Role of Board‐Certified Psychiatric Pharmacists in child and adolescent psychiatry

In the context of ongoing workforce shortages, rising symptom severity, and increased rates of psychotropic prescribing, the 2021 declaration of a national emergency in child and adolescent psychiatry (CAP) has highlighted the need for innovative strategies to address access to quality care. As valued members of the interdisciplinary team, Board‐Certified Psychiatric Pharmacists (BCPPs) in CAP are well‐positioned to address these needs as they are integrated across various settings (e.g., ambulatory clinics, and psychiatric hospitals) and have expertise in psychiatric and neurodevelopmental disorders. As educators and advocates for evidence‐based psychotropic medication management, BCPPs in CAP decrease polypharmacy, increase medication adherence and knowledge, and enhance patient outcomes. Given the need for interdisciplinary collaboration among BCPPs, CAP, and primary care providers, it is crucial for pharmacy administrators to respond and recognize the necessity of integrating pharmacy services into CAP and integrating BCPPs into pharmacy departments.

necessity of integrating pharmacy services into CAP and integrating BCPPs into pharmacy departments.

K E Y W O R D S
child and adolescent psychiatry, mental health, psychiatric pharmacy, substance use, youth

| INTRODUCTION
2][3] They are educators and advocates for the evidence-based use of psychotropic medications through comprehensive medication management (CMM).In addition to unique settings and roles, BCPPs work with a variety of patient populations, including children and adolescents. 4,5The American Association of Psychiatric Pharmacists (AAPP) is the community of practice for BCPPs, and it initiated this exploration of the role of BCPPs in child and adolescent psychiatry (CAP).A general literature search was performed to accumulate relevant studies pertinent to this topic.
[8] As a result, national pediatric and CAP organizations have urged government agencies to address longstanding workforce challenges in CAP, expand access to care, and strengthen efforts to integrate mental health services into primary care. 70][11][12] This manuscript aims to (1) describe the unique role of BCPPs on an interdisciplinary CAP team; (2) outline opportunities for education and collaboration among BCPPs in CAP and their patients, interdisciplinary team, and community; and (3) identify strategic areas to integrate BCPPs across the mental health and pediatric workforce.

| CAP-CURRENT STATE
It is estimated that 8%-12% of children and adolescents are prescribed psychotropic medications, with stimulants, nonstimulants (i.e., alpha-2 agonists), antidepressants, and atypical antipsychotics among those most frequently prescribed. 13Neurobiologic changes during childhood, pediatric-specific risk for adverse effects, and developmental considerations (e.g., physical development) warrant thorough evaluation of psychotropic medication use in this patient population. 13lnerable populations are prescribed psychotropic medications at even higher rates.Children and adolescents in foster care, juvenile justice systems, and with developmental or intellectual disabilities are the most likely to be prescribed high-risk psychotropic medication regimens (e.g., >1 agent from the same pharmacologic class, ≥ 3 concomitant psychotropic medications). 13,14Not only are 13%-31% of youth in foster care prescribed at least one psychotropic medication, but they are four times as likely to be prescribed at least three psychotropic medications and twice as likely to be prescribed at least one concomitant antipsychotic as those, not in foster care. 15,16ildren and adolescents experienced disproportionate harm to their mental health during the coronavirus disease 2019 (COVID- 19)   pandemic.Emergency department visits associated with suicide attempts increased 50.6% in females 12-to 17-year-olds in February to March 2021 as compared to 2019. 8Overdose deaths primarily related to unintended fentanyl exposure among 14-to 18-year-olds increased 94% from 2019 to 2020 and 20% from 2020 to 2021, despite non-prescribed drug use declining overall among surveyed middle and high school students during this time period. 17creased reports of disordered eating and rising rates of hospital admissions/readmissions secondary to medical complications of eating disorders were also seen during the COVID-19 pandemic and are ongoing. 18The need for specialized pharmacotherapy expertise in these and other high-risk patient populations is evident.

| The role of a BCPP in CAP
Addressing the increasing mental health and complex psychotropic medication needs of children and adolescents is difficult, with a national average of only 14 child and adolescent psychiatrists per 100 000 children. 19 Board-Certified Psychiatric Pharmacists in CAP can help to mitigate this provider shortage through collaborative, innovative, and practical strategies that can improve quality of care.

| Evidence-based practice
Landmark trials, pediatric-specific guidelines, state-driven initiatives, and regulatory standards aim to support the evidence-based use of psychotropic medications in children and adolescents. 13Collaborative decision-making among the treatment team, patients, and their caregivers is also essential and should include a review of short-and longterm benefits, risks, treatment goals, target symptoms, and expected duration of treatment.Board-Certified Psychiatric Pharmacists in CAP can broadly support the use of psychotropic medications in children and adolescents with a variety of mental health conditions (Table 1), and regulatory standards are of a critical point of focus (Table 2).

