FOSTER CARE

HHS Has Taken Steps 

to Support States’ 

Oversight of 

Psychotropic 

Medications, but 

Additional Assistance 

Could Further 

Collaboration

Report to Congressional Requesters

January 2017

GAO-17-129

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-129, a report to 

congressional requesters

January 2017

FOSTER CARE:

HHS Has Taken Steps to Support States' Oversight of 

Psychotropic Medications, but Additional Assistance 

Could Further Collaboration

What GAO Found

State child welfare and Medicaid officials in seven selected states reported a 

variety of practices to support the appropriate use of psychotropic medications, 

which affect mood, thought, or behavior, for children in foster care. Practices

include screening for mental health conditions, developing prescription 

guidelines, and monitoring a child’s health while on medication. Additional state 

efforts aim to increase mental health knowledge among stakeholders and 

improve access to mental health services. However, officials in four selected 

states and from five national mental health organizations said limited access to 

mental health services was a challenge. Five of the selected states have begun 

offering remote consultation services that connect patients with mental health 

specialists. State officials said strong interagency collaboration and outreach to 

stakeholders helped them implement practices more effectively.

While some selected states have reduced medication use among these children, 

states focused on other measures to gauge the results of their efforts. Four of 

the seven selected states reduced medication use from 2011 through 2015, two 

states had steady rates, and the remaining state did not have data during this 

time period. These data, however, cannot be compared across states because 

states use different methodologies to collect data. Officials in three selected 

states said reducing medication use may not be appropriate for every child, and 

officials in all seven states said they focus instead on measures such as tracking 

the use of medications that can have negative side effects and the use of 

psychosocial services (e.g., therapy) for children in foster care. Officials in most 

selected states discussed limitations with gathering data needed to oversee 

medication use, such as disparate data systems, resource constraints, and

privacy concerns related to data sharing among state child welfare and Medicaid 

agencies and with managed care organizations. Officials in some states that 

shared data said they overcame privacy concerns through written interagency 

agreements and educating stakeholders.

The Department of Health and Human Services (HHS) has taken steps to help 

state child welfare and Medicaid agencies support the appropriate use of 

psychotropic medications and identify mental health needs and treatments for 

children in foster care. HHS has focused its efforts on practices for prescribing, 

screening and diagnosis, and access to trauma-related services. HHS is also 

working with states to implement voluntary measures to track medication use,

other mental health treatments, and a child’s overall health. In 2012, HHS hosted 

a meeting for state leaders to help them establish effective medication oversight 

practices. Despite the positive outcomes resulting from this meeting, and HHS 

guidance that says an agency goal is to facilitate cross-system collaborations, 

such as in the oversight of psychotropic medications, it has not convened 

meetings with all stakeholders together since 2012. Though HHS has conducted 

webinars, created learning communities, and convened smaller meetings, HHS 

officials said it has no plans to convene all stakeholders as it did in 2012 due to 

resource constraints. Officials in three selected states said more federal support 

to bring together state stakeholders could help address ongoing issues, such as 

privacy concerns around data sharing. 

View GAO-17-129. For more information, 

contact Kay E. Brown at (202) 512-7215 or 

brownke@gao.gov.

Why GAO Did This Study

GAO previously reported that children 

in foster care in five selected states 

were prescribed psychotropic 

medications at higher rates than other 

children on Medicaid. GAO also 

reported that some prescriptions were 

not supported by research and could 

pose health risks. GAO was asked to 

study efforts to oversee psychotropic 

medications for children in foster care 

since GAO last reported on the issue in 

2014.

GAO examined (1) how child welfare 

and Medicaid agencies in selected 

states ensure the appropriate use of 

psychotropic medications for children 

in foster care, (2) what is known about 

the results of their efforts, and (3) the 

extent to which HHS helps states 

support appropriate medication use. 

GAO reviewed relevant federal laws, 

regulations, and guidance; visited a 

nongeneralizable group of seven 

states and five counties in two of those 

states, selected by foster care 

population and diversity of location; 

analyzed selected states’ data on 

medication use in foster care

populations; and interviewed officials 

from federal, state, and county child 

welfare, Medicaid, and other agencies,

as well as officials from nine relevant 

national organizations selected to 

represent a variety of views.

What GAO Recommends

GAO recommends that HHS consider 

cost-effective ways to convene state 

child welfare, Medicaid, and other 

stakeholders to promote collaboration 

and information sharing on 

psychotropic medication oversight.

HHS agreed with GAO’s 

recommendation and provided 

technical comments.
Page i GAO-17-129 Foster Care

Letter 1

Background 5

Selected States Have Practices to Support the Prescribing 

Process and Educate Stakeholders on the Appropriate Use of 

Psychotropic Medications 14

While Some Selected States Reduced the Use of Psychotropic 

Medications, They All Focused on Other Measures to Gauge 

the Results of Their Efforts 25

HHS Assists States in Addressing Medication Use and the Mental 

Health Needs of Children, Though More Could Be Done to 

Support Collaboration across State Agencies 33

Conclusions 44

Recommendation for Executive Action 45

Agency Comments and Our Evaluation 45

Appendix I Objectives, Scope, and Methodology 47

Appendix II Selected State Information 51

Appendix III Agency Comments from the Department of Health 

and Human Services 58

Appendix IV Staff Acknowledgments 61

Related GAO Products 62

Figures

Figure 1: Examples of Stakeholders That May Be Involved in 

Ensuring Appropriate Mental Health Treatments for 

Children in Foster Care 9

Figure 2: Activities for Physicians in Prescribing Psychotropic 

Medications to Children 12

Contents
Page ii GAO-17-129 Foster Care

Figure 3: Selected States’ Practices to Assess Children’s Mental 

Health Needs 16

Figure 4: Selected States’ Practices to Support Appropriate 

Treatments for Children 17

Figure 5: Selected States’ Practices to Seek Agreement on a 

Child’s Prescription 19

Figure 6: Selected States’ Practices for Ongoing Oversight of a 

Child’s Prescriptions 20

Figure 7: Selected States’ Practices to Increase Stakeholders’ 

Mental Health Knowledge and Access to Mental Health 

Services for Children 21

Abbreviations 

AACAP American Academy of Child & Adolescent Psychiatry

ACF Administration for Children and Families

ADHD attention deficit hyperactivity disorder 

CMS Centers for Medicare & Medicaid Services

EPSDT Early and Periodic Screening, Diagnostic, and Treatment 

HEDIS Healthcare Effectiveness Data and Information Set

HHS Department of Health and Human Services

SAMHSA Substance Abuse and Mental Health Services 

Administration 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-17-129 Foster Care

441 G St. N.W.

Washington, DC 20548

January 5, 2017

The Honorable Orrin Hatch

United States Senate

The Honorable Ron Wyden

United States Senate

The Honorable Tom Carper

United States Senate

The Honorable Claire McCaskill

United States Senate

Multiple studies have shown that children in foster care may have more 

mental health conditions than those in the general population,1 and prior 

GAO reports have looked at the rate at which these children are 

prescribed psychotropic medications, which affect mood, thought, or 

behavior.2 While information on the number of children in foster care on 

psychotropic medications nationwide is limited, in our prior work we found 

that these children in five selected states were prescribed psychotropic 

medications at rates 2.7 to 4.5 times higher than other children on 

 1

See, for example, H. Ringeisen, C. Casanueva, K. Smith, and M. Dolan, National Survey 

of Child and Adolescent Well-Being II Baseline Report: Children’s Services, OPRE Report 

#2011-27f (Washington, D.C.: Office of Planning, Research and Evaluation, 

Administration for Children and Families, U.S. Department of Health and Human Services, 

November 2011) and D. Johnson and M. R. Gunnar, “Growth Failure in Institutionalized 

Children,” Monographs of the Society for Research in Child Development, vol. 76, no. 4 

(2011).

