FOSTER CHILDREN

HHS Guidance Could Help 

States Improve Oversight of 

Psychotropic Prescriptions 

Statement of Gregory D. Kutz, Director

Forensic Audits and Investigative Service

Testimony 

Before the Subcommittee on Federal Financial Management, 

Government Information, Federal Services, and 

International Security, Committee on Homeland Security 

and Governmental Affairs, U.S. Senate

For Release on Delivery 

Expected at 10:30 a.m. EST 

Thursday, December 1, 2011

GAO-12-270T

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-270T, a testimony 

before the Subcommittee on Federal Financial 

Management, Government Information, 

Federal Services, and International Security; 

Committee on Homeland Security and 

Governmental Affairs; U.S. Senate 

December 2011 

FOSTER CHILDREN

HHS Guidance Could Help States Improve Oversight 

of Psychotropic Prescriptions

Why GAO Did This Study

Foster children have often been 

removed from abusive or neglectful 

homes and tend to have more mental 

health conditions than other children. 

Treatment may include psychotropic 

drugs but their risks to children are not 

well understood. Medicaid, 

administered by states and overseen

by the Department of Health and 

Human Services (HHS), provides 

prescription drug coverage to foster 

children.

This testimony examines (1) rates of 

psychotropic prescriptions for foster 

and nonfoster children in 2008 and (2) 

state oversight of psychotropic 

prescriptions for foster children through 

October 2011. GAO selected Florida, 

Maryland, Massachusetts, Michigan, 

Oregon, and Texas primarily based on 

their geographic diversity and size of 

the foster care population. Results 

cannot be generalized to other states.

In addition, GAO analyzed Medicaid 

fee-for-service and foster care data

from selected states for 2008, the most 

recent year of prescription data 

available at the start of the audit. 

Maryland’s 2008 foster care data was

unreliable. GAO also used expert child 

psychiatrists to provide a clinical 

perspective on its methodology and 

analysis, reviewed regulations and 

state policies, and interviewed federal 

and state officials. 

What GAO Recommends

In our draft report, GAO recommended 

that HHS consider endorsing guidance 

for states on best practices for 

overseeing psychotropic prescriptions 

for foster children. HHS agreed with 

our recommendation. Agency 

comments will be incorporated and 

addressed in a written report that will 

be issued in December 2011.

What GAO Found

Foster children in the five states GAO analyzed were prescribed psychotropic 

drugs at higher rates than nonfoster children in Medicaid during 2008, which 

according to research, experts consulted, and certain federal and state officials, 

could be due in part to foster children’s greater mental health needs, greater 

exposure to traumatic experiences and the challenges of coordinating their 

medical care. However, prescriptions to foster children in these states were also 

more likely to have indicators of potential health risks. According to GAO’s

experts, no evidence supports the concomitant use of five or more psychotropic 

drugs in adults or children, yet hundreds of both foster and nonfoster children in 

the five states had such a drug regimen. Similarly, thousands of foster and 

nonfoster children were prescribed doses higher than the maximum levels cited 

in guidelines developed by Texas based on FDA-approved labels, which GAO’s 

experts said increases the risk of adverse side effects and does not typically 

increase the efficacy of the drugs to any significant extent. Further, foster and 

nonfoster children under 1 year old were prescribed psychotropic drugs, which 

GAO’s experts said have no established use for mental health conditions in 

infants; providing them these drugs could result in serious adverse effects.

Psychotropic Prescription Rates for Foster and Nonfoster Children Age 0-17 in Medicaid Feefor-Service in Five States

0

20

40

60

80

100

MAFL TXORMI

Source: GAO analysis of state Medicaid and foster care data.

% of foster children

Prescribed at least one

psychotropic medication:

% of nonfoster children

Selected states’ monitoring programs for psychotropic drugs provided to foster 

children fall short of best principle guidelines published by the American 

Academy of Child and Adolescent Psychiatry (AACAP). The guidelines, which 

states are not required to follow, cover four categories. 

• Consent: Each state has some practices consistent with AACAP consent 

guidelines, such as identifying caregivers empowered to give consent. 

• Oversight: Each state has procedures consistent with some but not all 

oversight guidelines, which include monitoring rates of prescriptions. 

• Consultation: Five states have implemented some but not all guidelines, 

which include providing consultations by child psychiatrists by request. 

• Information: Four states have created websites about psychotropic drugs for 

clinicians, foster parents, and other caregivers. 

This variation is expected because states set their own guidelines. HHS has not 

endorsed specific measures for state oversight of psychotropic prescriptions for 

foster children. HHS-endorsed guidance could help close gaps in oversight of 

psychotropic prescriptions and increase protections for these vulnerable children. View GAO-12-270T or key components. For 

more information, contact Gregory D. Kutz at 

(202) 512-6722 or kutzg@gao.gov. 
 

Page 1 GAO-12-270T 

Chairman Carper, Ranking Member Brown, and Members of the 

Subcommittee:

Thank you for the opportunity to discuss psychotropic drug prescriptions 

provided to foster children under state care. Children placed in foster care 

are among our nation’s most vulnerable populations. Often having been 

removed from abusive or neglectful homes, they tend to have more 

numerous and serious medical and mental health conditions than do 

other children.1 Treatment of mental illness may include prescribing 

psychotropic drugs, such as antidepressants and antipsychotics. Because 

foster children are under state care they typically receive prescription 

drugs and other medical services through Medicaid, a joint federal-state 

program that finances health care coverage for certain low-income 

populations.2

This testimony discusses, for selected states, (1) rates of psychotropic 

drug prescriptions for foster children compared with nonfoster children 

covered by Medicaid in 2008, including indicators of health risks, and (2) 

federal and state oversight policies as of October 2011 for psychotropic 

drugs prescribed to foster children. We have received comments on a 

draft of the report this testimony is based on from the Department of 

Health and Human Services (HHS) and relevant state agencies. We plan 

to incorporate their comments into the report that we will issue in 

December 2011. We contracted with two child psychiatrists with clinical 

and research expertise in the use of psychotropic drugs in children to 

provide a clinical perspective on our methodology and data analysis. To 

compare rates of psychotropic drug prescriptions, we reviewed calendar 

year 2008 fee-for-service prescription claims and foster care data for 

 

1

GAO, Foster Care: State Practices for Assessing Health Needs, Facilitating Service 

Delivery, and Monitoring Children’s Care. GAO-09-26, (Washington, D.C.: February 6, 

2009). 

2

Medicaid programs vary from state to state. 
 

Page 2 GAO-12-270T 

Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas.3,4 At 

the start of our audit, 2008 data were the most recent calendar year 

prescription claims data available from the Centers for Medicare & 

Medicaid Services (CMS). These states were selected primarily for 

geographic diversity and the size of their foster care populations.