| Regulatory standards
Given prescribing complexity, pediatric-specific risk for adverse effects, and changing trends in psychotropic prescribing, evidencebased CAP standards have been established to promote best practices for psychotropic prescribing, monitoring, and follow-up. 34Regulatory standards, including the Hospital Based Inpatient Psychiatric Services measure set, a collection of quality measures created by The Joint Commission, aims to standardize the quality of care patients receive in psychiatric care settings. 1,35Board-Certified Psychiatric Pharmacists in CAP are well positioned to support these quality care initiatives given their roles in medication monitoring, deprescribing practices, medication safety, medication reconciliation, and psychotropic stewardship (Table 2). 1,4

| Prescribing antipsychotics
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends avoiding simultaneous use of multiple antipsychotics given the risk for additive adverse effects and lack of evidence to support the routine use of more than one antipsychotic. 36 (2) prescribed an antipsychotic for an off-label use in conjunction/ after appropriate psychosocial intervention(s), and (3) receiving annual metabolic monitoring. 35I G U R E 1 Board-Certified Psychiatric Pharmacist's (BCPP's) role in child and adolescent psychiatry interdisciplinary team.
T A B L E 1 Unique patient populations served and childhood conditions treated by BCPPs in CAP.

BCPP interventions
Youth in Foster Care 12,13,15 • Higher rates of antipsychotic prescribing, supratherapeutic dosing, and off-label use  Through the implementation of psychotropic stewardship, BCPPs have an opportunity to optimize these PQMP standards. 1When pharmacists are involved in decision-making regarding prescribing antipsychotics, the rates of antipsychotic polypharmacy decrease in both inpatient and outpatient levels of care. 37According to the National Committee for Quality Assurance (NCQA), in 2018, of youth prescribed an antipsychotic, 2.6% (Commercial Health Maintenance Organization [HMO]), 2.7% (Commercial [Preferred Provider Organization {PPO}]), and 2.4% (Medicaid HMO) were prescribed ≥2 concurrent antipsychotics for ≥3 months. 35

| Antipsychotic metabolic monitoring
Routine metabolic monitoring is crucial because children and adolescents are more susceptible to the metabolic effects of atypical antipsychotics than adults, including a threefold risk of developing type 2 diabetes, weight gain, and dyslipidemia. 38,39Pediatric guidelines provide recommendations for the frequency of metabolic monitoring among youth prescribed atypical antipsychotics. 39According to the NCQA, only 35.6% (Commercial HMO), 34.6% (Commercial PPO), and 36.6% (Medicaid HMO) of children and adolescents prescribed antipsychotics received the recommended annual metabolic monitoring in 2021, with national averages between 30% and 38% since 2015. 35 collaboration with child psychiatrists and pediatricians, BCPPs can play an essential role in optimizing metabolic monitoring through participation in CMM, psychotropic stewardship, and primary care education via collaborative education models (e.g., Extension for Community Health Outcomes [ECHO], The REsource for Advancing Children's Mental Health [REACH] Institute).1,40,41 Although collaboration among child psychiatrists and pediatricians improves the rates of metabolic monitoring, these rates continue to be low.42 Pharmacist involvement in metabolic lab monitoring is associated with increased engagement in metabolic monitoring.43 When a pharmacist is embedded in an outpatient psychiatry clinic, pharmacist-driven lab ordering, patient/provider notification, and primary care provider collaboration are associated with improvement in lab completion rates and followup on abnormal lab results.43 Additionally, pharmacist development of a collaborative practice agreement (CPA) improves metabolic monitoring in inpatient psychiatry units.44

| Attention-deficit/hyperactivity disorder medication follow-up
Expertise in the treatment of attention-deficit/hyperactivity disorder (ADHD) allows BCPPs to play an important role in ADHD medication follow-up.When pharmacists collaborate with psychiatrists in outpatient settings, access to care, time to follow-up, monitoring, side effect management, and patient satisfaction have been shown to improve. 21,22Additionally, a billing model has been described, with the creation of a BCPP-psychiatrist CPA. 22  caregivers on overdose recognition and response. 48,49reening, Brief Intervention, and Referral to Treatment (SBIRT) is an integrated, public health approach for the delivery of early intervention and treatment of individuals with SUD, as well as those who are at risk of developing SUD. 50Board-Certified Psychiatric Pharmacists, as part of the interdisciplinary team, are well positioned to provide SBIRT given their established role in SUD treatment.Notably, reimbursement is available for SBIRT.When an opioid use disorder (OUD) is identified, BCPPs can support use of medications for opioid use disorder (MOUD).
While effective OUD treatment for adolescents includes psychosocial treatments (e.g., cognitive behavioral therapy) and MOUD, pharmacotherapy is underutilized in this population with only 10%-30% of adolescents prescribed MOUD. 17,24,51Board-Certified Psychiatric Pharmacists can increase access to MOUD through development of a CPA. 47

