The DCFS Guardian’s Office consent process is now much more efficient as it has moved to an electronic system as part of IllinoisConnect. Medical providers and other consent requestors can now utilize the new Guardian’s Office Consent Portal to request consent for the following:

Who does this change affect?

Anyone who currently requests consent from the DCFS Guardian’s Office using the forms mentioned above. Requestors may include medical providers, caseworkers and other designated service providers.

 Why should I use the portal?

To find out more visit the DCFS Guardian Consent Portal: guardianconsent.dcfs.illinois.gov

Questions? Please email: DCFS.IllinoisConnect@Illinois.gov

When submitting CFS 431-A Psychotropic Medication Request Forms for antipsychotic medications or mood stabilizers, please attach the most up-to-date lab results available. These labs are essential for DCFS psychiatric consultants to assess the appropriateness and effectiveness of the requested medications. Laboratory tests are recommended at least once a year. Upon receiving a request, CSP team members check for recent or annual labs that are either attached or previously submitted. If unavailable for the consultants review, the CSP team member may contact the submitter for up to date lab results.

When uploading labs through the Online Portal, you must choose one of three options. Select “Yes” if labs are attached for the current request. Select “No” if labs are not available and provide the expected future date for lab completion—note that this date cannot be in the past. Select “N/A” only if labs are not required for the specific medication requested.

Whenever possible, ensure that labs are relevant to the medication. For example, lithium levels should be included when requesting Lithium Carbonate, and HgA1c and lipids should be included for atypical antipsychotic requests. If obtaining a full panel is not feasible, provide the most critical labs related to the medication. Including appropriate labs can help expedite the review process and lead to faster request completion.

DCFS psychiatric consultants allow for a single consent to cover multiple formulations of the same medication (such as immediate and extended release formulations) up to the approved daily maximum dose (i.e. consent range). For example, a consent for Methylphenidate Extended Release (e.g., Concerta) may also apply to an added dose of Methylphenidate Immediate Release (e.g., Ritalin), if used together. If a consent for a stimulant is approved, providers may add a different formulation of the same active ingredient to the medication regimen at any time without requesting consent, so long as the total daily dose of the medications does not exceed the approved range. This policy is not limited to stimulant medications alone; many other medication consents allow for flexibility with regards to extended or immediate release formulations.

One notable exception to the policy above is guanfacine. Tenex (guanfacine IR) and Intuniv (guanfacine ER) are medications which require separate medication consents for each formulation prior to the initiation of the medication. Consent for guanfacine immediate release (Tenex) can be used to fill guanfacine extended release (Intuniv) prescriptions if and only if one formulation is going to be prescribed at a time. To administer both formulations of guanfacine concurrently, a consent is needed from DCFS for each formulation prior to the initiation of the second formulation.

If your request is for a change or additional formulation, and it does not exceed the approved maximum range, and the current consent is not yet eligible for renewal (less than 45 days before expiration), a CSP team member will notify you that the active consent still applies to the new formulation. If the consent is eligible for renewal, the switch can be processed without further contact, provided all other required information is included. When switching from one formulation of a medication to another (e.g., from guanfacine ER to guanfacine IR), you must state that the original formulation will be discontinued and include a taper plan if needed. This clarification helps avoid delays in processing the new consent.

Q: I had requested Depakote DR to treat mood instability for a 15 year old female patient and it was denied. What lead to this determination?

A: The Consultants for DCFS require that an injectable or implantable birth control regimen for female patients of reproductive age be started prior to any approval for a regimen utilizing a form of valproic acid. The consultants for DCFS will also ask providers to justify the use of divalproex sodium over other mood stabilizing agents.

Valproic Acid is a widely used medication that can treat a wide array of both neurological and psychiatric disorders. VPA is used to treat various types of seizures, for migraine prophylaxis, and as a mood stabilizer to treat bipolar disorder and several other psychiatric disorders. Although it can be effective in the right contexts, Valproic acid is the most teratogenic anticonvulsant medication currently in clinical use ¹.

Although autism spectrum disorder has a strong genetic component, fetal exposure to valproic acid during pregnancy has been noted to increase autism susceptibility.  This is likely caused by epigenetic changes brought about by VPA itself. In an animal model of autism, rodents who were prenatally exposed to VPA displayed behavioral components of the human condition, as well as cellular and molecular alterations observed in patients with autism ².

According to an Article published in 2013, children exposed to VPA in utero had a three-fold greater risk of developing autism and a five-fold increase in the risk of developing Autism Spectrum Disorder compared to the risk of autism for the general population ³.

In addition, in utero exposure to Valprioc Acid also increased the frequency of dysmorphic craniofacial features in children. Children exposed to valproic acid in utero were more likely to develop telecanthus, wide philtrum, and an increased length of the upper lip. Additionally, the most consistent result of in utero exposure to VPA was a larger cephalic index which resulted from a disproportionate widening of the skull relative to shorter anterior and posterior skull length ¹. Orofacial clefting has also been observed in infants exposed to VPA prenatally including cleft lip and palate and isolated cleft palate ⁴. Furthermore, in utero exposure to VPA may induce neural tube defects, such as spina bifida, as quickly as the third week after fertilization. These effects may occur before pregnancy is first diagnosed, and negative neurobehavioral effects throughout pregnancy may warrant a change of medication even during pregnancy if an alternative can be effective ⁵.

As part of their many evaluations, the NIMH-funded Systemic Treatment Enhancement Program for Bipolar Disorder has shown that valproic acid is associated with new-onset menstrual-cycle irregularities and hyperandrogenism. These two features comprise the reproductive features of PCOS, while obesity and insulin resistance are the associated metabolic features. Use of valproic acid agents in a female population of reproductive age not only increases the risk of birth defects for a fetus, but can also lead to endocrine disorders for the patient themselves. Three of the four participants who developed new-onset PCOS following the initiation of valproic acid treatment for bipolar disorder experienced remission of the reproductive features of PCOS within a year of discontinuation. However, metabolic features such as obesity and insulin resistance persisted after the discontinuation of valproic acid, and the cellular changes associated with polycystic ovarian morphology (PCOM) also persisted despite discontinuation of the medication ⁶.

The risks outlined above provide the basis for possible denial of new Depakote requests for youth who do not meet the criteria outlined by the consulting psychiatrists.

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