief of the child, adolescent andfamily branch at samhsa's cewntr for mental health services.today, we're going to focus ourfirst ksoc-tv discussion on psychotropic medication and itsimpact on the mental health ofchildren, youth and families. i'd like to introduceour distinguished panel of guess. first, welcome to welcome jane walker familymember and social worker from temaryland coalition of families for children'smental health. dr. al from thestate of maryland, department of

health and mental hygiene. andkristen kroeger ptakowski fromthe american academy of child and adolescentpsychiatry. lets check in onwhat's happening with the systems of care. stephanie dukeis at our news desk with thelatest headlines stephanie. >> thanks gary and helloeveryone. let's start with astory from our system of care community in guam. governoreddie baza calvo has taken aleadership role in addressing children's mental health issuesin guam. he created thegovernor's executive committee for systems of care tohelp implement systems of careexpansion efforts throughout the u.s. tort hesigned an executive order lastnovember forming the committee the committee which includesrepresentatives from the gustchild servicing agencies has

met three times since to addressissues related to best practice,efficiency and funding. lauren grimes of on our ownwill receive the young adultleadership award at samhsa's voice awards in hollywood laterin september. samhsa and itsprogram partners will honor consumer and peer leaders inrecovery from mental andsubstance use disorders. theawards also recognize television andfilm professionals who educatethe public about the real experiences of people livingwith behavioral health problems.nominated productions include feature films silverlinings playbook and the perks fbeing a wallflower along with television shows such aselementary, the newsroom call mecrazy and homeland and perception. visit the voiceawards website on september 25thand watch the live

webcast starting at 6:00 p.m.pacific time. the entertainmentcommunity has certainly experienced some difficultlosses this year including therecent suicide by the african-american television starlee thompson young. the augustissue ebony magazine addresses this traditionallytaboo issue in "black suicide:when prayer is not enough." according to the article suicideis the third leading cause ofdeath among african-american communitiesacross the country haveparticipated including faces ofmiami and systems of care.communities can still log in tothe summer of learning virtual campus to explore learningopportunities and engage withother systems of care. finally the wall street journal reportsthat federal health officialshave launched a probe into

the is you of antipsychoticdrugs on children in the medicadsystem, as concerns grow that medications are beingprescribed too often to treatbehavioral problems in the very young the inspector general'soffice in the department ofhealth and human services began a review of antipsychotic druguse by medicaid recipients age 7and under. the story reports that in 2008 medicaidspent 3.6 billion onantipsychotic medications up frm1.65 billion in 1999. the number ofpeople under age 20 receivingmedicaid-funded prescriptions for antipsychoticdrugs tripled between 1999 and2008, according to an analysis by mathematica and anew study conducted ativan vanreveals that an anti sigh cot medications can triple achild's risk of developing typeii diabetes within the

first year of usage. details ofthis study can be found in theaugust 21st issue of jama psychiatry. gary. >> thanks stephanie. before weget started, i want to let all four viewers know that we'll be taking questions fromyou throughout the show. ifyou'd like to ask a question, you can do it three ways:submit a question directlythrough the site airing thisprogram . where you'll find that buttondepends on whether you'rewatching us using mediasite or silverlight. if you're usingmediasite, click on the roundbubble in the upper left corner above the video. ifyou're using silverlight, clickon the round bubble in the lower right corner next to thevolume control. after you clickon the button a dialogue

box will come up, type in yourquestion and send it to us. youmay also call us toll free at 1-800-527-1401. some of youwill be on the air with us live.or, ask a question through twitter by using thehashtag ksoc. okay. let's firttalk about that wall street journal article stephaniementioned we know that fda hasbegun looking into medication ue by children through medicaid.what does this signal about theactual significant increase in spending for antipsychoticmedications that has occurredbetween 1999 and today related to this. let me start with dr.zachel. >> thanks. i'm a childpsychiatrist and i am the mentalhealth director in state of maryland mental hygieneadministration. so i think iwould come at an answer orbeginning

answer to what's a very complexquestion and complex issue fromboth of those perspectives. i knowmedications. i use medicationsin a small private practice buti'm very conservative and careful intheir use. but i also take myrole as a children's mental health director for thestate working in collaborationwith our systems of care partners in the state childwelfare juvenile justice and knwthat many children in those agencies who receive medicaidare frequently prescribed thesemedications, antipsychotic medications and others, and weknow that the rate, as you'vesaid from this study is increasing. so i guess complexquestion, complex the answers towhat might be going on, i think, first of all, thesemedications work. so i thinkthey're relatively easy to use