However, we then excluded Maryland from our analysis due to the 

unreliability of their foster care data.5

To determine federal and state oversight policies, we interviewed officials 

from CMS, the Administration for Children and Families (ACF), and the 

six selected states’ Medicaid and foster care agencies. We also reviewed 

policies and regulations related to the prescribing of psychotropic drugs to 

foster children. Based on a literature review and discussions with officials 

To identify potential health risk 

indicators, we consulted with our experts, performed literature searches, 

and reviewed state guidelines. The final indicators of potential health risks 

were: concomitant prescriptions of five or more drugs, prescriptions 

exceeding dosage guidelines in the Psychotropic Medication Utilization 

Parameters for Texas Foster Children based on Food and Drug 

Administration (FDA) approved labels, and psychotropic prescriptions to 

children under 1 year old. In addition, we evaluated gaps of 7 to 29 days 

in prescriptions of a drug to identify nonadherence to drug regimens, 

which can pose significant risks to a patient.

 

3

Some states’ prescription drugs are covered by Medicaid managed care plans in which 

drug payments are included in the capitated payments that plans receive from states. For 

this review, we selected states that cover psychotropic medications largely under fee-forservice programs so that individual drug claims could be analyzed. In Michigan, Oregon, 

and Texas, psychotropic medications were primarily paid on a fee-for-service basis. In 

Florida and Massachusetts, psychotropic prescription claims for most foster children were 

paid on a fee-for-service basis, with the remaining children largely covered by managed 

care. In these states, since we examined only fee-for-service data, we were more likely to 

identify psychotropic prescriptions to foster children during calendar year 2008 than to 

nonfoster children. 

4

In addition, the Medicaid prescription claims data do not include diagnosis codes, and 

therefore, we cannot be sure that all the drugs in our analysis were prescribed for mental 

health purposes.

5

We performed data checks to determine the reliability of the MSIS prescription claims 

data provided by CMS, state Medicaid files provided by Medicaid agencies in the six 

selected states, databases of children in foster care provided by child welfare agencies in 

the six selected states, and Thomson Reuters Redbook. While a small number of 

Medicaid and foster care records may contain inaccurate personal data or prescription 

information likely resulting from data entry errors, based on our discussions with agency 

officials and our own testing, we concluded that the data elements in five of the six states 

used for this report were sufficiently reliable to address our audit objectives.
 

Page 3 GAO-12-270T 

from HHS, we selected the American Academy of Child and Adolescent 

Psychiatry’s (AACAP) guidelines as a basis for assessing the extent to 

which selected states were implementing recommended practices.6

We performed this audit from February 2010 through November 2011 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. Our full scope and detailed 

methodology will be provided in our report that will be issued in December 

2011.

Foster care begins when a child is removed from his or her parents or 

guardians and placed under the responsibility of a state child welfare 

agency. Removal from the home can occur because of physical abuse or

neglect. It can also occur when a child’s own behavior or condition is 

beyond the control of his or her family or poses a threat to their 

community. Foster care may be provided by a family member, caregivers 

previously unknown to the child, or a group home or institution. Ideally, 

foster care is an intermediate step towards a permanent family home. 

When reuniting the child with his or her parents or guardian is not in the 

child’s best interest, caseworkers seek a new permanent home for the 

child, such as an adoptive home or guardianship. However, some 

children remain in foster care until they reach adulthood. As we have 

previously reported, children in foster care exhibit more numerous and 

serious medical conditions, including mental health conditions, than do 

other children.7

States are responsible for administering their Medicaid and foster care 

programs; the programs are overseen at the federal level by HHS through 

CMS and ACF, respectively. HHS may issue regulations, provide 

guidance on some issues, or simply provide informational resources for 

 

6 AACAP guidelines are available at 

http://www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf 

7

GAO, Foster Care: State Practices for Assessing Health Needs, Facilitating Service 

Delivery, and Monitoring Children’s Care, GAO-09-26 (Washington, D.C.: Feb 6, 2009). 

Background
 

Page 4 GAO-12-270T 

states to consider for their programs, the latter being the case for 

psychotropic drugs provided to children in state custody. Among these 

resources are best principles developed by AACAP, a nonprofit 

professional association. While HHS does not require states to follow 

these guidelines, AACAP developed them as a model to help inform state 

monitoring programs for youth in state custody. AACAP guidelines point 

out that, “as a result of several highly publicized cases of questionable 

inappropriate prescribing, treating youth in state custody with 

psychopharmacological agents has come under increasingly intense 

scrutiny,” leading to state implementation of consent, authorization, and 

monitoring procedures. More recently, Congress passed the Child and 

Family Services Improvement and Innovation Act in September 2011, 

requiring states that apply for certain federal child welfare grants to 

establish protocols for the appropriate use and monitoring of psychotropic 

drugs prescribed to foster children.

8

The use of psychotropic drugs has been shown to effectively treat mental 

disorders, such as attention deficit hyperactivity disorder (ADHD), bipolar 

disorder, depression and schizophrenia. While many psychotropic drugs 

that have been approved by the FDA as safe and effective in adults have 

not been similarly approved for children of all ages, prescribing them to 

children is legal and common medical practice in many instances. 

According to the National Institute of Mental Health (NIMH), some 

children with severe mental health conditions would suffer serious 

consequences without such medication.9 However, psychotropic drugs 

can also have serious side effects in adults, including irreversible 

movement disorders, seizures, and an increased risk for diabetes over 

the long term. Further, additional risks these drugs pose specifically to 

children are not well understood.10

Psychotropic drugs affect brain activity associated with mental processes 

and behavior. These drugs are also called “psychotherapeutic” drugs. 

 

8

Pub. L. No. 112-34, § 101(b)(2), 125 Stat. 369.

9

National Institute of Mental Health, Treatment of Children with Mental Illness, NIH 

Publication No. 09-4702, (Bethesda, MD.: Revised 2009).

10For example, see Medicaid Medical Directors Learning Network and Rutgers Center for 

Education and Research on Mental Health Therapeutics. Antipsychotic Medication Use in 

Medicaid Children and Adolescents: Report and Resource Guide from a 16-State Study,

MMDLN/Rutgers CERTs, Publication 1 (July 2010).
 

Page 5 GAO-12-270T 

While psychotropic drugs can have significant benefits for those with 

mental illnesses, they can also have side effects ranging from mild to 

serious. Table 1 highlights the psychotropic drug classes studied in this 

report and provides examples of drugs within those classes, as well as 

conditions treated and possible side effects.

Table 1: Psychotropic Drug Classes 

Drug class Examples of drugs

Types of conditions treated by 

drug class

Examples of possible adverse 

side effects

ADHD drugs Atomoxetine (Strattera)

Lisdexamfetamine dimesylate (Vyvanse)

Methylphenidate (Ritalin, Concerta)

Amphetamine (Adderall)

Dextroamphetamine (Dexedrine, Dextrostat)

Attention deficit hyperactivity 

disorder

Decreased appetite

Tics

Psychosis 

Anti-anxiety Clonazepam (Klonopin)

Lorazepam (Ativan)

Alprazolam (Xanax) 

Generalized anxiety disorder

Post-traumatic stress disorder

Social phobias

Dependence

Drowsiness and dizziness

Blurred vision

Nightmares

Antidepressants Fluoxetine (Prozac)

Citalopram (Celexa)

Sertraline (Zoloft)

Paroxetine (Paxil)

Escitalopram (Lexapro)

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Bupropion (Wellbutrin)