2

See, for example, GAO, Foster Children: HHS Guidance Could Help States Improve 

Oversight of Psychotropic Prescriptions, GAO-12-201 (Washington, D.C.: Dec. 14, 2011), 

Children’s Mental Health: Concerns Remain about Appropriate Services for Children in 

Medicaid and Foster Care, GAO-13-15 (Washington, D.C.: Dec. 10, 2012), and Foster 

Children: Additional Federal Guidance Could Help States Better Plan for Oversight of 

Psychotropic Medications Administered by Managed-Care Organizations, GAO-14-362 

(Washington, D.C.: April 28, 2014). Also see related GAO products listed at the end of this 

report. 

Letter
Page 2 GAO-17-129 Foster Care

Medicaid in 2008.3 As part of that review, we also reported on the 

prevalence of certain prescribing patterns not supported by research that 

could pose health risks. These patterns included the use of five or more 

psychotropic medications at the same time, doses exceeding maximum 

levels based on labels approved by the Food and Drug Administration, 

and prescriptions made to children under the age of 1.

There are a number of state and federal agencies that play a role in 

ensuring that children in foster care receive appropriate treatments for 

mental health conditions. At the state level, child welfare and Medicaid 

agencies, along with other partners, have various responsibilities that 

help ensure appropriate treatments for children in foster care.4 State child 

welfare agencies are primarily involved in determining where and with 

whom a child in foster care should live (placement) and for providing or 

arranging needed supports, including certain physical and mental health 

services. In addition, most children in foster care are eligible for Medicaid,

and state Medicaid agencies may choose from a variety of delivery 

systems to provide and pay for their health services.5 At the federal level, 

the Department of Health and Human Services (HHS) monitors state 

implementation of relevant federal programs, including those that provide 

federal assistance to support state child welfare and foster care 

 3

GAO-12-201. Determining the number of children in foster care on psychotropic 

medications nationwide is difficult, in part, because the Medicaid Statistical Information 

System—used to collect key eligibility, enrollment, program, utilization, and expenditure 

data for the Medicaid program from states—may not reliably identify information 

specifically for children in foster care. In the report cited above, we identified psychotropic 

medication claims for children in foster care and on Medicaid by requesting and matching 

Medicaid and foster care data in the states selected for review.

4

Several states provide child welfare and Medicaid services under county- rather than 

state-administered agencies. While this report focuses on states, the District of Columbia, 

certain U.S. territories, and Indian tribal organizations may also participate in federal 

programs that support child welfare and foster care programs, as well as Medicaid. 

5

Medicaid is a joint federal-state program that pays for covered health care services, 

including prescription medications, for eligible low-income individuals. See 42 U.S.C. § 

1396 et seq. Certain children in foster care are categorically eligible for Medicaid, such as 

those receiving foster care maintenance payments under title IV-E of the Social Security 

Act. States are required to provide Medicaid coverage to such children. Children in foster 

care who are not eligible under this category may qualify for Medicaid under optional 

eligibility criteria established by a particular state. According to the Congressional 

Research Service, nearly all children who are in foster care are eligible for health care 

services funded via Medicaid. In addition, some children in foster care may be eligible for 

the State Children’s Health Insurance Program, a federal-state program that provides 

health care coverage to children living in families whose incomes exceed the eligibility 

requirements for Medicaid. However, we focus only on Medicaid in this report.
Page 3 GAO-17-129 Foster Care

programs, through the Administration for Children and Families (ACF). 

HHS also oversees the Medicaid program through the Centers for 

Medicare & Medicaid Services (CMS), in accordance with federal laws, 

regulations, and guidance. These agencies, along with HHS’s Substance 

Abuse and Mental Health Services Administration (SAMHSA)—which 

undertakes efforts to improve substance abuse and mental health 

treatment, prevention, and related services for individuals—provide 

support to states in their efforts to ensure child well-being.

You asked us to study efforts to oversee psychotropic medications for 

children in foster care since we last reported on the issue in 2014. This 

report examines:

1. how child welfare and Medicaid agencies in selected states work to 

ensure the appropriate use of psychotropic medications for children in 

foster care;

2. what is known in selected states about the results of their efforts to 

ensure the appropriate use of psychotropic medications for these 

children; and

3. the extent to which HHS helps states support the appropriate use of 

psychotropic medications for children in foster care.

To address all objectives, we conducted in-person and telephone 

interviews with officials in seven selected states, including those from 

child welfare and Medicaid agencies, and with nine national professional 

and research organizations selected to represent a variety of views on 

child welfare, Medicaid, and mental health-related policy and research. 

The states we selected were Arizona, California, Illinois, Maryland, New 

Jersey, Ohio, and Washington. Our selection criteria included (1) a high 

percentage of children in foster care in the state when compared 
Page 4 GAO-17-129 Foster Care

nationwide in fiscal year 2014;6 (2) variation in Medicaid7 and child 

welfare systems;8 (3) recommendations from national organizations; and 

(4) geographic diversity. In the two selected states with countyadministered child welfare systems, California and Ohio, we selected five 

counties and conducted interviews with officials from the respective 

county-level child welfare and Medicaid agencies, as appropriate.9 These 

counties were selected based on factors similar to those mentioned 

above as well as variation in population density (i.e., rural versus urban). 

We also conducted a review of selected literature related to the use of 

psychotropic medications among children in foster care.

To examine how state child welfare and Medicaid agencies work to 

ensure the appropriate use of psychotropic medications, we also 

reviewed guidance and other documents identified by officials from 

selected states and counties. While we identified selected states’

oversight practices related to psychotropic medications based on 

interviews and these document reviews, we did not assess states’

 6

We paid particular attention to states that placed a high percentage of their children in 

foster care in congregate care, which provides structured 24-hour care in a group setting. 

For example, residential treatment centers are inpatient facilities other than a hospital that 

provide specialized services to children, such as psychiatric services. We included these 

data as part of our selection criteria because HHS previously reported that children placed 

in group homes or residential treatment centers had higher rates of psychotropic 

medication use than children in other placements, which may be related to these children 

having higher rates of potential mental health need. See L.F. Stambaugh et al., 

Psychotropic Medication Use by Children in Child Welfare, OPRE Report #2012-33 

(Washington, D.C.: Office of Planning, Research and Evaluation, Administration for 

Children and Families, U.S. Department of Health and Human Services, 2012) and H. 

Ringeisen et al., OPRE Report #2011-27f. For the purposes of our report, references to 

“children in foster care” include those placed in congregate care as well as in other types 

of settings. 

7

Of our seven selected states, three states—Illinois, Maryland, and Ohio—use a fee-forservice system to deliver psychotropic medications and mental health services to children 

in foster care on Medicaid. Of the remaining four states, Arizona uses multiple managed 

care organizations to deliver these services, California may deliver these services under 

fee-for-service or managed care depending on the county, New Jersey uses multiple 

organizations to deliver psychotropic medications and a fee-for-service system for other 

mental health services, and Washington transitioned the delivery of these services from a 

fee-for-service system to a single managed care organization as of April 1, 2016.