| Patients and caregivers
Patient and caregiver education is successfully provided in both group and individual settings by BCPPs.Patient medication education groups (PMEG) are unique opportunities for BCPPs to provide education in group settings and are associated with improved medication-related outcomes, patient satisfaction, and cost savings. 33 an inpatient CAP unit, PMEGs co-led by a BCPP and pharmacy interns are opportunities to optimize medication-related interventions. 33In addition to PMEGs, BCPPs provide individual education to patients and/or their caregivers at hospital discharge, lead multifamily groups in outpatient settings, and create tools to support children in various developmental stages (e.g., medication picture schedules).

| Interprofessional trainees
Board-Certified Psychiatric Pharmacists are often involved in leading didactic lectures, journal clubs, and patient-case discussions to support CAP fellows, residents, and students.A pharmacotherapy rotation model for CAP fellows led by BCPPs has been described. 52 This warrants further exploration and consideration for state-based organizations that support children and adolescents prescribed psychotropic medications, such as the Texas medication Psychotropic Prescribing Guidelines. 34Third, not all BCPPs have direct and practical access to pediatricians.This is of utmost importance knowing that the majority of psychotropic medications are prescribed in the primary care setting.
Board-Certified Psychiatric Pharmacists can continue to partner with programs like ECHO and The REACH Institute, among others, to broaden their interprofessional impact in primary care.
Notwithstanding these limitations, further integration of BCPPs into the CAP workforce is essential.With pediatric health-system expansions (e.g., building psychiatry pavilions) to meet growing CAP needs, pharmacy administrations must be prepared to acquire expertise in these growing patient care areas.The 2023 pharmacy forecast by the American Society of Health-System Pharmacists Foundation revealed that 63% of pharmacy departments feel somewhat or very unprepared to meet the increased demand for pharmacists with advanced training in mental health. 56Postgraduate year two Psychiatric Pharmacy Residents and BCPPs can be a cost-effective addition to the department to address this evolution in health care and are equipped to implement psychotropic stewardship to meet regulatory standards and optimize the evidence-based use of psychotropic medications. 1,4,57,58The Core Outcome Set for Psychiatric Pharmacists is used to standardize outcome reporting by BCPPs and serves as an evidence-based tool to track data. 59ke child psychiatrists, BCPPs in CAP have opportunities for As part of the quality care initiatives, the Pediatric Quality Measures Program (PQMP), the Agency for Healthcare Research and Quality Centers for Medicare and Medicaid Service, and the National Collaborative for Innovation in Quality Measurement Center of Excellence developed standards assessing the safe and judicious use of antipsychotics in youth.These include evaluating the percentage of children and adolescents (1) prescribed ≥2 concurrent antipsychotics for ≥3 months, This data highlights the need to ensure access to SUD screening, harm reduction strategies, and evidence-based treatment.Harm reduction strategies reduce morbidity and mortality in people who use drugs (PWUD), recognize social inequities surrounding drugrelated harm, and call for nonjudgmental services that promote individual and community well-being.As part of an interdisciplinary team, BCPPs can play a critical role in (1) providing education surrounding harm reduction, (2) increasing access to evidence-based harm reduction tools through clinical practice and advocacy efforts, and (3) reducing stigma toward PWUD.Some practical examples of harm reduction strategies that BCPPs can support include furnishing intranasal naloxone and fentanyl test strips to adolescents, in addition to training adolescents and their Education provided by BCPPs to patients, caregivers, trainees, and colleagues is a practical way to enhance the quality of care provided to children and adolescents, support collaborative decision-making among youth and their caregivers, increase visibility and understanding of CAP regulatory standards, and enhance interdisciplinary collaboration among pediatric providers.Education among trainees and colleagues may take the form of in-services, didactics, topic discussions, journal clubs, learning collaboratives, and more.Psychotropic medication training sessions led by BCPPs have demonstrated high rates of participant satisfaction (95% very satisfied), intent to apply information within work (88%), and post-training topic confidence (93%) among interdisciplinary audiences.23Through such educational initiatives, BCPPs can extend their reach beyond clinical settings to include academic settings, communities, and state/national organizations.