Depression

Generalized anxiety disorder

Obsessive-compulsive disorder

Social phobia

Suicidal thoughts

Sleeplessness or drowsiness

Agitation

Sexual dysfunction

Antipsychotics Chlorpromazine (Thorazine)

Haloperidol (Haldol)

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Aripiprazole (Abilify)

Bipolar disorder

Schizophrenia

Tourette’s syndrome

Rigidity (muscular tension)

Tremor

Tardive dyskinesia (uncontrollable 

movements) 

Diabetes

High cholesterol

Weight gain

Neuroleptic malignant syndrome 

(a life-threatening, neurological 

disorder most often caused by an 

adverse reaction to antipsychotic 

drugs)

Hypnotics Quazepam (Doral)

Zolpidem (Ambien)

Eszopiclone (Lunesta)

Insomnia

Anxiety

Dependence

Sleep-walking
 

Page 6 GAO-12-270T 

Drug class Examples of drugs

Types of conditions treated by 

drug class

Examples of possible adverse 

side effects

Mood stabilizers Lithium

Divalproex sodium (Depakote)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

Oxcarbazepine (Trileptal)

Bipolar disorder Suicidal thoughts 

Loss of coordination

Hallucinations

Kidney, thyroid, liver and 

pancreas damage

Polycystic ovarian syndrome

Weight gain

Source: NIMH, NIH, and our experts.

Note: The drug class categorizations and the corresponding examples of medications used in this 

analysis are intended to capture the common uses of psychotropic drugs and were reviewed by our 

experts. However, some of the drugs may have been developed and used for different purposes. For 

example, certain anti-anxiety drugs, such as benzodiazepines, may also be prescribed for insomnia. 

Similarly, some medications developed to treat depression, such as selective serotonin reuptake 

inhibitors (SSRI) and tricyclic antidepressants, may also be used to treat anxiety disorders. 

Foster children in each of the five selected states were prescribed 

psychotropic drugs at higher rates than were nonfoster children in 

Medicaid during 2008.11 These states spent over $375 million for 

prescriptions provided through fee-for-service programs to foster and 

nonfoster children.12 The higher rates do not necessarily indicate 

inappropriate prescribing practices, as they could be due to foster 

children’s greater exposure to traumatic experiences and the unique 

challenges of coordinating their medical care.13

 

11We also examined Maryland, but found that its 2008 data on foster children were not 

sufficiently reliable for this study. State officials told us that Maryland’s transition to a new 

records system in 2007 resulted in incorrect and missing data for foster children. A state 

audit in 2008 reported duplicate records with different identifying numbers for the same 

child, records showing children who had exited foster care as still enrolled in the program, 

and personal information for the mother recorded as that of the child. Our analysis of the 

data Maryland provided to us identified 8,869 children in foster care as of September 30, 

2008—about 16 percent more than the 7,613 children that Maryland reported to ACF that 

year. However, audit reports for Maryland indicated that the state had taken some 

corrective actions as of March 2011.

However, psychotropic 

12Based on our analysis of Medicaid fee-for-service claims data, these five states spent 

over $317 million on psychotropic drugs for nonfoster children and about $59 million on 

psychotropic drugs for foster children (in care 30 days or more) during 2008. This amount 

paid includes only claims paid for by a fee-for-service program and does not include 

manufacturer rebates or costs such as managed care (e.g., health maintenance 

organization (HMO)).

13For example, see Leslie et al, Multi-State Study on Psychotropic Medication Oversight in 

Foster Care, Tufts Clinical and Translational Science Institute (Boston, Mass.: 2010) 

Foster Children Have 

Higher Rates of 

Psychotropic Drug 

Prescriptions and 

Indicators of Potential 

Health Risks
 

Page 7 GAO-12-270T 

drug claims for foster children were also more likely to show the indicators 

of potential health risks that we established with our experts. According to 

our experts, no evidence supports the concomitant use of five or more 

psychotropic drugs in adults or children, yet hundreds of both foster and 

nonfoster children were prescribed such a medication regimen. Similarly, 

thousands of foster and nonfoster children were prescribed doses 

exceeding maximum levels cited in guidelines based on FDA-approved 

drug labels, which our experts said increases the potential for adverse 

side effects, and does not typically increase the efficacy of the drugs to 

any significant extent.14

Foster children in Florida, Massachusetts, Michigan, Oregon, and Texas 

were prescribed psychotropic drugs at rates 2.7 to 4.5 times higher than 

were nonfoster children in Medicaid in 2008.

Further, foster and nonfoster children under 1 

year old were prescribed psychotropic drugs, which our experts said have 

no established use for mental health conditions in infants and could result 

in serious adverse effects.

15

 

14According to our experts, medications are approved based on therapeutic research and 

doses above the recommended level have generally not been shown to be safe or 

effective. 

The rates were higher 

among foster children for each of the age ranges—0 to 5 years old, 6 to 

12 years old, and 13 to 17 years old—that we reviewed. See figure 1 for 

rates by state. Although a higher proportion of foster children received 

psychotropic drug prescriptions compared with nonfoster children, the 

vast majority of children receiving psychotropic drug prescriptions in these 

states were nonfoster children because the population of nonfoster 

children is much larger. In addition, according to our experts the higher 

rates of psychotropic drug prescriptions among foster children do not 

necessarily mean that the prescriptions were inappropriate; determining 

so would require, at minimum, a full review of each child’s medical 

15 The kinds of drugs included in prescription data reported to CMS in 2008 varied by 

state. Because the claims data we obtained from CMS contained fewer types of 

medications for Michigan and Oregon, we may understate the rates of psychotropic 

prescriptions for both foster and nonfoster children in those states. While rates of 

psychotropic prescriptions are not comparable across states, they are comparable 

between foster and nonfoster children within the same state. Similarly, the ratio of 

prescriptions to foster children to prescriptions to nonfoster children is comparable across 

states. 

Higher Rates of 

Psychotropic Drug 

Prescriptions among 

Foster Children
 

Page 8 GAO-12-270T 

history.16

 

16In Florida, nonfoster children were in fee-for-service Medicaid an average of 2 months 

less than foster children. Therefore, the number of nonfoster children with psychotropic 

prescriptions may be understated.

Figure 1 shows prescription rates for children in each state for 

various age ranges.
 GAO 

Blue Bo

Templat

Page 9 GAO-12-270T

Figure 1: Psychotropic drug prescription rates for 5 selected states

Rollover the shaded states for more information Print-friendly version

$

State:

Medicaid amount paid for 

psychotropic medications

prescribed to foster and

nonfoster children 

during 2008:

Percentage of children

prescribed psychotropic

medication age:

0–17 years old

13–17 years old

6–12 years old

0–5 years old

Ratio of foster to 

nonfoster children

Foster children Nonfoster children

Source: GAO analysis of state Medicaid and foster care data.

Note: Rates for foster and nonfoster children are comparable within the same state and the ratio of prescriptions to foster children to prescriptions to nonfoster children 

is comparable across states. However, prescription rates are not comparable across states because certain states covered more psychotropic drugs than other states. 

In addition, we excluded children whose prescriptions were not reported to CMS because they were covered by an HMO in the two states with both fee-for-service and 

HMO prescription coverage. Percentages and ratios are rounded to the nearest tenth, and therefore the reported ratio may be slightly different than the ratio of the 

rounded percentages.