8

Of our seven selected states, five states have state-administered child welfare systems 

(Arizona, Illinois, Maryland, New Jersey, and Washington) and two have countyadministered systems (California and Ohio).

9

The counties selected include Fairfield, Lucas, and Perry counties in Ohio, and Los 

Angeles and Sonoma counties in California.
Page 5 GAO-17-129 Foster Care

implementation of specific practices. In addition, while we focused our 

review on children in foster care, state oversight practices may also 

pertain to other children on Medicaid. To examine the results of state 

efforts to ensure the appropriate use of psychotropic medications, we 

gathered and analyzed available data from selected states on the use of 

these medications among children in foster care from 2011 through 

2015.10 We determined these data were sufficiently reliable for the 

purposes of describing trends in the percentage of children in foster care 

on psychotropic medications for each of the selected states. However, 

because these states use different methodologies to collect data, the data 

are not comparable among them. In addition, the results of our analyses 

are not generalizable nationwide. To examine HHS’s actions to support 

state efforts related to psychotropic medications, we interviewed officials 

from ACF, CMS, and SAMHSA, and we reviewed relevant documents. 

We also examined applicable federal laws, regulations, and guidance. For 

additional information on our scope and methodology, see appendix I.

We conducted this performance audit from September 2015 to January 

2017 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.

Children enter foster care when they have been removed from their 

parents or guardians for reasons such as abuse or neglect, and placed 

under the responsibility of a state child welfare agency. The agency 

generally places the child in the home of a relative, with unrelated foster 

parents, or in a group home or residential treatment center, depending on 

the child’s needs. Child welfare caseworkers at the agency are typically 

responsible for coordinating placement and needed support services for 

these children, including those for mental health. If a child is determined 

to be in need of mental health services, the caseworker is generally 

 10We analyzed data for six of our seven selected states. The remaining state—Ohio—was 

unable to provide data from 2011 through 2015. Ohio child welfare officials said they did 

not collect data on the use of medications in the past, but began to do so as of May 2016. 

Background

Administration of Child 

Welfare and Medicaid 

Programs
Page 6 GAO-17-129 Foster Care

responsible for arranging such services to be provided by primary care 

physicians, child psychiatrists, or other mental health providers.11 State 

courts, typically juvenile or family courts, are also frequently involved in 

decisions regarding a child’s removal, placement, and services.

Most children in foster care are eligible for Medicaid, and those enrolled 

may receive physical and mental health services through a variety of 

service delivery and provider payment systems, such as fee-for-service 

and managed care.12 In the traditional fee-for-service delivery system, the 

state Medicaid agency manages the program and reimburses physicians 

directly and on a retrospective basis for each health service delivered. 

Under a managed care model, states contract with one or more managed 

care organizations and prospectively pay the organizations a fixed 

monthly fee per patient to provide or arrange for defined health services, 

which may include mental health services and prescription medications. 

These organizations, in turn, pay physicians.

States are primarily responsible for administering their child welfare and 

foster care programs, consistent with applicable federal laws and 

regulations, which include some requirements that relate to ensuring the 

well-being of children served by these programs. For example, title IV-E 

of the Social Security Act authorizes federal funding to states to help 

cover the costs of operating their foster care and certain other 

programs.13 In addition, title IV-B of the Social Security Act authorizes 

federal funds to support state child welfare programs and services.14 Both 

of these programs establish various requirements that participating states 

must comply with in order to receive the federal funding. The Fostering 

Connections to Success and Increasing Adoptions Act of 2008 amended 

title IV-B to add a requirement that states develop a plan for the ongoing 

 11For the purposes of our report, we refer to providers who are able to prescribe 

psychotropic medications and provide mental health services as “physicians.” These 

providers may be primary care physicians, pediatricians, psychiatrists, or other kinds of 

providers.

12Some states may use various combinations of fee-for-service and managed care 

systems for different types of health services and populations. For example, a state may 

provide mental health services, such as therapy for children in foster care, under a fee-forservice system, but use a managed care system to provide prescription drug coverage to 

this population.

13Title IV-E is codified at 42 U.S.C. §§ 670-679c. Among other things, title IV-E provides 

federal financial support to states for the care of eligible children in foster care.

14Title IV-B is codified at 42 U.S.C. §§ 621-629m.
Page 7 GAO-17-129 Foster Care

oversight and coordination of health care services for children in foster 

care, including mental health and oversight of prescription medications.15

The Child and Family Services Improvement and Innovation Act amended 

this provision to require that these plans include protocols for the 

appropriate use and monitoring of psychotropic medications.16 HHS’s 

ACF is responsible for monitoring state implementation of title IV-E and 

IV-B programs. For example, ACF conducts reviews of state child welfare 

and foster care programs every 5 years to ensure conformity with 

requirements under these federal programs.17 ACF also monitors state 

compliance with title IV-B plan requirements, including the health care 

oversight and coordination plan, through its review of states’ five-year 

Child and Family Services Plans and Annual Progress and Services 

Reports.18 In addition, ACF’s mission is to promote the economic and 

social well-being of families, children, individuals, and communities 

through funding, guidance, training, and technical assistance.

Under the Medicaid program, states are required to provide eligible 

children under age 21 with coverage for certain health services, which 

may include mental health services, through the Early and Periodic 

Screening, Diagnostic, and Treatment (EPSDT) benefit.19 Specifically, 

 15Pub. L. No. 110-351, § 205, 122 Stat. 3949, 3961-62. Specifically, the act required that 

states develop, in coordination and collaboration with certain state agencies, including the 

state Medicaid agency, and in consultation with pediatricians, other experts in health care, 

and experts in and recipients of child welfare services, “a plan for the ongoing oversight 

and coordination of health care services for any child in a foster care placement, which 

shall ensure a coordinated strategy to identify and respond to the health care needs of 

children in foster care placements, including mental health and dental health needs.” The 

act further specified that the plan shall include, among several other required elements, an 

outline of the oversight of prescription medicines.

16Pub. L. No. 112-34, § 101(b)(2), 125 Stat. 369 (2011) (codified at 42 U.S.C. § 

622(b)(15)).

17ACF’s periodic assessments are known as Child and Family Services Reviews. They 

involve case file reviews and stakeholder interviews, and are structured to help states 

identify strengths and areas needing improvement within their agencies and programs. 

States found not to be in substantial conformity with federal requirements must develop a 

program improvement plan and undergo a review every 2 years instead of 5 years. See 

45 C.F.R. §§ 1355.31-1355.37. ACF has conducted two rounds of reviews to date. The 

third round, which should have started in 2012, was delayed because ACF was revising 

the instrument used to assess states. ACF reported that the third round of reviews began 

in 2015 and is expected to be completed in 2018. 

18See 45 C.F.R. §§ 1357.15-1357.16.