and prescribe. so i thinksometimes when a child is comingfor an attempt to someone, a physician, a prescriber, withsome probably very seriousbehavioral issues, and other things may or may not have beentried that are non-medicationoriented, sometimes a prescriber will use thesemedicines, because it's a crisissituation, a family, an agency, a foster family, is trying tomanage a child's behavior andthese medicines do work to settle those behaviors.however, use of these medicatiosneeds to be done as part of a whole plan of care development,a whole good assessment of thechild's needs to try to figure out why a child'sbehavior is more difficult. notjust quickly going towards the medication but trying to sortout all the things that areinvolved in causing the

behavior. and then trying tomake sure that other services aeavailable to the child which may or may not behappening. so sometimes in someareas in the rural areas where other services aren't available,medication might be used morequickly because other services aren't available. so ithink it's important to reallylook at, first of all, what's going on with the childand really trying to come outwith the ideal plan of care that may include medication ifthere's an appropriate indicatinfor that. these medicines are very sort of bigon medicines, the anti psychotisaffect endocrine systems and blood sugar to increase andcholesterol to increase andinvocational muscle movements that may not go away so they'revery serious side effects. so nmaryland we've taken on

with our colleagues in themedicaid administration a reviewof the prescription of anti-psychotics for all children17 and under and there are childpsychiatrists and pharmacists from our pharmacyschool of psychiatry in marylandwho look at each prescription to look at the careof child looking at otherservices being offered, whether the right levels are being donewhether there's a good indicatinfor this medicine in an attempt to get to what's reallythe prescribing practice forthese medicines in maryland. it's a complex question and ithink maybe others have some -- >> let me ask this because ithink you pointed out there's abalance. these medicines work. at the same time youmentioned some of the issuesregarding side effects. and the

concerns that people have that ithink are very real. i'll turnto ms. walker as sort of representing and being involvedwith families, particularly herein maryland and also across the country about whatare some of the biggest concernsthat you've heard in terms of families related to the useof these medications. >> it's a huge issue forfamilies. very often, as alindicated, the need for these medications are precipitated byaggressive behavior, behaviorthat may cause safety issues for the families for the child,sometimes in school and yetfamilies are still concerned about with these groups. we didfocus groups with families aroudmaryland. it was interesting the foe purpose ofour focus group was not to talkabout anti psycho trope

pick drugs but for the child'smental health. what spilled outfrom families everywhere and in every corner of the stateand urban and rural areas and wsthe concerns they had about weight gain for theirchildren, which could precipitaeother medical issues. they talked about sleep issues,either lack of sleep, notsleeping, roaming the house allnight or the converse of that withthem feeling drugged all day whnthey're trying to be in school. they talked about theirconcerns about multiplemedications being used at the same time. and probablythe one that's surprised us themost but was expressed over and over again was the lackof coordination between thepsychiatric prescriber and the primary care doctor that thechild is seeing on a regularbasis and the families would

put in the role of being thecommunicator of carrying therecords, transmitting the information. and that was alsoa major concern that familiesraised. >> and what would you say orsuggest to a family memberperhaps that's put into that roe because obviously that couldbecome pretty concerning. >> it's very concerned. and iwould say that often whenfamilies are going to a doctor, they are feeling very much thatthe doctor is the authority, theexpert. and i know myself when i was a youngmother, i would go and feel veryintimidated about asking questions. and i think familieshave to ask questions becauseit's our child's welfare. it's their health as well astheir mental health. so weencourage families to come

prepared. very often on thespot, very difficult to think ofthose questions. so planning ahead of time and thenmonitoring when their child is na new medication, looking for patterns of arethere certain times of day whentheir behavior may be worse than other times. are youseeing these side effects atcertain times, and then writingit down. so you've got thatrecord. so for your next visit,you can be very much a participant in your child'streatment. >> so you talk about planningahead. sort of like taking notecards. >> absolutely. >> here they give us, i evenhave a pad that sort of promptsme for things. so

in this case families couldbring their own pads and figurethat out. i like that a lot. thank you. let me turn a littlebit to ms. kristen kroegerptakowski and when jane talked about some of the concerns thatthe families had, one was theidea of taking multiple medications. and i know thatthe american academy has beeninterested and concerned about these issues, and also offeringa balanced approach about what'simportant here and that there have been essentially someguidelines or things that werediscussed through the academy. i'm wondering if youcould share that with ourviewers. >> first and foremost this is acomplex issue like al had said.and i think that families, if they have concernsabout options of a childpsychiatrist or another physicin