Interactive Graphic
 

Page 10 GAO-12-270T 

Through our interviews with state and federal officials and our experts, 

and our review of academic studies, we identified several factors that may 

contribute to these higher rates of prescribed psychotropic drug regimens. 

These factors included the greater exposure to trauma before entering 

state care, frequent changes in foster placements, and varying state 

oversight policies. However, our literature search identified a relatively 

small number of studies that have been conducted to determine to what 

extent each of these factors contributes to higher prescription rates, or 

whether additional factors are involved.

Greater exposure to trauma. Research and interviews with certain state 

officials suggest that children entering foster care have more emotional 

and behavioral issues than do nonfoster children. For example, an 

analysis of 1996 service claims in one county revealed that 57 percent of 

foster children were diagnosed with a mental disorder—nearly 15 times 

that of nonfoster children receiving Medicaid assistance. ADHD, 

depression, and developmental disorders were the most common 

diagnoses.17 According to the National Survey of Child and Adolescent 

Well-Being (NSCAW), 46 percent of children investigated by child welfare 

services (CWS) primarily came to the attention of CWS from a report of 

neglect, while 27 percent had experienced physical abuse as the most 

serious form of recorded maltreatment.18 According to another study 

based on NSCAW data, approximately half of youths aged 2 to 14 years 

with completed child welfare investigations had clinically significant 

emotional or behavioral problems.19

State officials and our contracted child psychiatrists stated that higher 

levels of psychotropic drug prescriptions may be appropriate to deal with 

 

17S. dosReis, et al., Mental health services for youths in foster care and disabled youths, 

Am J Public Health, 2001, 91(7): pp. 1094-9.

18Children in states that required CPS to initially contact the family before the study’s field 

staff were excluded from the study. Those states are not represented. See National 

Survey of Child and Adolescent Well-Being (NSCAW), No. 7: Special Health Care Needs 

Among Children in Child Welfare, Office of Planning, Research and Evaluation, 

Administration for Children and Families. (Washington, D.C.: 2007). 

19Children in states that required CPS to initially contact the family before the study’s field 

staff were excluded from the study. Those states are not represented. See B. J. Burns, et 

al., Mental health need and access to mental health services by youths involved with child 

welfare: A national survey, Journal of the American Academy of Child and Adolescent 

Psychiatry, 43, (2004), pp.960-70.
 

Page 11 GAO-12-270T 

the increased prevalence and greater severity of mental health conditions 

among foster children. Further, Dr. Naylor noted that past trauma creates 

unique treatment challenges for those with multiple severe symptoms. In 

some cases, their symptoms do not clearly fit into existing diagnoses, 

which may cause them to receive multiple diagnoses that change with 

time, foster care placement, and medical provider. Dr. Naylor also noted 

that very little research has been done on the use of psychotropic drugs 

in foster children with severe symptoms. This limits the information 

available to providers on how best to treat their conditions.20

Frequent changes in foster placements. Foster children who change 

placements often do not have a consistent caretaker to plan treatment, 

offer consent, and provide oversight. As we have previously reported, 

changes in placement pose significant challenges for agencies, foster 

parents, and providers with regard to providing continuity of health care 

services and maintaining uninterrupted information on children’s medical 

needs and courses of treatment.21 Several studies of the utilization of 

psychotropic drugs have also noted that multiple foster care placements 

over short periods prevent an individual familiar with the child from 

coordinating and overseeing his or her long-term medical care.22

 

20As we have previously reported, some steps have been taken to address the lack of 

drug research in the pediatric population. For example, as part of the Food and Drug

Administration Amendments Act of 2007, Congress reauthorized two laws, the Pediatric 

Research Equity Act (PREA) and the Best Pharmaceuticals for Children Act (BPCA). The 

PREA requires that sponsors conduct pediatric studies for certain products unless the

FDA grants a waiver or deferral. See GAO, Pediatric Research: Products Studied under 

Two Related Laws, but Improved Tracking Needed by FDA, 

Children 

entering foster care may lack medical care prior to entry, while children 

with prior medical care may have experienced disruptions in care and 

have missing or incomplete records. (We discuss how each of the six 

states oversee psychotropic drug prescriptions in the next section of this 

testimony that discusses federal and state oversight over psychotropic 

drugs prescribed to foster children.)

GAO-11-457 (Washington, 

D.C.: May 2011).

21GAO, Foster Care: State Practices for Assessing Health Needs, Facilitating Service 

Delivery, and Monitoring Children’s Care, GAO-09-26 (Washington, D.C.: Feb 6, 2009).

22For example, see Leslie et al, Multi-State Study on Psychotropic Medication Oversight in 

Foster Care, Tufts Clinical and Translational Science Institute (Boston, Mass.: 2010).
 

Page 12 GAO-12-270T 

Varying state oversight policies. States surveyed by the Tufts Clinical 

and Translational Science Institute in 2010 reported on several 

challenges that may affect prescribing patterns for foster children. These 

included a lack of collaboration among state agencies, professionals, and 

organizations responsible for the care of foster children; the consent 

process for foster children, which may require the input of multiple 

individuals or organizations; and the need for access to up-to-date 

guidelines on clinical practices regarding psychotropic prescriptions for 

foster children across stakeholder groups, including caregivers, child 

welfare agencies, schools, and prescribers. For example, the study found 

that 34 of 48 states had not implemented a system to identify 

prescriptions with dosages exceeding current maximum 

recommendations set by the product manufacturer, professional or 

federal standards, or state expert panels.23

In each of the five states analyzed, psychotropic prescription claims data 

for foster children showed higher rates of potential health risk indicators 

than those of nonfoster children in Medicaid. According to our experts, the 

following three prescribing practices carry increased levels of risk for 

children, concomitant prescriptions of five or more medications,24 doses 

exceeding maximum levels in FDA-approved drug labels, and 

prescriptions for infants.25

 

23Leslie et al, Multi-State Study on Psychotropic Medication Oversight in Foster Care, 

Tufts Clinical and Translational Science Institute (Boston, Mass.: 2010).

Figure 2 provides more information on these 

indicators by state.

24According to one of our experts, this may be justified in rare cases of children with 

serious, complex mental health issues. 

25These indicators are similar to those used by Texas to identify cases for further review, 

and were cited by our experts as indicators of potential health risks.

Higher Rates of Potential 

Health Risk Indicators 

among Foster Children
 GAO 

Blue Bo

Templat

Page 13 GAO-12-270T

Figure 2: Psychotropic drug potential health risk indicators for 5 selected states

Rollover the shaded states for more information Print-friendly version

State:

Children age 0–17 prescribed five (5) or more 

medications concomitantly

Children 0–17 with a dosage exceeding maximum

guidelines based on FDA-approved labels

Children under 1 year old prescribed a 

psychotropic drug

Percentage of 

foster children

Percentage of 

nonfoster children

Source: GAO analysis of state Medicaid and foster care data.

Note: Rates for foster and nonfoster children are comparable within the same state and the ratio of prescriptions to foster children to prescriptions to nonfoster children 

is comparable across states. However, prescription rates are not comparable across states because certain states covered more psychotropic drugs than other states. 