19See 42 U.S.C. §§ 1396a(a)(43), 1396d(a)(4)(B) and (r). 
Page 8 GAO-17-129 Foster Care

federal law requires coverage of periodic screening services, including a 

comprehensive health and developmental history of both physical and 

mental health development, a comprehensive physical exam, appropriate 

immunizations, laboratory tests, and health education. The EPSDT 

benefit also covers treatment services necessary to correct or ameliorate 

any identified physical or mental illnesses or conditions. HHS’s CMS 

oversees state Medicaid programs and provides federal matching funds 

for eligible services. On an annual basis, states are required to report to 

CMS information on their Drug Utilization Review programs, including 

prescribing patterns, cost savings generated by the programs, an 

assessment of the programs’ impact on quality of care, and program 

operations, including information on new innovative practices adopted by 

states.20 CMS includes these reports on its website.21

In addition, state mental health agencies are generally responsible for 

planning and operating state mental health systems, and play an 

important role in administering, funding, and providing treatments.22

These agencies may manage mental health-related federal grants and 

may work with other state agencies—such as state Medicaid agencies—

to identify and treat mental health conditions. They may also contract 

directly with physicians to deliver treatments or may contract with county 

or city governments responsible for the delivery of treatments within their 

local areas. HHS’s SAMHSA engages in activities intended to help 

improve the behavioral health of children in foster care. Such efforts 

include grants that support the development of community-based services 

 20The Medicaid statute and regulations require states to establish Drug Use Review 

programs (commonly referred to as Drug Utilization Review programs), which are to 

include a prospective drug review (screening before prescriptions are filled to identify 

potential problems, such as duplication of drug therapies, incorrect dosages, and clinical 

misuse or abuse); a retrospective drug use review (an examination of claims data that is 

to occur at least quarterly, to identify patterns of fraud, abuse, gross overuse, or 

inappropriate or medically unnecessary care); and an ongoing educational outreach 

program to educate practitioners on common drug therapy problems with the aim of 

improving prescribing and dispensing practices. 42 U.S.C. § 1396r-8(g); 42 C.F.R. §§ 

456.700-456.725. These reviews are required only for claims made under fee-for-service 

systems, although managed care organizations providing drug coverage will be required 

to conduct such reviews beginning in 2017. 81 Fed. Reg. 27,498, 27,857 (May 6, 2016) 

(to be codified at 42 C.F.R. § 438.3(s)(4)).

21See https://www.medicaid.gov/medicaid-chip-program-information/bytopics/benefits/prescription-drugs/drug-utilization-review.html.

22State mental health agencies can be referred to as “behavioral health agencies.” These 

agencies may also be involved in efforts related to substance abuse and other behavioral 

health conditions.
Page 9 GAO-17-129 Foster Care

for children with mental health conditions and information sharing on 

psychotropic medication practices. Many stakeholders may be involved in 

ensuring appropriate mental health treatments for children in foster care 

(see fig. 1).23

Figure 1: Examples of Stakeholders That May Be Involved in Ensuring Appropriate Mental Health Treatments for Children in 

Foster Care

a

For the purposes of our report, we refer to providers who are able to prescribe psychotropic 

medications and provide mental health services as “physicians.” These providers may be primary 

care physicians, pediatricians, psychiatrists, or other kinds of providers.

Note: Because each state may have a different structure for delivering child welfare and mental 

health services, all of these stakeholders may not be involved in a child’s mental health treatment and 

stakeholders may be associated with different local, county, state, or federal agencies. In addition, 

this graphic may not represent all stakeholders that may be involved.

 23For the purposes of our report, references to “stakeholders” can include those described 

in figure 1.
Page 10 GAO-17-129 Foster Care

Psychotropic medications can have significant benefits for those with 

mental health conditions by affecting brain activity associated with mental 

processes and behavior.24 However, they can also have side effects 

ranging from mild to serious, depending on the class and type of 

medication used. According to the American Academy of Child & 

Adolescent Psychiatry (AACAP), medications for attention deficit 

hyperactivity disorder (ADHD), such as amphetamines (e.g., Adderall) 

and methylphenidate (e.g., Ritalin and Concerta), can reduce symptoms 

such as hyperactivity in children as well as improve their attention and 

increase their ability to get along with others.25 These medications have 

been widely tested in children and are generally considered safe; 

however, ADHD medications have also been associated with side effects 

such as sleeplessness, loss of appetite, tics, agitation, hallucinations, liver 

problems, and suicidal thoughts. In addition, antidepressants, such as 

fluoxetine (e.g., Prozac) and sertraline (e.g., Zoloft) can be used to treat 

conditions such as depression and anxiety. However, possible adverse 

side effects include agitation, sleeplessness or drowsiness, and suicidal 

thoughts. The use of antipsychotics—one class of psychotropic 

medication—has been of particular concern. Antipsychotic medications, 

such as aripiprazole (e.g., Abilify) and risperidone (e.g., Risperdal), were 

developed to treat conditions such as bipolar disorder or schizophrenia. 

 24The definition of what is considered a psychotropic medication can vary among states. 

Some states have developed lists that identify medications they consider to be 

psychotropic while others have not, for example, due to challenges with determining which 

medications to include. Among the available medication lists we examined in the seven

states we selected for review, classes of medications included for most or all states 

include ADHD medications, anti-anxiety medications, anticonvulsants or mood stabilizers, 

antidepressants, antipsychotics, and hypnotics or sleep agents. Some states also include 

antihistamines, anti-hypertensives, and anti-Parkinson and dementia medications. Child 

welfare and Medicaid officials in one state explained that medications such as 

antihistamines and anti-hypertensives can be used for psychiatric purposes; however, if it 

is clear that the medication is being used for a non-psychiatric reason, the state may not 

consider it a psychotropic medication. While these states include similar classes of 

medications in their lists, they may not include all of the same medications in each class. 

In addition, child welfare and Medicaid officials in a few of the selected states said they 

were in the process of updating their lists, and officials in one state noted they use 

different lists depending on their purpose (e.g., examining trends in medication use versus 

determining which prescriptions are subject to additional reviews before they can be 

dispensed).

25AACAP is a non-profit professional organization that promotes the healthy development 

of children, adolescents, and families through advocacy, education, and research, and 

helps meet the professional needs of child and adolescent psychiatrists throughout their 

careers. It has issued a number of resources and guidance for families, physicians, and 

government agencies on mental health treatments for children. See 

http://www.aacap.org/. 

Psychotropic Medications 

and Other Mental Health 

Treatments for Children
Page 11 GAO-17-129 Foster Care

However, possible adverse side effects can be serious, including 

increased levels of cholesterol, rapid weight gain, and the development of 

diabetes or irreversible movement disorders.26 Mental health researchers 

and others have stated the need for further research on the safety, 

effectiveness, and long-term effects of antipsychotics for children.

Psychosocial services are mental health treatments that generally involve 

therapy sessions with a mental health professional that are designed to 

reduce patients’ emotional or behavioral symptoms. Such therapies may 

be used instead of, or in combination with, psychotropic medications to 

treat children with mental health conditions. Several large, federally 

funded studies have demonstrated that treatment with a combination of a 

psychosocial therapy and a psychotropic medication can be more 

effective than either treatment alone for certain conditions.27 Further, 

psychosocial services shown to be effective in treating mental health 

conditions may be referred to as evidence-based therapies. While there is 

no standard definition of what constitutes “evidence-based,” some federal 

agencies and provider organizations, such as SAMHSA and AACAP, 

evaluate and compile information on available therapies.28

In response to concerns about psychotropic prescribing practices for 

children, especially involving those in foster care, AACAP has developed 

multiple resources to promote the appropriate and safe use of these 

medications. For physicians, AACAP issued best practice guidelines in 

 26For example, a 2009 study of 272 children who were prescribed an antipsychotic 

medication found that after a median treatment period of nearly 11 weeks, children who 

had taken a medication had gained, on average, between 9.7 and 18.7 pounds compared 

to minimal weight gain by children who had refused medication. See C. Correll, P. Manu, 

V. Olshanskiy, B. Napolitano, J. Kane, and A. Malhotra, “Cardiometabolic Risk of SecondGeneration Antipsychotic Medications During First-Time Use in Children and 

Adolescents,” JAMA, vol. 302, no. 16 (2009).