diverse training experiences in both adult and pediatric patient populations.While there are many skilled clinical pharmacists, the BCPP credential provides verification that the pharmacist has achieved a significant level of relevant expertise to provide psychotropic stewardship to children and adolescents.The BCPP examination content domain 1.21 requires knowledge of the management of mental health conditions in specialty populations, including pediatrics and those with intellectual disabilities.3Many BCPPs have completed a PGY2 psychiatric pharmacy residency, which requires that they achieve competency in all aspects of a variety of mental illnesses and their treatments, including psychiatric disorders in children and adolescents and developmental disorders (e.g., autism spectrum disorder, Down syndrome, Wilson's disease, and Prader-Willi syndrome).3Some PGY2 programs also provide other rotations and learning experiences within CAP, including outpatient psychiatry in an ADHD clinic, consult and liaison psychiatry at a children's hospital, and clinics that serve youth with intellectual and/or developmental disabilities.Even if a department hires a pharmacist who has not yet earned the BCPP credential, the BCPP should be maintained as the gold standard that establishes the expected level of knowledge and expertise.Pharmacy administrators can foster and promote the expansion of psychiatric pharmacy services within CAP by (1) supporting and rewarding board certification of its pharmacists, (2) supporting learning experiences for both PGY1 and PGY2 residents at their institution, (3) providing CAP rotations for student pharmacists to expose future pharmacists to psychiatry, and (4) forming affiliation agreements with other health systems (e.g., partnering with a local children's hospital).Compelling outcomes are being achieved in CAP through interprofessional collaboration among child and adolescent psychiatrists, primary care providers, and BCPPs, among other team members.Thus, it is crucial for administrators to respond to the ongoing state of emergency by integrating pharmacy services into CAP and BCPPs into pharmacy departments.
Reduce medication-related problems, such as improper medication selection, medication non-adherence, and subtherapeutic doses Limited data on the use of LAI-A• Engage in quality improvement programs to improve metabolic monitoring • Recommend clozapine, provide education, and support monitoring • Provide high-quality education to increase the comfort of team members in using LAI-A One of the most common pediatric psychiatric disorders • High comorbidity with other psychiatric disorders • Discuss black box warnings for antidepressants and importance of close monitoring • Provide education about behavioral activation/agitation when starting SSRIs/SNRIs Youth with ADHD 21,22,29 • Increasing rates of stimulant prescribing during COVID-19 pandemic • High comorbidity (>50%) with other psychiatric conditions • Need for innovative treatment strategies among youth with complex ADHD • Improve access to care, time to follow-up, monitoring, side effect management, and patient satisfaction • Collaboratively prescribe ADHD medications and increase follow-up care • Support prescribing decisions during stimulant shortages • Ensure effective use of medications in those with complex ADHD • Review pharmacogenomic test results (CYP2D6) with patients, caregivers, and interdisciplinary teams for patient-prescribed atomoxetine Bidirectional effect of physical and mental health conditions • Increased health care utilization • Impact on quality of life of patient and family • Build therapeutic relationships to aid transition of both medical and psychiatric care from adolescence to adulthood • Early onset associated with changes in developing brain • Increasing rates of marijuana and hallucinogen use • Increasing rates of electronic cigarette use • Increasing rates of overdose-related deaths • Provide SBIRT and recommend evidence-based pharmacotherapy, when needed • Offer harm reduction strategies (e.g., naloxone and fentanyl/xylazine test strips) and education regarding overdose recognition and response • Improve access to pharmacologic treatment and improve treatment outcomes Youth with ASD 10,13 • Higher rates of side effects with psychotropic medications • Higher rates of psychiatric comorbidities • High rates of polypharmacy • High rates of CAM use • Limited data on long-term medication use • Reduce medication-related problems such as improper medication selection, medication non-adherence, and subtherapeutic doses • Support thoughtful deprescribing, when appropriate • Educate families regarding evidence-based use of CAM • Mitigate potential drug-drug and drug-CAM interactions • Support medication adherence through unique dosage formulations (e.g., chewable or liquid) Youth with IDD 10,13 • High rates of polypharmacy • High rates of off-label antipsychotic use; concern for overuse of antipsychotics • High rates of long-term psychotropic use • Greater vulnerability to psychotropic adverse effects • Challenges in monitoring for psychotropic adverse effects, with low rates of metabolic monitoring with antipsychotics • • Educate patients to improve medication adherence Abbreviations: ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; CAM, complementary and alternative medicine; COVID-19, coronavirus disease 2019; CYP2D6, Cytochrome P450 2D6; IDD, intellectual and/or developmental disability; LAI-A, long-acting injectable antipsychotics; PHQ-9, patient health questionnaire-9; SBIRT, screening, brief intervention, and referral to treatment; SMI, severe mental illness; SNRIs, serotonin norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; SUDs, substance use disorders.T A B L E 2 TJC cap regulatory standards.Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CAP, child and adolescent psychiatry; CDTM, collaborative drug therapy management; CPA, collaborative practice agreement; CMM, comprehensive medication management; OUD, opioid use disorder; TJC, The Joint Commission.