might lay out they shouldclearly seek another opinion andi think they need to feel comfortable doing that as well.the academy of child psychiatritunderstands that medication is a part of anoverall treatment plan as al hassaid and there are instances where children might havemultiple diagnoses where theyneed to be put on multiple medications, i.e., polypharmacy. those childrenobviously need to be monitored consistently. we have at theacademy we have numerous practieparameters and these are guidelines for all clinicians ontreating children withmedications, specific treatment guidelines for differentdiagnoses, whether it be bipola,adhd, schizophrenia, so on. the academy also has resourcesfor parents. we have what wecall parents med guides that

it's on a link to our websitecalled parents med guide.org.and these are guidelines for parents to understand the use ofmedications specific disordersthat the academy developed with the american psychiatricassociation and the americanacademy of pediatrics and other organizations advocacyorganizations. and we haveparent resource centers that are helpful to parents with regardsto understanding specificdiagnoses, and we also have what's called facts forfamilies, we have probably over80 facts for families onquestions that a parent should ask apsychiatrist before putting yourchild on medications, and we have a wonderful new part ofour website, thanks to thesupport of cewnter for mental health services foryouth and we have information onour website developed by

youth for youth. we have anumber of resources as well asvideos of youth talking about their experiences with themental health system as well asbeing treated with medication as well as their resiliencythrough treatment. >> in fact, small plug here,that's the young peoplethemselves developed a tip sheetfor psychiatrists specifically abouthow to better communicate withother young people. so it's sort of a top ten list ofthings that whatever childpsychiatrist should know about talking to young people. sothat website is a fountain ofinformation. as one of the other things, and i thinkhearing from families about someof their concerns, the other thing that we heard verydefinitively had to do with boththe short and long-term side

effects. and i'm wondering fromyou al if you could share yourthoughts about those side effects and what folks should belooking for and how to addressthis, again, complex issue and then if it were certainlysomething that we were looking omedicate for a child, that we would want to be worriedabout. >> well, gary, and i thinklistening to kristen and janeherself, we've worked together in our roles in the state formany years i've always found thtfor the many years i've been in practice and it's beentrue throughout the state,listening to families and youth is first and foremost. ifyou're going to use medicationsas part of the plan of care. families know their childrenbest, just as jane said.children know themselves very,very

well. like you said, gary, ithink we need to teach our youngpeople to talk with us as child psychiatrists and othermental health professionals,because a young person, a family, they know what they'reexperiencing, they know what itfeels like and i think they very much need to be engaged andlistened to as you evaluate,first of all, the decision to use a medication but also interms of side effects. and i akyoung people in my practice and their families avery simple question when istarted a medication as kristen said you want to do carefulmonitoring all through theprocess of prescribing. i ask achild so how do you feel on this medicine. asking thatsimple question a child says i'mokay, if they say okay it might be terms of side effectsbut they might say my stomachaches or i have a headache

and they give you an opening tostart to explore what might begoing on in terms of potential side effects. many ofthe medications don't haveserious side effects other than the antipsychoticmedications. those are the onesthat affect endocrine systems, weight gain probablythe most serious side effects.other medications, the medicines for attention deficitdisorder depression and anxietyhave very few and not life -threatening or serious in thesense of affecting other organsystems, kinds of side effects. but the antipsychoticmedications and some of theso-called mood stabilizers they can affect other organsystems and sometimes you needlaboratory work and other things a physician would need tolook for those that would besilent sort of changes. but

i think really things like how achild feels is the way to gobecause a parent knows their child, a child knows themselvesand they will kind of tell youwhat might be happening in terms of side effects and youtry to address it. >> so we're learning a lottoday about the balance and whatpeople need to do. i would share with folks that not toforget if you would like to askaquestion, you submit one through the website. you canask via twitter by using thehashtag ksoc or call 1-800-527-1401. now i'd like toshow you an interview segment bysharon spencer from the national federation of familiesfor children's mental health.she talks about psycho trope pick drugs let's watch.my son was given a whole host ofpsychotropic medications

there's not been enough researchon these medications on whatimpact they have on children. okay. so a lot ofthese clinical trials have beendone on adults. they haven't been done on aneight-year-old. and so puttingkids on psycho tropic medicatios long-term, if you start ateight, you may take it untilyou're 18. and we don't have ay data, research, definitiveanswer in what impact long-termthese medications have on children. so i think for one weneed to deal with that issue.and i think the second thing is that parents need a wayto be more educated aroundmedications. what would be the long-term effect, ismedication the only way to go?there are some other resources, there are othertreatments, there are othertherapeutic interventions that

families can choose. >> sandra, like many familymembers, is worried about thelong-term effects of psycho tropic medication on children,along with the lack of testingand clinical trials. i guess one of the big questionsfor me is in terms of as we'reinvolving families and young people in the treatmentplan, that's one piece. but italso sounds like we need better data, more empiricalinformation about how medicationworks and what the best uses of medication. let me ask thisquestion of kristen about what sacap doing or what have you seen as your roleat acap in government andlegislative affairs to look at strategies for sort ofbroadening the research questio?