27See, for example, J. Walkup et al., “Cognitive behavioral therapy, sertraline, or a 

combination in childhood anxiety,” New England Journal of Medicine, vol. 359, no. 26 

(2008).

28See, for example, SAMHSA’s National Registry of Evidence-based Programs and 

Practices, a list of treatments that have been assessed by independent evaluators and 

rated on the strength of the evidence showing their effectiveness. 

http://nrepp.samhsa.gov/.

Guidance on Oversight of 

Psychotropic Medications
Page 12 GAO-17-129 Foster Care

2009 that establish key activities before and after prescribing 

psychotropic medications to children (see fig. 2).29

Figure 2: Activities for Physicians in Prescribing Psychotropic Medications to Children

Building on these guidelines for physicians, AACAP developed best 

practice guidelines for states in 2012 and 2015, with support and partial 

funding from SAMHSA, that establish practices for overseeing the use of 

psychotropic medications for children in foster care as well as other 

children in state custody.30 An overarching principle outlined in AACAP 

guidelines is that the use of psychotropic medications for these children 

should be part of a holistic and collaborative mental health treatment 

approach that recognizes (1) the biological, psychological, and social 

factors that may impact a child; (2) trauma-informed care principles that 

acknowledge the prevalence and impact of trauma, and a commitment to 

minimize its effects and avoid additional traumatization; and (3) childserving agencies as part of a system of care for the child, and services 

that should be youth-guided, home and community-based, integrated 

across systems, data-driven, and outcome-oriented, among other things.

 29J. Walkup et al., “Practice Parameter on the Use of Psychotropic Medication in Children 

and Adolescents,” Journal of the American Academy of Child & Adolescent Psychiatry, 

vol. 48, no. 9 (2009).

30American Academy of Child & Adolescent Psychiatry, A Guide for Community Child 

Serving Agencies on Psychotropic Medications for Children and Adolescents (Feb. 12, 

2012) and American Academy of Child & Adolescent Psychiatry, Recommendations about 

the Use of Psychotropic Medications for Children and Adolescents Involved in ChildServing Systems (2015). 
Page 13 GAO-17-129 Foster Care

HHS issued an Information Memorandum to states in April 2012 to 

provide guidance to states on complying with the statutory requirement to 

develop protocols for the appropriate use and monitoring of psychotropic 

medications.31 The memorandum cited our previous work that raised 

concerns about states’ efforts to oversee the use of psychotropic 

medications among children in foster care.32 This memorandum identified 

policy statements and guidelines from AACAP, the American Academy of 

Pediatrics, and the state of Texas, among others, and discussed 

consistent elements among these sets of guidelines. These elements, 

summarized below, include the need for state policies to contain 

provisions for:

• screening, assessment, and treatment planning mechanisms to 

identify children’s mental health and trauma-treatment needs;

• informed and shared decision-making and methods for ongoing 

communication among the physician, child, family, and other key 

stakeholders;

• effective medication monitoring;

• availability of mental health expertise and consultation; and

• mechanisms for sharing up-to-date information and educational 

materials related to mental health and trauma-related interventions, 

including psychotropic medications.

 31Administration for Children and Families, Information Memorandum, ACYF-CB-IM-12-

03. 

32GAO-12-201. 
Page 14 GAO-17-129 Foster Care

In addition to issuing this memorandum to states, we reported in April 

2014 that ACF had worked collaboratively with CMS and SAMHSA to 

provide technical assistance; facilitate information sharing; and 

emphasize the need for collaboration among state child welfare, 

Medicaid, and mental health officials in overseeing psychotropic 

medications from January 2012 through July 2013.33 Notably, these 

agencies cohosted a conference entitled “Because Minds Matter” in 

August 2012 that focused on collaborative medication monitoring as well 

as creating data systems to facilitate collaboration, among other things. 

According to ACF, CMS, and SAMHSA officials, the conference was an 

opportunity for states to talk and share practices, and representatives 

from 49 states attended.34

 33GAO-14-362. 

34A Florida child welfare official said that Florida officials were unable to attend the 

conference due to a hurricane.

Selected States Have 

Practices to Support 

the Prescribing 

Process and Educate 

Stakeholders on the 

Appropriate Use of 

Psychotropic 

Medications
Page 15 GAO-17-129 Foster Care

Officials we spoke with in the seven selected states told us they 

developed a variety of practices to better support appropriate mental 

health diagnoses and treatments for children in foster care in their 

states.35 These range from requiring initial mental health screenings to 

monitoring children after they are prescribed psychotropic medications.36

State officials in all seven of the selected states told us they require 

mental health screenings of children entering foster care, which is 

consistent with the guidelines on screenings identified in HHS guidance 

(see fig. 3).37

 35Officials in this context refers to officials from state and county child welfare and 

Medicaid agencies and other partners. Practices described in this report may be required 

or recommended by state laws, regulations, child welfare or Medicaid agency policies, or 

guidance. These practices may apply to the oversight of all psychotropic medications for 

all children in foster care, may apply to all children on Medicaid, or may focus on children 

in foster care who are below a certain age or on certain types or combinations of 

medications. In this report, we describe practices required, recommended, or implemented 

at the state level. In states with county-administered programs, counties may vary in their 

implementation of practices recommended at the state level, and they may use additional 

oversight practices as well. This report does not examine county-level variation in 

oversight practices.

36The states we selected were Arizona, California, Illinois, Maryland, New Jersey, Ohio, 

and Washington. For this review, we did not evaluate the effectiveness of the selected 

states’ or counties’ implementation of specific practices, their compliance with state or 

federal requirements, or whether there are controls in place to help ensure required 

practices are followed. See appendix II for further information on each state’s practices. 

GAO compiled appendix II from information and documents provided to us by selected 

state agency officials. We did not independently verify the information provided, but gave 

officials the opportunity to review the content for accuracy. Additional oversight practices

or measures may exist in these states that were not mentioned to us, and in some states, 

these practices and measures may vary by county. 

37Administration for Children and Families, Information Memorandum, ACYF-CB-IM-12-

03. In addition, state Medicaid agencies are required to cover physical and mental health 

screenings under the Early and Periodic Screening, Diagnostic, and Treatment benefit. 

See 42 U.S.C. §§ 1396a(a)(43), 1396d(a)(4)(B) and (r).

