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SAFE Rx: DCYF's Psychotropic Medication Oversight Program


Children within the child welfare system are more likely to be placed on psychotropic medications than those not within the child welfare system, and to have more frequent poly-pharmacy, but with less consistent follow up, less monitoring, and less continuity of care. For these reasons, federal laws are now mandating child welfare agencies to monitor the use of psychotropic medications prescribed to these children and youth. (Public Law 112-34 - Child and Family Services Improvement and Innovation Act of 2011).

Further, researchers have found extensive variation in the use of psychotropic medications in foster children, suggesting factors other than clinical need contribute to prescribing for this population.

In July 2015, DCYF released Policy Directive 1653, Use of Psychotropic Medicines for Children and Youth in Out-of-Home Placements Adobe Acrobat Reader Symbol. DCYF, together with Geisel School of Medicine at Dartmouth and NH Medicaid, is working to improve practice here in NH.

Key program components

Consent: We want to ensure that the consent process is working and that people providing consents have the information necessary to make an educated, well informed decision about the use of psychotropic medicines for a particular child or youth.

For a number of years, DCYF has had a policy and process in place requiring prior authorization for psychotropic and narcotic medications prescribed for children in DCYF's Guardianship. DCYF policy and procedures state that the prescribing practitioner must seek permission for narcotic, psychotropic and other prescriptions from the DCYF Director or an authorized DCYF Administrator for this group of children/youth. The consent form Adobe Acrobat Reader Symbol is available here and can be filled out electronically. All consent forms must be completed as thoroughly as possible. The completed forms can be sent to either the CPSW/JPPO assigned to that child or to the DCYF Nurse Consultants listed below.

Dee Houle
Phone: 603-271-8945
Fax: (603) 271-4729

Debra Foss
Phone: (603) 752-8327
Fax: (603) 271-4729

Education and support: We want to ensure that resources and materials are available to inform and educate parents, caregivers, youth, staff, and prescribers on this issue.

Oversight and review: With support from the Medicaid office and the Medicaid Managed Care companies, data regarding the use of psychotropic medications for all children/youth in foster care will be reviewed by DCYF and Dartmouth. DCYF is using select red flag criteria to discern which child/youth may need a review of the medications he/she is prescribed. Red flags are markers used within child welfare, Medicaid, mental health, and managed care plans to identify cases in which available data suggest medication use may not be appropriate. Red flag criteria that will prompt a review include:

Diagnostic Criteria

  • Lack of a thorough Behavioral Health Assessment
  • Lack of a DSM Diagnosis


  • Child/youth is prescribed:
    • 4 or more psychotropic medicines
  • Child/youth is prescribed:
    • 2 or more concurrent antidepressants
    • 2 or more concurrent antipsychotic medications
    • 2 or more concurrent stimulant medications (excluding long acting and Immediate release combinations)
    • 2 or more concurrent mood stabilizers (Some concurrent use of these medications may be clinically appropriate, e.g., drug switching.  Resultantly, the definition of concurrent use is use of two medications for more than 60 days.)
  • Psychotropic polypharmacy is prescribed without proper justification before utilizing a monotherapy medication plan

Age of the Child/Youth

  • Antidepressants prescribed for children less than 7 years of age
  • Antipsychotics prescribed for a child less than 7 years of age
  • Psychostimulants prescribed for a child less than 5 years of age

Inconsistent practices

  • Medication is determined to be inconsistent with appropriate care for child/youth's mental health disorder or the documented symptoms it is supposed to target
  • Dose exceeds usual recommended dose and proper justification is not documented
  • Frequent changes in psychotropic medications are made without clear rationale
  • Lack of adequate monitoring for metabolic side effects and abnormal movements.

Resource Materials and Links

For Parents, Caregivers and Caseworkers

Resources for Youth

Resources for Prescribers and Providers

Screening Tools and Measures
Note: Scoring tools are located in the next section

Scoring Tools

Adobe Acrobat Reader Symbol Adobe Acrobat Reader format. You can download a free reader from Adobe.

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New Hampshire Department of Health and Human Services
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