>> so one of the things theacademy does as well as the whoemental health community is to encourage increased fundingfor research into childpsychiatric illnesses, first and foremost. we also haveadvocated for policies that woudprovide what we call incentives to pharmaceutical companies todo some research in pediatricmental health disorders, and we've been successful in that.there are some incentives forpharmaceutical companies to do this and as a consequencethey receive marketingexclusivity for their medicationafter the fact that it's approved byfda. so there are policies inplace to do this, moving forward, but we still need moregovernment funding into pediatrcmental health research. >> so we have this idea of thebroad picture where we're fundigand providing these

ideas and we sort of go down tothe individual level where peopemake decisions every day about what they're going to dofor their own children and janeii know you and i have talked about this before aboutyour own personal story relatedto the use of medications, and i wonder if you might shareit with our audience a little btabout decision-making. >> i'd be happy to. it's avery difficult decision. mydaughter, while she's an adult, has developmental disabilities.so we're still making decisionson her behalf. but she started taking medications at avery young age, and i couldn'tagree more with sandra's comment about the lack ofresearch on children. i knowthat's a very, very tricky issue about doing clinical researchbut as al said earlier on, thesemedications do work. we

had a situation this past yearwhere we had five crises. and sit better that my daughter the police were calledfive times she was hand cuffedand taken off to the police station where she stayed andthen we made a decision inconsultation with thepsychiatrist to put her on antipsychoticmedications. since that timewe've not had a single incident of aggression. and yet it wasnot an easy decision to make. idon't want any family who might be listening to thisprogram to feel guilty if theymake that decision. but i do want them to feel that they havea right and the responsibility oask the questions and get the answers. >> thank you, jane, and i thinkthat's such an important messageand a lesson, and one

of the other things that i thinkyou're talking about and sandrawas talking about as part of this discussion really wasthat the research on medicationfor various age groups is still limited. and so al one ofthe things that we're wonderingabout is your thought about doctors who prescribeparticularly the antipsychoticsthat you just talked about with the side effects and an offlabel that's sort of the termthat's used when folks are using the medication notnecessarily completely approved.and the children, however it is, why you had to treatchildren with forms of violenceand aggressive behavior. wondering if you can talk alittle bit about the idea of offlabel use. >> and gary it's a greatquestion, because i think manyfamilies will come and say, wel,

what does this fda approval,federal drug administrationapproval. and it's a fairly narrow approval it certainlyspeaks to safety but the researhto get fda approval is based on an age group and acertain diagnosis and a certainrange of medication dosage. so it's a fairly narrowapproval. so if you are withinthose guidelines, it's the right age group. it's the rightdiagnosis. you're using theright amount of medicine. youcan feel there's a little extrasafety and research behind yourprescription within those guidelines. however, it's notillegal. it's not bad toprescribe what's called off-labl which means using a medicationoutside of those fairly narrowparameters that the fda approves. and sometimes yousort of have to do that. theresanother concept called

standard of care, which is sortof based on sort of the standardof practice in various fields of medicine but in childpsychiatry oftentimes an offlabel use of the medicine has been supported by someresearch that hasn't gone throuhfda approval but research out of our medical centersaround the country that showedthat you can use the medication safely at least over a period oftime for a child of a certain aefor a certain indication, certain diagnosis.so that could be considered offlabel. but yet still okay in terms of basic standard ofcare. now, i think if you wantdto be very, very careful and i think these are the kindsof discussions that we would haewith the family member, hey, this is what fda says, thisis what some of the researchsays, there have been an

article here or there that saysthis might work for a child undrthis circumstance, but for me as i'm listening to ourconversation today, it all comesdown to, again, connecting with a child and family andreally knowing that child andfamily if you're the prescriber, trying other things first if youcan. if it's not a crisissituation where we're responding to the crisis quicklyand look at what's going on withthe child. what are the various biological things goingon, the diagnoses. the childmight not be able to learn in school because someone'smissed a learning disability andthat's why the child is being difficult in the classroom andthat's never been picked up on.other physical health issues as jane said.collaborating really criticalwith the child's pediatrician.