Selected States Have 

Practices to Support 

Appropriate Treatment 

Decisions and Monitor the 

Child

Screenings
Page 16 GAO-17-129 Foster Care

Figure 3: Selected States’ Practices to Assess Children’s Mental Health Needs

For example, Washington officials told us that staff in their child welfare 

screening program are expected to screen children entering foster care 

within thirty days using validated tools, such as a trauma-related screen 

for anxiety and post-traumatic stress disorder, which have been tested 

and found to draw consistent results for the same child across multiple 

screeners. In addition, the screeners ask children whether they are taking 

psychotropic medications or receiving health services, and how their 

symptoms are progressing. Screeners then provide a report to 

caseworkers, who can follow up to ensure the child receives the 

appropriate referrals and services. Washington child welfare officials said 

they also use screening data to analyze how many children with mental 

health needs are receiving services. Arizona requires that children 

entering foster care receive a mental health screening within 72 hours to 

identify and provide services for any immediate mental health needs and 

reduce the child’s stress and anxiety. Screenings are also to include 

provision of mental health services to each child’s new caregiver. These 

services include guidance on how to respond to the child’s immediate 

needs as the child transitions to foster care, information on mental health 

symptoms to watch for and report, assistance in responding to such 

symptoms, and provision of a contact in the mental health system. The 

child’s caseworker is to be provided with findings and recommendations 

for needed mental health services. Illinois officials said their child welfare 

agency requires all children in foster care to receive a comprehensive 

health assessment from a licensed social worker and the child’s 

caseworker within 55 days of entering the foster care system. According 

to these officials, this assessment should include a discussion of mental 

health issues and can prompt a referral for a psychiatric evaluation for the 

child.
Page 17 GAO-17-129 Foster Care

State officials in the seven selected states said they have a variety of 

guidelines and restrictions to support appropriate mental health 

treatments for children in foster care (see fig. 4).

Figure 4: Selected States’ Practices to Support Appropriate Treatments for Children

State and county officials from some of the selected states described 

physicians’ lack of knowledge of child and adolescent mental health 

issues as a challenge,38 and officials in all seven states said they 

developed practices to promote effective treatment decisions.39 For 

example, all seven of the selected states developed guidance on the use 

of psychotropic medications, such as dosage limits for children of different 

ages and weights, or medication lists that identify medications considered 

psychotropic.40 All seven states also require or recommend restricting 

 38We interviewed these officials using a semi-structured interview protocol, which included 

open-ended questions on some topics, including challenges related to psychotropic 

medication oversight. The answers provided by officials were volunteered in response to 

open-ended questions.

39Throughout this report we describe the number of states providing responses using “a 

few” to represent two states, “some” to represent three to four states, and “most” to 

represent five to six states. 

40Washington officials told us a medical advisory group formulates this list for their state 

because medications may be used for different purposes. In addition, they said including 

too many medications increases the administrative burden on physicians and may inflate 

statistics on psychotropic medication use. 

Guidelines and Restrictions for 

Prescribing
Page 18 GAO-17-129 Foster Care

who can prescribe psychotropic medications, or require or recommend 

the physician consult a specialist in some cases. For example, in New 

Jersey, only a psychiatrist, pediatric neurologist, neurodevelopmental 

pediatrician, or an advanced practice nurse certified in psychiatry or 

mental health and collaborating with one of these specialists may

prescribe psychotropic medications, except in cases of ADHD. In 

Maryland, if the prescribing physician is not a child psychiatrist, he or she 

must consult with or refer the child to a specialist before prescribing a 

psychotropic medication and within 60 to 90 days after making the initial 

prescription. In addition, Maryland officials said the state’s Medicaid 

agency contracts with mental health specialists at the University of 

Maryland to review all antipsychotic medication prescriptions for children 

in Medicaid.41

State officials in all seven of the selected states said they require or 

recommend that physicians obtain agreement—sometimes in writing—

from an adult who has responsibility for the child in foster care (informed 

consent) and from the child (assent) on prescriptions for psychotropic 

medications (see fig. 5).42 These practices are among the consistent 

elements across guidelines identified by HHS on informed and shared 

decision-making.

 41References to “mental health specialists” or “specialists” in this report may include 

health care providers with relevant specialties, such as child and adolescent psychiatrists, 

or specialized training or experience. Practices involving specialists’ review of medications 

prior to filling the prescription may be called prior authorization or second opinion. 

Washington officials said requiring secondary reviews decreased medication prescriptions 

because such reviews helped to educate physicians and support their response to foster 

parents or others who are concerned about difficult behaviors. 

42Depending on the state, an adult may be the parent, foster parent or other caregiver, 

child welfare agency official, judge, or some combination of the above. Each state has its 

own guidelines or requirements regarding which individuals are to provide consent. This 

practice is usually called informed consent, but may also be called authorization. 

Agreement on Prescriptions
Page 19 GAO-17-129 Foster Care

Figure 5: Selected States’ Practices to Seek Agreement on a Child’s Prescription

In Washington, the child welfare agency requires agreement from the 

parent if the child is under age 13, or from the child if he or she is age 13 

or older. If the parent of a young child is unavailable, unable, or unwilling 

to consent, the child’s caseworker must obtain a court order approving 

the use of psychotropic medication. In Maryland, caseworkers must 

collect a consent form signed by the parent or legal guardian as well as 

the child (if age 16 or older), when able. Similar to Washington, if the 

parent or guardian is unavailable or unwilling to provide consent, child 

welfare officials may obtain a court order in cases of medical necessity.

State officials in all seven of the selected states said they have practices 

related to monitoring children: They track or recommend tracking of highrisk prescriptions, such as those involving antipsychotic medications or 

multiple medications taken at the same time, or they require or 

recommend periodic follow-up visits or reauthorization of certain 

prescriptions (see fig. 6).43 Monitoring medication use for each child in 

foster care is one of the consistent elements across guidelines identified 

in HHS guidance.

 43For the purposes of this report, we use the term “high risk” to describe prescriptions 

identified by a state for additional oversight due to safety or other concerns. While these 

practices generally involve monitoring individual children, California officials said they are 

developing a related practice to monitor group homes. According to officials, the practice 

will involve quarterly reviews of data on psychotropic medication use among children living 

in congregate care and annual investigation of homes with high rates of use or where 

children have prescriptions flagged by Medicaid officials for review, such as psychotropic 

prescriptions for children under the age of 5. 

Ongoing Monitoring of the 

Child
Page 20 GAO-17-129 Foster Care

Figure 6: Selected States’ Practices for Ongoing Oversight of a Child’s 

Prescriptions

In Illinois, child welfare officials said their agency conducts ongoing 

oversight of prescriptions by examining a list of children taking 

antipsychotics and children under age 6 referred for uncommon 

conditions, such as aggression or bipolar disorder; consulting with mental 

health specialists; and referring cases for intensive case management, as 

needed.44 California officials said county courts review psychotropic 

medications every 6 months, while in Maryland, officials said that, for 

children taking antipsychotic medications, they require physicians to 

monitor the child’s height, weight, tremors, liver functioning, and blood 

sugar and lipid levels to identify side effects. They must then submit 

results to mental health specialists for review. In addition, Maryland 

caseworkers are required to review positive and negative effects of 

medications at their monthly home visits.

 44Related to this practice, California, New Jersey, and Washington officials said their 

states use nurses and other staff to perform health care case management services. 

According to New Jersey officials, nurses perform a mental health screen, track 

psychotropic medications and children’s health status, and submit quarterly reports to the 

child welfare agency, among other activities. Washington officials said their care 

coordination staff provide services such as analyzing a child’s records, assessing for gaps 

in care, facilitating access to health care providers, offering consultation to caseworkers 

and caregivers, and producing reports to help caseworkers develop the child’s case plan. 
Page 21 GAO-17-129 Foster Care

State officials in all seven of the selected states said they work to educate 

relevant stakeholders on mental health conditions and treatments.45

Practices to educate stakeholders are among the consistent elements 

across guidelines identified by HHS on sharing information on mental 

health and trauma-related interventions with clinicians, child welfare staff, 

and consumers. In addition, officials in most of the selected states said 

their state works to increase access to mental health services for children 

in foster care (see fig. 7).46

Figure 7: Selected States’ Practices to Increase Stakeholders’ Mental Health 

Knowledge and Access to Mental Health Services for Children

State officials from five of the seven selected states said they provide 

relevant stakeholders with access to informational materials. For 

example, California maintains an online information bank of evidencebased treatments, and Ohio officials developed guides to help children 

and their families communicate with physicians and participate more 

actively in treatment decisions.47 States may offer other types of 

 45As explained earlier, stakeholders can include agency officials, physicians, foster 

parents, biological parents, and children in foster care. 