In addition, we excluded children whose prescriptions were not reported to CMS because they were covered by an HMO in the two states with both fee-for-service and 

HMO prescription coverage. 

Interactive Graphic
 

Page 14 GAO-12-270T 

Concomitant psychotropic drug prescriptions.

26 Across the five 

states, the rate of children prescribed five or more psychotropic drugs 

concomitantly ranged from 0.11 to 1.33 percent among foster children 

compared with a lower 0.01 to 0.07 percent rate among nonfoster 

children. This translates to 1,752 children with such prescriptions in the 

five states—609 foster children and 1,143 nonfoster children. According 

to our experts, the use of five or more drugs at once is a high-risk 

practice. Our experts also said that no evidence supports the use of five 

or more psychotropic drugs in adults or children, and only limited 

evidence supports the use of even two drugs concomitantly in children. 

Increasing the number of drugs used concurrently increases the likelihood 

of adverse reactions and long-term side effects, such as high cholesterol 

or diabetes, and limits the ability to assess which of multiple drugs are 

related to a particular treatment goal.27

Doses exceeding maximum levels in FDA-approved drug labels. The 

rate of children prescribed medications exceeding maximum doses for the 

child’s age, as cited in the Texas Utilization Parameters based on 

information in FDA-approved drug labels for the child’s age ranged from 

1.12 to 3.27 percent among foster children compared with a lower 0.16 to 

0.56 percent rate among nonfoster children.28

 

26In our analysis of rates of psychotropic prescriptions, we included stimulants (e.g., 

ADHD drugs), anti-anxiety drugs, antidepressants, antipsychotics, hypnotics, mood 

stabilizers, and medications containing combinations of these drug classes. Other 

psychotropic drugs, such as anticonvulsants and alpha agonists, may be used to treat 

both physical and mental health conditions. However, because they are more likely to be 

used for mental health indications when combined with another psychotropic drug, we 

included them in our concomitant analyses when combined with a second psychotropic 

drug.

A total of 20,965 children in 

the five states had such a prescription—2,165 foster children and 18,800 

nonfoster children. Of children prescribed drugs for which there was no 

FDA-recommended dose for their age, 0.34 to 1.52 percent of foster 

children and 0.05 to 0.16 percent of nonfoster children were prescribed 

dosages that exceeded the maximum standards published in the medical 

27For example, see Zito et al, Psychotropic Medication Patterns Among Youth in Foster 

Care, Pediatrics 2008; Volume 121; 157-163.

28For this analysis, we used dosage guidelines developed by the state of Texas based on 

FDA-approved drug labels, where available, for 33 drugs. For additional information, see 

Heiligenstein, Psychotropic Medication Utilization Parameters for Foster Children, Office 

of the Commissioner, Texas Department of Family and Protective Services (Austin, Tex.: 

December 2010). 
 

Page 15 GAO-12-270T 

literature. According to our experts, taking drugs at dosages exceeding 

levels recommended by the FDA and medical literature increases the 

potential for adverse side effects. Although there may be cases in which 

such doses are clinically justified, in general, there is a lack of research 

demonstrating that high dosages are more effective. In addition, our 

experts said that for some drugs, a higher dose may be less effective 

than the more moderate recommended dose.29

Psychotropic prescriptions for infants. The rate of children age under 

1 year old prescribed a psychotropic drug ranged from 0.3 to 2.1 percent 

among foster children compared with a lower 0.1 to 1.2 percent rate 

among nonfoster children. This translates to 76 foster children and 3,765 

nonfoster children under 1 year old in the five states—a total of 5,265 

prescriptions.30

 

29According to one of our experts, the effect of psychotropic medications has not been 

proven to be safe or effective above the maximum recommended dose by an FDA review. 

At lower dosages, psychotropic medications generally show an increase in efficacy with 

an increase in dose, but this dose-response relationship changes as the dose increases.

At higher dosages, increasing doses of medications are often accompanied by an 

increased risk in adverse effects with little or no added benefit.

Our experts said that there are no established mental 

health indications for the use of psychotropic drugs in infants, and 

providing them these drugs could result in serious adverse effects. 

According to our data, fewer than 10 infants in foster care and 22 

nonfoster infants were prescribed clonidine—with dosages generally used 

in older children—which one of our experts said could result in significant 

sedation and potential cardiac problems including, on rare occasions, 

sudden death. Fewer than ten infants in foster care were prescribed an 

antidepressant or an antipsychotic, compared with 44 and 12 infants not 

in foster care, respectively. According to our experts, antidepressants and 

antipsychotics have significant potential side effects, including 

cardiovascular and metabolic problems. Anti-anxiety drugs such as 

antihistamines and benzodiazepines accounted for the vast majority of 

the prescriptions for infants. Our experts noted that these drugs could 

30While the data we used for this analysis were generally reliable, the date of birth field 

was blank for some records. The number of foster infants, in particular, captured in the 

claims data may be underreported. It is also possible that a small number of Medicaid and 

foster care records may contain inaccurate personal data or prescription information likely 

resulting from data entry errors. 
 

Page 16 GAO-12-270T 

have been prescribed for nonmental health conditions.31

Table 2: Children age 0-1 year old prescribed psychotropic drugs in five selected 

states

For example, the 

antihistamines could be prescribed to treat allergies, itching, and skin 

conditions such as eczema, the benzodiazepines for seizures or as 

sedation for a medical procedure. While physicians may use their 

discretion to prescribe these drugs to infants, these nonmental health 

uses still carry the same risk of adverse effects, including, for 

antihistamines, diminished mental alertness and excitation in young 

children. According to our experts, these cases raise significant concerns 

because infants are at a stage in their development where they are 

potentially more vulnerable to the effect of psychotropic drugs. See table 

2 for more information.

Drug category (subclass)

a

Foster children Nonfoster children

Anti-anxiety (antihistamines) 55 b 3,454

Anti-anxiety (benzodiazepines) 17 254

Other anti-anxiety drugs 0 <10

ADHD drugs <10 37

Antidepressants <10 44

Antipsychotics <10 12

Hypnotic 0 <10

Mood stabilizer 0 <10

Source: GAO analysis of state Medicaid and foster care data.

a

Note: A total of 76 foster children and 3,765 nonfoster children, or 3,841 children age 0-1, were 

prescribed a psychotropic drug. The totals in the table above do not add up to 3,841 because some 

infants were prescribed more than one psychotropic drug. 

b

Of children prescribed antihistamines, 26 foster children and 2,169 nonfoster children had 

prescriptions covering fewer than 20 days. According to one of our experts, this more likely 

represents a non-mental health use, such as for allergies or rashes. 

Claims data also raise concerns about patient adherence to prescribed 

drug regimens, which our experts noted as a patient safety matter. 

Although foster children as a group were 1.7 to 3.3 times more likely to 

have three or more gaps of 7 to 29 days between prescriptions than 

nonfoster children, this is likely related to their overall higher rates of 

 

31Experts also noted that some of these prescriptions may have been written with the 

intention of treating an uninsured parent or sibling. It is not possible to determine from the 

data whether this was the case. 
 