looking at all these otherpossibilities that go into why achild's behavior is the way it is. a family is coming toyou to try to help with. i thikthose are the intervenings that i think you could bethinking about, good assessmentand simple therapy, traditional child psychiatrist. i still dotherapy. if i'm going to usemedicine it's sort active worked into working with thefamily, doing individual therap. >> it's not just about themedication issues for you. >> definitely not. and whenyou get to know a child andfamily you come to sometimes a point and gee, maybe we need tothink about biologicalintervention so you can lower teb iological push that some ofthese illnesses, difficultieshave, obsessive compulsive

disorders, depression, bipolar,schizophrenia, they havebiological underpinnings. colleagues at nih are seeing howthey're related and medicines cnaffect and lower the pressure of the biology so thatmaybe the other interventions cnwork. so it's a neither nor. it's like everythingtogether in my mind is the idealway to approach these questions, whether you're usingantipsychotics or othermedications, and i think you've got to really think about thatall but sometimes the biology adthe person needs some temporary help so a child can bemore open to other interventionsand learn other techniques to help them managewhat is going on and then you cntaper off the medicine. >> let me add to that. i liketo say al is a unique childpsychiatrist but he's not.

all child psychiatrists go intothis field to treat kids and maethem feel better. i think that's so important tosay and there's so many otherfactors that weigh into this. there's payment factors,payors being willing to pay forthe psychosocial treatment and lack of mental healthproviders overall specificallythe child and adolescent psychiatrists trained to treatthese kids and trained to treatthese kids and prescribe the medications whenappropriate. there's a lack ofconsistency of using professionl medical guidelines in thetreatment of children's mentalhealth disorders as well. so there's so many factors we'vementioned today so the issue ofallowing an appropriate amount of time for acomprehensive diagnosis as wellas not allowing for 15-minutevisits

for medical checks. there's somuch more involved in that ininterviewing a child and there's so much more al is aunique child psychiatrist of hisown but there's many unique psychiatrists out there becausethey go into the professionbecause they want to do the best for kids. >> i think that's our goal hereat ksoc tv to identify what ourbest practice is and look at strategies to implement themacross the country. and i thinkthat is really critical. right now i'd like to play ashort interview segment with laykendrick burke. lacy is a graduate of our foster caresystem who now runs a mentalhealth professional system calld youth m.o.v.e. national.motivating others through thevoice of experience. so these

young people have been throughthe system and know a little bitwhat it's like to experience it from that side.and lacy talks about how youngpeople should be involved in the consultation process when itcomes to prescribing medication. >> when consideringpsychotropic medications, and aytype of mental health service delivery with young people youngpeople should be consulted inthat process. they should be informed as to whatthe psychiatrist or doctors seethe symptoms are. why he thinks that medication would beuseful, what the potential sideeffects are, what's the name of it, and most youngpeople say i'm on five pills. itake these blue ones in the morning and the green ones inthe afternoon and i don't knowwhy. that's a huge, huge

traf vest tiz for young people.we need to be educated andinformed we need to be consulted. >> lacy makes a critical pointhow and when should we involveyouth about decisions regarding psycho tropictreatment options. this is thewhole premise of the problem.let me start with jane. >> the short answer as soon aspossible. no question about it.i sometimes have looked at my daughter over all theseyears and thought to myself ican't comprehend what she may be feeling like inside. andi assert al's comment aboutasking the children how they feel i have seen my daughterwhether she was shaking tremor omuch from medication, that

she had difficulty feedingherself. that broke my heart bti can't imagine what that felt like for her. and sohearing her voice in that and wehad to wait another month for the doctor's appointment, eventhough we had called and this iswhat's going on, and al's comment about doing bestpractices and all that is one ithink we would all get behind te practicality of it is often itcan't work out that way. youhave to wait for appointments and such. so involving youth inthat process is absolutelyparamount, as soon as possible. i thinkthere's another reason thatthat's important to do and that's because i think we knowthat when youth turn 18, theyvery often take themselves off medications. so unless theyfully understand why they'retaking it, what it is, and

what they're getting from it, ithink that's going to continue ohelp. we also see that in the mid-20s young may thenreturn to therapy or return totaking medications. but it's absolutely critical. >> i would just add to whatjane is saying. i don't think achild is almost ever too young to participate in thedecision around medicines, thefamilies are the ones who make the ultimate decision, butunderstand that this is amedicine and in sort of simpleterms based on a child's developmentalage or where they are to helpthem understand, i don't know why they're takingthe medicine. so even aseven-year-old or six-year-old even then it's kind of young touse medicines, but you mightconsider as mentioned

attention deficit disorder for achild six to seven, things thatare important to know what the medicine some for, whatpotential side effects to workout and certainly for old er children. they need to beengaged i think teenagers andyoung people need to be engaged in the decision so theycan feel they're participatetorso they can understand why it's being used and they can buyinto it. >> both you bring up aimportant point that even theidea that young children shouldbe brought into the process to helpthem understand what the medicieis for. as lacy saidty take the blue ones in themorning, green ones at night.the answer is why are we taking them. one of the issues that'scome out, and i think that ithink whether it's the