46We identified these efforts through interviews with officials in selected states’ child 

welfare and Medicaid agencies and their partners, as referred to us. However, there may 

be additional state initiatives to increase access to mental health services that were not 

identified during our interviews. 

47Officials in some of the selected states described the education and empowerment of 

children and youth in foster care as important for protecting the interests and rights of the 

child.

Selected States Have 

Taken Steps to Increase 

Stakeholders’ Mental 

Health Knowledge and 

Access to Related 

Services, but Concerns 

about Limited Access to 

These Services Remain
Page 22 GAO-17-129 Foster Care

informational resources as well. For example, Washington child welfare 

officials said they staff mental health specialists to a telephone hotline to 

provide physicians who call with consultations on mental health 

diagnoses and treatments as well as information about local service 

providers. In addition, officials said the state’s child welfare agency and 

managed care provider offer in-person and online trainings on children’s 

mental health, psychotropic medications and other mental health 

treatments, and the child welfare system.

State and county officials in four of the seven selected states and five of 

nine national organizations identified limited access to mental health 

services as a challenge.48 These officials described a variety of factors 

limiting access, including insufficient numbers of professionals 

specializing in related fields, low Medicaid reimbursement rates, 

underserved rural areas, and physicians’ limited knowledge of services 

available in their area.49 As officials from one state explained, patients 

need access to a wider variety of evidence-based treatments. Other 

officials noted there are particular shortages among some specialties, 

such as child psychiatrists,50 or needed training in areas such as trauma-

 48GAO has previously reported on challenges faced by children in foster care and more 

generally by Medicaid enrollees in accessing mental health services. See GAO-13-15 and 

Medicaid: Overview of Key Issues Facing the Program, GAO-15-746T (Washington, D.C.: 

July 8, 2015). The Institute of Medicine reported that a shortage of mental health providers 

is a major factor affecting access to mental health services, especially for children. 

Institute of Medicine of the National Academies, Committee on Crossing the Quality 

Chasm: Adaptation to Mental Health and Addictive Disorders, Improving the Quality of 

Health Care for Mental and Substance-Use Conditions: Quality Chasm Series 

(Washington, D.C.: 2006).

49GAO reported in 2013 that families in rural areas may have more difficulty accessing 

mental health providers. GAO, Child Welfare: States Use Flexible Federal Funds, but 

Struggle to Meet Service Needs, GAO-13-170 (Washington, D.C.: Jan. 30, 2013).

50In 2011, we found that psychiatrists and psychologists were among the most difficult 

specialist referrals to obtain for children in low-income families covered by Medicaid. GAO, 

Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty 

Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.: June 30, 2011). 

Furthermore, we found in 2012 that among 55 surveyed states, U.S. territories, and the 

District of Columbia, respondents most frequently reported having difficulty ensuring 

sufficient Medicaid providers for psychiatry, among other specialties. GAO, Medicaid: 

States Made Multiple Program Changes, and Beneficiaries Generally Reported Access 

Comparable to Private Insurance, GAO-13-55 (Washington, D.C.: Nov. 15, 2012).
Page 23 GAO-17-129 Foster Care

informed care.51 To increase children’s access to mental health services, 

state and county officials in five of the selected states said they provide 

remote consultation services.52 In addition, Ohio state officials said the

state offers fellowships for medical students in needed mental health 

specialties as well as training curricula for students to provide mental 

health services as part of primary care.53

Officials in the seven selected states identified factors that helped them 

implement oversight practices for psychotropic medications, such as 

collaborating with other agencies, conducting outreach with relevant 

stakeholders, and gradually implementing new oversight practices. State 

officials in all seven of the selected states said strong collaboration 

among child welfare, Medicaid, or other partnering agencies was key to 

implementing these practices. Specifically, Washington officials said 

supporting children in foster care requires coordinated solutions across 

the agencies serving this population. In Ohio, officials said the directors of 

their child welfare, Medicaid, and mental health agencies have worked in 

the other agencies and as a result share resources and talent more easily 

and encourage open communication. In Washington, officials said strong 

collaboration allows their agencies to complement each other’s roles, 

develop more holistic practices, and implement oversight programs more 

effectively. Officials in Ohio and Washington attributed successful 

collaboration within their state to executive leadership support, the 

commitment and longevity of state agency leaders, and leaders’ and 

managers’ breadth of experience in multiple agencies and front-line roles. 

Washington officials emphasized the importance of developing integrated 

programs in order to institutionalize collaboration.

 51HHS highlighted the importance of trauma-informed care for children in foster care in its 

2013 tri-agency letter to states on trauma. HHS reported on the central role of exposure to 

trauma on mental and physical health and substance use disorders. HHS found that a lack 

of trauma-informed care may have a direct impact on psychotropic medication use among 

children in foster care. See https://www.medicaid.gov/federal-policyguidance/downloads/smd-13-07-11.pdf. 

52These services, often called telemedicine, may use two-way video or other 

telecommunication technologies to enable health consultations between a patient and a 

physician in different locations. Such services can be particularly useful to address a lack 

of access in rural areas.

53Related to this practice, Ohio officials said the state manages a loan repayment program 

for psychiatrists who choose to work in regional state hospitals.

State Officials Said 

Collaboration, Outreach, 

and Gradual Rollout of 

New Practices Were Key 

to Effective 

Implementation
Page 24 GAO-17-129 Foster Care

State and county officials in three of the seven selected states said 

conducting outreach helped them educate stakeholders on relevant 

issues and requirements and gain stakeholders’ buy-in. For example, 

Maryland officials said conducting extensive outreach to physicians on 

how to best implement new requirements for medication approval and 

monitoring helped ensure stakeholder adoption of the program and was 

essential to its success. These officials said they shared information with 

physicians about antipsychotic medications, monitoring side effects, and 

available psychosocial services. In response to physicians’ feedback, 

Maryland officials said they adapted the program to allow physicians to 

call in required information over the phone to avoid having to complete 

forms.

Officials in two of the selected states said the gradual rollout of new 

practices enabled mid-course corrections or supported higher rates of 

adoption or compliance with the practice. For example, Ohio officials said 

they developed their medications oversight program in several stages. 

One step entailed a pilot program that flagged potentially inappropriate 

prescriptions and required physicians to consult with mental health 

specialists. Through this program, officials said they identified a lack of 

mental health knowledge and access to mental health specialists as two 

causes of inappropriate prescriptions. They said they redesigned their 

oversight practices to address these causes, tested the new practices, 

and are now implementing them statewide.
Page 25 GAO-17-129 Foster Care

Our analysis of available data from the seven selected states show that 

four of these states—California, Illinois, New Jersey, and Washington—

reduced the percentage of children in foster care on psychotropic 

medications from 2011 through 2015.54 Two other selected states—

Arizona and Maryland—had steady rates of medication use.55 Ohio did 

not have data for this time period.56 Because states use different 

 54California child welfare and Medicaid officials expressed concern that their Medicaid 

data could undercount the number of claims made for children in foster care. These 

officials said information indicating whether a child is in foster care may not always be 

available in their Medicaid data system, and this information cannot completely be 

reconciled with their child welfare data system.

