SafeRX: Psychotropic Medication Oversight
The Division for Children, Youth and Families closely monitors the use of psychotropic medications for children and youth in out-of-home placement.
Overview
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 mandate child welfare agencies to monitor and oversee 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 to improve practice here in NH.
Key program components
Consent: A key component to monitoring psychotropic medications is to ensure the persons giving consent on behalf of a child have the information necessary to make an educated, well informed decision about the use of psychotropic medicines for a particular child or youth.
DCYF policy and procedures state the prescribing practitioner must seek permission for narcotic, psychotropic and other prescriptions from the child’s parent(s) or, when a child is in DCYF guardianship, from the DCYF Director or an authorized DCYF Administrator. The DCYF Psychotropic Medication Consent Request Form, required for children in DCYF guardianship, is available here and can be filled out electronically. All consent forms must be completed as thoroughly as possible and accompanied by the clinical assessment or progress notes supporting the request. The completed forms can be sent either to one of the DCYF Foster Care Health Program Managers listed below, or to the CPSW/JPPO assigned to that child.
Oversight and review
With support from the NH Department of Health and Human Services Medicaid office and the Medicaid Managed Care companies, data regarding the use of psychotropic medications for all children and youth in foster care will be reviewed by DCYF. DCYF uses select red flag criteria to discern which child or youth may need a review of the medications he or 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, as described in DCYF policy 1653, that prompts a review includes:
Diagnostic Criteria
- Lack of a thorough Behavioral Health Assessment
- Lack of a DSM Diagnosis
Polypharmacy
- 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 6 years of age
- Antipsychotics prescribed for a child less than 6 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.
Medication Consultation and Review
DCYF Nurse Consultants are integral members of the child protection team and are located in each District Office throughout the state. Nurses are the primary DCYF team members who provide ongoing monitoring and oversight of all behavioral health medications for children. They may request consultation and medication reviews through the child’s Medicaid managed care insurance company, or the contracted DCYF psychiatric provider when there are any medication questions or evidence of red flag criteria in a child’s treatment plan.