newspaper articles or otherstudies or investigations,whether it's really about young children being put on some ofthese very serious medicationsand being prescribed perhaps multiple serious medications.in fact, some of our dataindicates that right now abillfy is actually the nation's numberone prescription drug by salesacross the country. and that medication, interestingenough, has been approved by thefda for treating ir ritability to treat aukchildren, as early as six yearsold. and respiradol is for treating conditions in childrenas young as five years old. andi think with this level of controversy, i'm wondering ifthe american academy, forexample, kristen, has thought about this and has any sort ofideas or combines related toproviding these kinds of

medications to very youngchildren. >> first and foremost providingmedication to very young childrnis something that really needs to be consideredagainst of course by the parentand age appropriated by the child. but in discussions withthe child psychiatrist. i thinkit needs to be prescribed by someone who is clinicallytrained to treat these children,not just children, but children this young. i thinkthat's something that the acadeyfully supports and the increase of these medications,the use of these medicationsalthough they're fda approved needs to be understood thesekids are young and they need tounderstand the lack of understanding of the long-termconsequences to thesemedications.

>> i also know that there'ssomewhat of a controversial issewhere what we've seen in this country is the use ofmedications, particularly infaster children. and that there are higher rates of youthof utilization of prescriptionmedication in foster children than there are in thegeneral population. now, somesay obviously that's because children in foster care may bemore vulnerable, more traumaexperiences. others are saying that it's really been aeasy way out for providers tosay, you know, we'll just prescribe medication to try tokeep children from beingaggressive or trying these other alternatives. al, i'm sure inyour practice you've seen some fthese types of discussions, could you sort ofenlighten us a little bit aboutthis.

>> again, in my role aschildren's mental health directrfor maryland i work closely with our department of resourcesand the system both on this isse-- both our city has a medical monitoring system forchildren coming into the fostercare system to look at all t he physical health needs andchild psychiatrists and mentalhealth workers part of monitoring the team to look atneeds of children in thehealthcare foster care system so hopefully these children can befound for them and if they haveaneed based on assessment when they come into the systemthese four medications are used.but that's maybe sort of an ideal model, model stateshave been doing that. i thinkmost states are approaching. and i think what you said, gary,both are possibilities thatchildren coming into the

foster care system obviouslyhave been removed from theirfamilies and have experienced trauma in their life. it has tobe noted and identified andsupported and helped so maybe these children are more reactiveor having more difficultiesbecause of life events that they've had to experience, onthe other hand if a child'splacement with a foster care family is not ready, if a childis in need of more placementsbecause of their behavior, i think sometimes there'spressure on subscribers so achild doesn't lose that placemet so it has negative implicationsin terms of cash. andcomplications but what we'retrying to do in maryland is have somestability. the question issupporting the families and working with the biologicalfamily and consequently assessigthe needs of the person,

talking to the young personabout what they're healing in tehopes we don't go right to the medication, the monitoringof antipsychotics all the fostercare children in the state have medicaid for each child tobe looked at to see if they'represcribed one of these medications that stateguidelines are being followed adother treatment is offered, and hopefully this indications areappropriate. so we are trying oin a cool year way it's not a gotcha system, but it'smore to more doctor to doctor,why did you prescribe this medication, what are the needsto the child, are you findingaccess to these other services, would that help youmaybe not use the medicine lowerthe dose but try to develop that kind of dialogue betweenthe prescriber and ourcolleagues.

>> by doing that you'veimproved quality and i think youtalked about and we sorted of shared about where this ideawhere various children not justfoster children, but many children in our country haveexperienced different kinds ofadverse experiments and traumas and the bass decadethere's been a trauma approach otreatment. let's talk about this a a little minute as itrelates to medication. i thinkone of the questions would be are there other types oftherapies and maybe jane, thatyour family went through, other than this medication whatcould work, other than themedication, whether it's trauma related or other ideas fortreatment. do you have anythoughts about thesealternatives? >> yes, we're very involvedwith wrap around, which is veryvariable, not necessary to

implement in all instances butas an additional support alongwith medication or if medication is deemed not to beneeded. and 㺠that's what ittakes moving in with that family and wrapping servicesaround that child and family toboth teach them the skills, go through different types oftherapy that might be appropriaeand oftentimes if they're doing this it could betherapeutic horseback riding orart therapy things that touch te child in their strength areas.additionally, our organization salso working with the university of maryland school ofmedicine on a study childrenunder ten prescribed anti psychotics are paired with afamily navigator, a family membrwho has been trained to talk with them on the phone andwho talks to them about whatcommunity resources are there

as well as also if they haveconcerns with their child'sdedication, the side effects. encourages families to get backright away. >> it's interesting to talkabout a family navigator, youtalked about wraparound bringing all these ideas andservices and bring them togetherand you say wrap around child and family, which can bean alternative to the medicatio,or had jumped to it. i wonder from the standards pointof view, when you talk aboutchild and excellent psychiatry, you're talking aboutal being unique in many ways, ntcompletely in terms of the guideline, how doespsychiatry connect with thesealternatives and help create ths wraparound approach?