Page 17 GAO-12-270T 

psychotropic prescriptions. When comparing only those prescribed 

psychotropic drugs, nonfoster children were 1.2 to 2.0 times more likely to 

have three or more gaps than foster children, suggesting that adherence 

is higher among foster children. Frequent gaps of 7 or more days in 

prescription claims have a number of potential causes, including a parent 

or the caretaker’s failure to fill prescriptions on behalf of a child in a timely 

manner or a lack of consistent access to care.32 Gaps in drug claims do 

not indicate that the drugs as prescribed have potential health risks. 

However, nonadherence to drug regimens can pose significant risks to a 

patient, such as reduced efficacy from undertreatment, rebound of 

symptoms, and withdrawal symptoms. For example, the sudden 

discontinuation of benzodiazepines such as alprazolam can cause 

seizures33 and the sudden discontinuation of SSRIs34 such as paroxetine

can cause a variety of problems, including dizziness, headaches, fatigue, 

and nausea.35 Nonadherence to a drug regimen can cause the drug to 

appear ineffective even though it was not taken for a full trial. For 

example, antidepressants generally take 3 to 6 weeks to have a beneficial 

effect on the patient’s symptoms.36 Failure to take the antidepressant 

medications for a sufficient length of time may be interpreted as a lack of 

response to the treatment, which can result in the premature switch to or 

addition of other drugs. Table 3 provides more information on gaps in 

prescriptions for foster and nonfoster children by state.

 

32Infrequent gaps may also be caused by a serious illness that prevents the patient from 

taking the medication as prescribed, or patients who choose to discontinue a medication 

because of side effects.

33G. Chouinard, Issues in the clinical use of benzodiazepines: potency, withdrawal, and 

rebound. J Clin Psychiatry. 2004; 65 Suppl 5:7-12.

34Selective serotonin reuptake inhibitors (SSRIs) are antidepressants.

35S. Hosenbocus , R. Chahal, SSRIs and SNRIs: A review of the Discontinuation 

Syndrome in Children and Adolescents. J Can Acad Child Adolesc Psychiatry. 2011 Feb; 

20(1): 60-7.

36National Institute of Mental Health, Mental Health Medications, U.S. Department of 

Health and Human Services. (Bethesda, Md.: Revised 2008).
 

Page 18 GAO-12-270T 

Table 3: Percentage of Children Age 0-17 Prescribed a Psychotropic Drug with 

Three or More Gaps of 7-29 Days in Drug Claims in 5 States

Percent of children who had

three or more gaps in drug 

claims

Percent of children prescribed 

a psychotropic drug who had

three or more gaps in drug 

claims

State 

Foster 

Children

Nonfoster 

Children

Foster 

Children

Nonfoster 

Children

Florida 1.8 1.1 7.8 12.1

Massachusetts 3.4 1.8 8.4 16.4

Michigan 1.7 0.9 7.9 11.3

Oregon 1.6 0.5 7.7 9.5

Texas 2.2 0.7 6.6 8.6

Source: GAO analysis of Medicaid and foster care data for Florida, Massachusetts, Michigan, Oregon, and Texas.

a

Since we used both primary and secondary lists in our gaps analysis, the number of foster and 

nonfoster children prescribed a psychotropic drug is slightly higher than reported in our overall 

prescription rates, which were based on primary drugs only. 

Comparing the selected states’ monitoring programs for psychotropic 

drugs provided to foster children with AACAP’s guidelines indicates that, 

as of October 2011, each of the state programs falls short of providing 

comprehensive oversight as defined by AACAP. Though states are not 

required to follow these guidelines, the six states we examined had

developed monitoring programs that satisfied some of AACAP’s best 

principles guidelines to varying degrees. Such variation is not surprising 

given that states set their own oversight guidelines and have only recently 

been required, as a condition of receiving certain federal child welfare 

grants, to establish protocols for the appropriate use and monitoring of 

psychotropic drugs prescribed to foster children.37

HHS has provided limited guidance to the states on how to improve their 

control measures to monitor psychotropic drug prescriptions to foster 

children. Without formally endorsing specific oversight measures for 

states to implement, HHS conducts state reviews and provides other 

online resources, including the AACAP guidelines, to help states improve 

their programs. ACF performs Child and Family Services Reviews 

(CFSR) of states to ensure conformity with federal child welfare 

 

37Child and Family Services Improvement and Innovation Act, Pub. L. No. 112-34, § 

101(b)(2), 125 Stat. 369 (2011).

Selected States’ 

Psychotropic Drug 

Monitoring Programs 

Fall Short of AACAPBest Principles 

Guidelines
 

Page 19 GAO-12-270T 

requirements—which include provisions for safety, permanency, and 

family and child well-being—and to assist states as they enhance their 

capacity to help families achieve positive outcomes.38 These reviews 

include the examination of a limited number of children’s case files, in part 

to determine whether the state foster care agency conducted 

assessments of children’s mental health needs and provided appropriate 

services to address those needs. However, these reviews are not 

designed to identify specific potential health risk indicators related to 

psychotropic medications, and since they occur every 2 to 5 years, states 

cannot rely on these reviews to actively monitor prescriptions. In addition, 

ACF operates technical assistance centers and provides online resources 

such as links to state guidance on psychotropic drug oversight, academic 

studies on psychotropic drugs, and recordings of teleconferences related 

to the oversight of psychotropic drugs.39

The AACAP guidelines are arranged into four categories, including 

consent, oversight, consultation, and information sharing, that contain 

practices defined as minimal, recommended, or ideal. The following 

describes the extent to which the selected states’ monitoring programs 

cover these areas.

While HHS makes a variety of 

resources available to states developing oversight programs for 

psychotropic drugs, it has not endorsed any specific guidance. In the 

absence of HHS-endorsed guidance, states have developed varied 

oversight programs that in some cases fall short of AACAP’s 

recommended guidelines.

Consent: According to interviews and documentation provided by state 

Medicaid and foster care officials, all six selected states have 

 

38CFSRs, which occur on a regular and recurring basis in every state (generally every 2 to 

5 years depending on the results of the prior review), are the central and most 

comprehensive component of federal efforts to determine state compliance with federal 

child welfare requirements. ACF also reviews states’ progress related to areas found not 

to be in substantial conformity with federal requirements based on the last CFSR, 

generally on an annual basis. 

39In order to be eligible for certain federal child welfare grants, state child welfare agencies 

are required to develop a plan for ongoing oversight and coordination of health care 

services for foster children, including mental health, in coordination with the state Medicaid 

agency, pediatricians, other health care experts, and child welfare experts. See 42 U.S.C. 

§ 622(b)(15). Among other things, the state plans must also include the oversight of 

prescription drugs, and how the agency actively consults and involves physicians and

other professionals in assessing the health and well-being of children in foster care in 

determining appropriate medical treatment for the children. 
 