>> the academy fully supportsthe wraparound approach inlooking to the child in the schools and looking at anythinghaving to do with the childwelfare system. wrapping it around child in the communitiesit's the best. and having thephysician work with whether it's the therapist, whether it'sthe school. obviously theteacher and what any other parents, aunts, uncles, anybodywho the parent chooses to bringto the table and meet with them together and have teammeetings with the childpsychiatrist, everybody be a pat of the team and the youth, ofcourse, having the youthempowerment and youth voice is absolutely important. >> that sounds great. but ifi'm in a system of care inmontana, i said that's wonderful

i don't have the resourcesavailable w we were talking abotthis issue. and there's issues with child psychiatriststo do just that. so it's in thecontext of reimbursement issues, within the context ofaccessibility. how do wecontinue to work on these kindsof best practices where awraparound team actually getsconsultation and involvement bythe child psychiatrist. >> that's right. and it's partof the team and medicaltherapists who are a part of tht child's life. and there are anumber of points popping aroundthe country that are working with pediatricianseducating them when they seemental health issues, they're te first they'll go to. it's soimportant to them to be educatedabout mental healt

issues. there are programsaround the country that linkchild psychiatrists up with physicians for consultationbasis. sometimes they see thechild, sometimes they don't. and al has one in maryland thatis very successful that's modeldafter a massachusetts program and i think the otherpiece besides the integrated caecomplication program. there's telly society. so it'swidely important. i thinkthere's some concerns, not concerns, but restrictions withregard to state licensure whichhas rooted up. but i think hopefully that can beworked out. and i know mon tonna wyoming, very few child psychiatrists, this is the kindof medicine they need topractice. >> folks, i understand we havea caller on the line with aquestion. joan from bethesda

is dialed in request ready toask our ksoc panel a question. >> dr. blow, i have a teenagerproblem she has problems withdrugs and mental health challenges. i'm wondering interms of her being on medicatio,considering she's had all these drugs problems r. themoderator: so basically we'retalking about the idea that where they're co-occurringdisorders. co-occurring meaningthat the young person has mental health. bom right2:along with say a substance usedisorder and parents being concerned about medicating achild who has had issuesregarding substance abuse in ths past. i think that's a reallyimportant question. let me statwith al and get jane's perspective on this you'reasking a really importantquestion on i think on part of agood

question particularly with anolder child and a family you'regoing to want to be asking about the use of othersubstances that could interferechemically with something that a prescriber might prescribe. butanother challenge around youngpersons using other substances is sometimes thechild is doing that toself-medicate and sometimesyou're really not seeing what'sunderlying, it's either coveredby the substance or the substane has sort of symptoms of its own.so i think again reallyconnecting with a good mental health professional, agood physician to sort it out.but absolutely a lot of the psycho tropic medications caninterfere, the most common one santidepressant medications will frequently increase theeffect of alcohol and certainlymany teenagers college saged

students unfortunately a littletoo freely sometimes, and thesemedications can cause someone to feel the effect ofalcohol way sooner than if theyweren't. some of the medicines can be abuses and themedicine for attention deficitdisorder can be opened and i think there needs to be adiscussion with the familiesabout some of these difficulties. again i keepcoming back to a good assessmen,a good evaluation, a relationship between treatingprofessionals and a family and achild hope we can sort the things out. >> jane. >> well, i want to say to youthat i'm sorry. my heart goesout to you, and that you are

not alone. that there are manyfamilies out there who strugglewith the issues you described. the co-occurringdisorders. that being said ifeel that's perhaps the next frontier. i feel there's beenlittle attention paid toco-occurring disorders. and i'm sure that i don't have anyanswers for you right now." iwill say that we have done so good that families withco-occurring disorders, and theyare rallying. i think it is becoming more recognized and ithink people are seeing thestruggles that you are going through and feeling like thereis an urgency, and prior to thisi don't think there was an agency. so what i can say toyou is that i feel for you. ithink you and your voice need to be very much heard increating the new systems of car.