Page 20 GAO-12-270T 

implemented some practices consistent with AACAP guidelines for 

consent procedures, though in varying scope and application. According 

to AACAP, the consent process should be documented and monitored to 

ensure that caregivers are aware of relevant information, such as the 

child’s diagnosis, expected benefits and risks of treatments, common side 

effects, and potentially severe adverse events. Thus, states that do not 

incorporate consent procedures similar to AACAP’s guidelines may 

increase the likelihood that caregivers are not fully aware of the risks and 

benefits associated with the decision to medicate with psychotropic drugs, 

and may limit the caregiver’s ability to accurately assess and monitor the 

foster child’s reaction to the drugs. Table 4 lists AACAP’s guidelines 

relative to consent and illustrates the extent to which states have 

implemented those guidelines.

Table 4: State Consent Laws and Policies Compared with AACAP’s Best Principles Guidelines

Florida and Michigan provide examples of how states vary in their 

approach to monitoring consent procedures used for psychotropic drugs 

prescribed to foster children. For example, Florida requires all prescribers 
 

Page 21 GAO-12-270T 

to obtain a standardized written consent form from the parental or legal 

guardian, or a court order, before a psychotropic drug is administered.

The consent form includes the diagnosis, dosage, target symptoms, drug 

risks and benefits, drug monitoring plan, alternative treatment options, 

and discussions about the treatment between the child and the parent or 

legal guardian. Florida law identifies who is authorized to give consent, 

and obtains assent for psychotropic drug management from minors when 

age and developmentally appropriate. Florida provides required training 

to caseworkers, but the names and indications for use of commonly 

prescribed psychotropic drugs are not included.

In contrast, Michigan has policies identifying who is authorized to give 

consent to foster children, but does not use a standardized consent form 

that can be used to help inform consent decisions. Instead, Michigan 

requires that caseworkers maintain in their files the consent forms used 

by individual prescribers, which likely vary in content and may thus vary in 

helpfulness to consent givers. Moreover, Michigan does not have training 

requirements in place to help caseworkers, court personnel, and foster 

parents become more effective advocates for children in their custody. 

Training for caseworkers is optional, but according to an agency official, 

the training was unavailable because no trainer had been hired as of 

September 2011. Michigan does not have policies for obtaining assent 

from minors when possible, thus meeting only one of AACAP’s guidelines 

for consent procedures.

Oversight procedures: Each of the six states has developed some 

procedures similar to AACAP’s guidelines for overseeing psychotropic 

drug prescriptions for foster children, as evidenced by interviews and 

documentation provided by state Medicaid and foster care officials.40

 

40Each of the six states reviewed performs a drug utilization review during the prescription 

claims process to promote patient safety, reduce costs, and prevent fraud and abuse as 

required by the Omnibus Budget Reconciliation Act (OBRA) of 1990 (Pub. L. No. 101-508, 

§ 4401, 104 Stat. 1388, § 1388-143). States were encouraged by enhanced federal 

funding to design and install point-of-sale electronic claims management systems that 

interface with their Medicaid Management Information Systems (MMIS) operations. The 

annual report requirement is used to assess patient safety, provider prescribing habits and 

dollars saved by avoidance of problems such as drug-drug interactions, drug-disease 

interactions, therapeutic duplication, and overprescribing by providers. However, the 

extent to which states’ DUR process included reviews of psychotropic drugs varied across 

our states and the DUR process is not focused on the foster child population specifically. 

According to one study, states that implement standards to improve 

oversight of the use of psychotropic drugs may create enhanced 
 

Page 22 GAO-12-270T 

continuity of care, increased placement stability, reduced need for 

psychiatric hospitalization, and decreased incidence of adverse drug 

reactions.41

 

41M. W. Naylor, et al, 2007. Psychotropic Medication Management for Youth in State 

Care: Consent, Oversight, and Policy Considerations, Child Welfare V 86, 5 (2007) p.175-

192. 

As such, states that do not incorporate oversight procedures 

similar to AACAP’s recommendations limit their ability to identify the 

extent to which potentially risky prescribing is occurring in the foster care 

population. Table 5 lists AACAP’s guidelines relative to oversight and 

illustrates the extent to which selected states have implemented those 

guidelines.
 

Page 23 GAO-12-270T 

Table 5: State Oversight Laws and Policies Compared with AACAP’s Best Principles Guidelines
 

Page 24 GAO-12-270T 

Texas and Maryland provide examples of how states vary in their 

approach to oversight of psychotropic drug use among foster children.

For example, the Texas Department of Family and Protective Services 

(DFPS) and the University of Texas at Austin College of Pharmacy 

assembled an advisory committee that included child and adolescent 

psychiatrists, psychologists, pediatricians, and other mental health 

professionals to develop psychotropic drug use parameters for foster 

children. These parameters are used to help identify cases requiring

additional review. Factors that trigger additional reviews include dosages 

exceeding usual recommended levels, prescriptions for children of very 

young age, concomitant use of five or more psychotropic drugs, and 

prescriptions by a primary care provider lacking specialized training.42

Maryland fully applies only one of the six AACAP guidelines for oversight 

procedures and partially applies others. Maryland provides foster children 

in out-of-home placement with a “medical passport” that serves as a 

record of the child’s previous and current medical file. Each topic included 

in AACAP’s guidelines for maintaining ongoing medical records, including 

diagnoses, allergies, and medical history, is documented in the passport, 

and an additional copy of the passport is kept in the child’s case record 

According to the Texas foster care agency’s data analysis, after Texas 

released these guidelines in 2005, psychotropic drug use among Texas 

foster care children declined from almost 30 percent in fiscal year 2004 to 

less than 21 percent in fiscal year 2010. Texas also analyzes Medicaid 

claims data to monitor psychotropic drug prescriptions for foster children 

and to identify any unusual prescribing behaviors. Texas provides 

quarterly reports to child welfare officials on the use of psychotropic drugs 

among foster children and treating clinicians have access to a child’s 

medical records on a 24-hour basis. However, the electronic health 

record system does not always capture the child’s height, weight, and 

allergies, which is optional for prescribers to enter into the system. This 

information is helpful as a child’s weight may be used to determine the 

recommended dose for some medications, while allergy information may 

be used to determine whether a child should take a particular medication.

In addition, ongoing medical problems are not recorded in the electronic 

health record system and Texas does not measure the rate of adverse 

reactions at the macro level among youth in state custody.

 

42Primary care provider prescriptions were not flagged when treating ADHD, 

uncomplicated depression, and uncomplicated anxiety disorders. 
 

Page 25 GAO-12-270T 

and maintained electronically. However, Maryland has not produced any 

specific guidelines for the use of all psychotropic prescriptions among 

foster children, thus limiting the state’s ability to identify potentially risky 

prescribing practices for the foster child population.43

Consultation program: According to interviews and documentation 

provided by state Medicaid and foster care officials, five of the six states 

have implemented some of AACAP’s guidelines for consultation, but only 

one of the six selected states has implemented a consultation program 

that ensures all consent givers and prescribers are able to seek advice 

from child and adolescent psychiatrists before making consent decisions 

for foster children. States that do not have a consultation program to help 

link consent givers and prescribers with child and adolescent psychiatrists 

may reduce the extent to which prescribers and consent givers are 

informed about the expected benefits and risks of treatments, alternative 

treatments, and the risks associated with no treatment. Table 6 lists the 

AACAP guidelines relative to consultation programs and illustrates the 

extent to which selected states have implemented those guidelines.

Without guidelines 

for psychotropic drugs, there are no criteria to help agency officials 

monitor the appropriateness of prescriptions. Moreover, Maryland does 

not review Medicaid claims data statewide specifically for foster children, 

and therefore does not produce quarterly reports to identify the rate and 

types of drugs used in the foster care population that could help identify 

and monitor prescribing trends. In addition, as stated earlier, Maryland’s 

2008 foster care data were found unreliable. Maryland officials told us

that transitioning to a new records system in 2007 resulted in incorrect 

and missing data for foster children.

 

43Beginning October 2011, the Maryland Medicaid Pharmacy Program (MMPP) 

implemented a peer-review authorization process to ensure the safe and effective use of 

antipsychotic medications in children. Claims for antipsychotic medications that are for 

children younger than the FDA-approved age require a Prior Authorization (PA) based on 

the peer-review assessment. The MMPP’s Board-Certified child psychiatrist oversees the 

peer-review project. According to a state agency official, a child and adolescent 

psychiatrist who is faculty at Johns Hopkins University School of Medicine monitors all 

psychotropic medication use for children entering foster care in Baltimore City. However, 

this practice is not statewide. 
 

Page 26 GAO-12-270T 

Table 6: State Consultation Programs Compared with AACAP’s Best Principles Guidelines

Massachusetts and Oregon provide examples of how states vary their 

approach in providing expert consultations to caregivers. For example, 

Massachusetts’s foster care agency started an initiative to connect child 

welfare staff to Medicaid pharmacists who can provide information on 

medications and the foster child’s drug history, including interactions 

between any current and proposed drugs. In addition, primary care 

physicians who treat children, including foster care children, also have 

access to the state-funded Massachusetts Child Psychiatry Access 

Project, a system of regional children’s mental health consultation teams 

designed to help pediatricians find and consult with child psychiatrists. 

Massachusetts has six child psychiatrists who are available to provide 

consultations on a part-time basis to child welfare staff, but these 
 

Page 27 GAO-12-270T 

consultations are not available for other consent givers such as foster 

parents. The foster care agency’s consultation program also provides 

face-to-face evaluations of foster children at the request of consent givers 

concerned about a child’s treatment.

In early 2009, Oregon put a consultation program in place to help consent 

givers make informed decisions. In 2010, Oregon’s foster care agency 

shifted the responsibility for all consent decisions where the agency has 

legal custody or is the legal guardian of the child from foster parents to 

child welfare agency officials, who now have access to a child and 

adolescent psychiatrist and can seek consultations before making 

consent decisions. However, the consultation program does not conduct 

face-to-face evaluations of children—by a child and adolescent 

psychiatrist—at the request of consent givers, nor does it enable 

prescribing physicians to consult with child and adolescent psychiatrists. 

Oregon has plans for the development of the Oregon Psychiatric Access 

Line for Kids, which would allow primary care physicians and nurse 

practitioners to consult with child psychiatrists, but agency officials told us 

the program is not operational due to a lack of funding.

Information sharing: Four of the six selected states have created 

websites with information on psychotropic drugs for clinicians, foster 

parents, and other caregivers. Access to comprehensive information can

help ensure that clinicians, foster parents, and other interested parties are 

fully informed about the use and management of psychotropic drugs. 

Table 7 lists AACAP’s guidelines relative to information sharing and 

illustrates the extent to which selected states have implemented those 

guidelines.
 

Page 28 GAO-12-270T 

Table 7: State Information-sharing Laws and Policies Compared with AACAP’s Best Principles Guidelines

For example, Florida’s foster care agency has partnered with the 

University of South Florida to implement Florida’s Center for the 

Advancement of Child Welfare Practice to provide needed information 

and support to Florida’s professional child welfare stakeholders.44

 

44According to the Center’s website, its mission is to support and facilitate the 

identification, expansion, and transfer of expert knowledge and best practices in child 

welfare case practice, direct services, management, finances, policy, and organizational 

development to child welfare and child protection stakeholders throughout Florida. 

The 
 

Page 29 GAO-12-270T 

program’s website is consistent with four of AACAP’s six guidelines for 

information sharing. For example, the website includes policies and 

procedures governing psychotropic drug management, staff publications 

and educational materials about psychotropic drugs, consent forms, and 

links to other informative publications and news stories related to foster 

children and psychotropic drugs. However, the website does not provide 

reports on prescription patterns for psychotropic drugs or adverse effect 

rating forms.

In comparison, Oregon’s foster care agency developed a website that 

includes information regarding psychotropic medication, but the website is 

not updated regularly to operate as an ongoing information resource. The 

website currently has information on state policies and procedures 

governing the use of psychotropic drugs and also contains web links to 

consent forms and a medication chart that can be used as a psychotropic 

medication reference tool. However, the website does not meet three of 

the six information-sharing guidelines, including those on posting adverse 

effect rating forms, reporting prescription patterns, and providing links to 

other informative websites. States with less accessibility to 

comprehensive information may limit the extent to which physicians, 

foster parents, and other interested parties are informed about the use 

and management of psychotropic drugs.

The higher rates of psychotropic drug prescriptions among foster children 

may be explained by their greater mental health needs and the 

challenges inherent to the foster care system. However, thousands of 

foster and nonfoster children in the five states we analyzed were found to 

have prescriptions that carry potential health risks. While doctors are 

permitted to prescribe these drugs under current laws, increasing the 

number of drugs used concurrently and exceeding the maximum 

recommended dosages for certain psychotropic drugs have been shown 

to increase the risk of adverse side effects in adults. Prescriptions for 

infants are also of concern, due to the potential for serious adverse 

effects even when these drugs are used for non-mental health purposes. 

Comprehensive oversight programs would help states identify these and 

other potential health risks and provide caregivers and prescribers with 

the information necessary to weigh drug risks and benefits. The recently 

enacted Child and Family Services Improvement and Innovation Act 

requires states to establish protocols for monitoring psychotropic drugs 

prescribed to foster children. Under the act, each state is authorized to 

develop its own monitoring protocols, but HHS-endorsed, nationwide 

guidelines for consent, oversight, consultation, and information sharing 

Conclusions
 

Page 30 GAO-12-270T 

could help states close the oversight gaps we identified and increase 

protections for this vulnerable population.

In our draft report, we recommended that the Secretary of HHS evaluate 

our findings and consider endorsing guidance to state Medicaid and child 

welfare agencies on best practices for monitoring psychotropic drug 

prescriptions for foster children, including guidance that addresses, at 

minimum, informed consent, oversight, consultation, and information 

sharing.

We have received written comments on our draft report from HHS and 

relevant agencies in 6 states. In written comments, HHS agreed with our 

recommendation and provided technical comments, which we 

incorporated as appropriate. In written comments and exit conferences, 

staff from state Medicaid and foster care agencies provided comments on 

key facts from the report. Agency comments will be incorporated and 

addressed in a written report that will be issued in December 2011.

Chairman Carper, Ranking Member Brown, and Members of the 

Subcommittee, this completes my prepared statement. I would be 

pleased to respond to any questions that you may have at this time.

For additional information about this testimony, please contact Gregory D. 

Kutz at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this statement.

Recommendation for 

Executive Action

GAO Contacts
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