>> joan, i hope that was aquestion that got a response, ithink that the idea is some caution and concern at the sametime to be thoughtful and dowhat's necessary. i think some parents have shared with metheir concerns if they start amedication, say a stimulant for adhd will it causea substance abuse disorder lateron. the simple answer is no, not specifically. it'sjust that we have to be mindfulfor that. i want to thank you all for submittingquestions. remember you cansubmit a question directlythrough our site that's airing this program.you can ask a question bysubmitting a question at hashtag ksoc or call us tollfree at 18005271401. i have aquestion that came through the mediasite here. the question isshould psycho tropics medicatiosbeing used with

children and adult whoexperienced trauma and what arethe pros and cons. i'll ask aland we'll share a little bit. >> we'll want to jump in. butthis is a very active topic ofdiscussion right now. i think, again, first andforemost you want to know ifthere's been trauma if you're assessing working with a childand a family. and there aretreatments, as you had alluded to earlier, gary, that arenonmedication treatments. someof the evidence of those practices cause, focusedpositive behavioral therapy, aprotocol, a protocol to help a young person through promise.there's the national traumaticstress network, which is on the internet has resources forfamilies for young people and orcolleagues and other

professions to gain a betterunderstanding of the #i78 packetof trauma on a child. i think there's been somediscussion that perhaps sometimsthings are made and the behaviors you're seeing now istrauma related or reasons foranxiety or depression. i think you've got to look atboth. psycho trope pickmedications are indicated again. caution caution caution. ithink if you can find the effectof the trauma and try to treat it with noninterventions.but if there's other issuescoming up that seems to be real and tired and depression,other things, i think sometimesthe medications need to be used for that. but i thinkagain looking at therapies ofvarious sorts and nonmedications that's probably the way tostart.

>> i know people want to jumpin. we're getting a number ofquestions. i want to try to get to several of them. maybefor kristen here, there's aperson that's interested obviously who had somebackground in this, indicating1996, seven percent of all publc behavior health is expendituresand purchases. 20 years later1995, it's risen to 12 percent for these expendituresin the public sector. again, ithink the question really is about why is it from yourperspective, i think al answereda little bit before, but from a national associationperspective this significantincrease in prescription costs. >> i think sort of throwingback that question is are parenspaying for the child psychiatry but are theyconcerned about the medication,and i think that's some of the

concern in the state medicationagencies but frankly all privatepayor systems. i think they better go back look for thecombined treatment being the beteffective treatment. >> question coming through ontwitter. very exciting. this sabout saying specifically: what about letprognosis youth and families knwmedication doesn't have to be a life sentence. they canbe part and temporary. ksoc-tv.could you respond to the twitter.statement. >> absolutely. i think it's anexcellent point they raise. itis not a life sentence. hopefully it is a temporary whatbridge over troubled waters mayeis a way to look at it. it certainly can be asupport or benefit during verydifficult times. but hopefully

not necessarily at all, anythingthat is long term. lif long. >> so again sort of thebalanced approach. >> yes. >> i think perhaps one thingwe're seeing for our audiencetoday is there are resources available. we have talked aboutsome from our website. we haveasamhsa.gov and samhsa. gov has the information relatedto the national stress initiatienetwork. and we also in response to the president and inthe wake of some of the issuesregarding mental health that's created mentalhealth.gov, and it's asignificant website withresources and information about mental healthissues. and i wonder if you allhave any other resources

you would identify assignificant for the viewerstoday? >> i would like to encourageany families that may be watchigor listening today to connect with their familyorganization in their state orcommunity and a listing of those can be found on the nationalfederation of family's website.and many of the issues that we discussed here today areissues that the statewide familynetworks or the local systems of care sites are working toaddress. building a system ofcare using wraparound as an adjutant to medication,empowering families to askquestions and youth as well. ithink that was a valuable resource forfamilies to become connectedwith. >> and that website isffcmh.org. and there's a locatrright on there that you can do,

and there's a treatment locaterat samhsa.gov for substance abueand mental health issues where people can look up andfind locations for treatmentoptions that are more local to them. >> so okay well that'swonderful. thank you very much.and as we're coming to tend of our time right now, i want tothank everyone for participatin.appears to me we've actually reached the end of ourvery first episode of ksoc tv. iwant to thank kristen and jane and al. thank you somuch for joining us andparticipating. i hope that this has given everyone anopportunity to think more aboutthis topic and how it relates toour children youth and families.don't forget the summer oflearning continues throughout

september make sure you checkback often in terms of ourofferings on the virtual campus. this episode will be archived soplease share the information andthe links around and we hope everyone enjoyed thistelecast and we hope to see yousoon. thank you very much.