55For the purposes of our report, we categorized a state as having a steady rate of 

medication use if the percentage of children in foster care on psychotropic medications 

fluctuated by less than 1 percent for each year from 2011 through 2015.

56Ohio child welfare officials said they did not regularly collect data on the use of 

medications in the past, but began to do so as of May 2016. 

While Some Selected 

States Reduced the 

Use of Psychotropic 

Medications, They All 

Focused on Other 

Measures to Gauge 

the Results of Their 

Efforts

Some Selected States 

Reduced Psychotropic 

Medication Use, though 

Mental Health and Foster 

Care Stakeholders Said 

Reducing Medications 

May Not Be Appropriate 

for Every Child
Page 26 GAO-17-129 Foster Care

methodologies to collect data, these data cannot be compared across 

states.57

While identifying all the factors that contribute to reduced medication use 

can be difficult,58 Washington child welfare and Medicaid officials said 

their second opinion program, which requires physicians to consult a child 

psychiatrist when prescribing certain medications, has likely prevented 

inappropriate prescribing. A 2009 study on this program also found that it 

helped reduce ADHD medications that were provided in high doses, in 

combinations, and for children under 6.59

Child welfare and Medicaid officials in some selected states and officials 

from most national professional and research organizations we 

interviewed said reducing medications may not be appropriate for every 

child. For example, child welfare and Medicaid officials in one selected 

state explained that without medication, a child in foster care may not be 

able to sit through a therapy session or perform in school. In addition, 

officials in all seven states said a child’s mental health can be affected by 

many factors, including psychotropic medications, psychosocial services, 

and other situational and environmental factors. Rather than focusing on 

reducing medications overall, officials in these states said their goal is to 

ensure the child receives appropriate treatment, which may involve efforts 

related to all of the factors mentioned above.

 57Specifically, selected states collect information on different populations of children in 

foster care (e.g., children from birth to age 18 in one state verses ages 3 to 17 in another 

state because it received a grant that focused on this population) and report information 

for different time periods (e.g., calendar year from January 1 through December 31 versus 

state fiscal year from July 1 through June 30). One state reports data quarterly rather than 

annually. Since this state provided data to us for the same quarter of each year, our 

calculations on percentages of children in foster care on psychotropic medications are 

likely unaffected. In addition, four of the six selected states that were able to provide data 

were unable to provide data for all years from 2011 through 2015. Specifically, one state 

was unable to provide data for 2011, one state conducted two point-in-time studies that 

did not include data for 2011 and 2015, and two states had time lags in reporting that 

precluded them from providing data for 2015. 

58Examples of factors that can contribute to reductions in medication use include state 

oversight practices, changes in the numbers of children in foster care, changes in the 

mental health needs of this population, and changes to the types of medications 

considered psychotropic.

59This study examined over 1,000 second opinion reviews provided from May 2006 

through April 2008. J. Thompson, C. Varley, J. McClellan, R. Hilt, T. Lee, A. Kwan, Taik 

Lee, and E. Trupin, “Second Opinions Improve ADHD Prescribing in a Medicaid-Insured 

Community Population,” Journal of the American Academy of Child & Adolescent 

Psychiatry, vol. 48, no. 7 (2009).
Page 27 GAO-17-129 Foster Care

Child welfare and Medicaid officials in all seven of the selected states told 

us they use a variety of measures to gauge the results of their efforts 

related to psychotropic medication use among children in foster care.60

These measures generally examine physician prescribing patterns, state 

oversight practices, and child placement, health, education, and juvenile 

justice outcomes. For additional information on measures collected by 

each selected state, see appendix II.

• Physician prescribing patterns. All seven selected states examine 

data to better understand certain prescribing patterns, such as the use 

of antipsychotics, the use of multiple psychotropic medications at the 

same time, and dosage levels for the medications prescribed. Child 

welfare and Medicaid officials in all of these states said they have 

particularly focused on antipsychotic medications, in part due to 

concerns about inappropriate use of these medications and their 

potential negative side effects for children. Officials in five states told 

us their state has experienced reductions in antipsychotic use among 

children in foster care in recent years. Researchers have also noted 

that concerns about the use of antipsychotic medications spurred 

state efforts to oversee and improve prescription behavior, and a June 

2016 study examining Medicaid data in 20 states from 2005 through 

2010 found that trends in the use of these medications are no longer 

increasing.61 However, the study noted that current prescribing 

patterns for antipsychotics at the “new normal” rates of use remain of 

great concern to many stakeholders.

Child welfare and Medicaid officials in one state also underscored the 

significance of examining prescribing patterns after they observed 

spikes in the use of certain medications. These officials said that after 

their state started requiring second opinions for ADHD prescriptions, 

they saw increases in prescriptions of antipsychotics, and after 

requiring second opinions on antipsychotics, they saw increases in 

prescriptions for the use of multiple psychotropic medications at the 

 60The measures discussed are collected by state child welfare, Medicaid, and/or other 

agency officials, depending on the state. We focused our review on state-level data to 

examine the results of selected state efforts, although counties may also collect data on 

these and other measures. State officials told us about the measures they collect, and 

provided examples of reports on these measures. The selected states vary in how 

frequently they examine their measures (e.g., monthly reports versus one point-in-time 

report). 

61S. Crystal, T. Mackie, M.C. Fenton, S. Amin, S. Neese-Todd, M. Olfson, and S. Bilder. 

“Rapid Growth of Antipsychotic Prescriptions For Children Who Are Publicly Insured Has 

Ceased, But Concerns Remain” Health Affairs, vol. 35, no. 6 (2016): 974-982.

States Use Information on 

Physician Prescribing 

Patterns and State 

Oversight Practices to 

Gauge Results, though 

Data Sharing Can Be a 

Challenge
Page 28 GAO-17-129 Foster Care

same time. Officials interpreted these patterns as showing that some 

physicians choose to prescribe certain medications partly to avoid 

their state’s oversight practices. These officials expressed concern 

that new requirements may cause increased medication use in other 

areas, which would need to be monitored.

• State oversight practices. While selected states may have similar 

reported practices for overseeing the use of psychotropic medications, 

they vary in whether they examine data to determine if their practices 

are followed. For example, while child welfare and Medicaid officials in 

all seven states told us their state requires some form of agreement or 

informed consent for a child’s treatment plan, officials in three of these 

states told us they review reports on whether such an agreement was 

obtained. In addition, while officials in six states said their state 

requires or recommends a caseworker or physician conduct follow-up 

visits with a child on psychotropic medications, officials in one of these 

states told us they examine data on the required follow-up, specifically 

for ADHD medications.62 Officials in three of these states told us they 

do examine data on whether a physician monitors the child’s 

metabolic health, including height, weight, and lipid panels. These 

measures can be used to monitor whether a child is experiencing any 

adverse effects as a result of taking medications. Child welfare and 

Medicaid officials in most selected states said they have particularly 

focused on ensuring children in foster care receive psychosocial 

services to help address experiences with trauma. Officials in all 

seven states said their state has guidelines that require or 

recommend the use of psychosocial services prior to or concurrently 

with a psychotropic medication, and officials in all of these states told 

 62Officials in the state that did not report having requirements or recommendations for 

follow-up visits told us they examine data on physician follow-up for children in foster care 

who are prescribed new psychotropic medications or ADHD medications. Examining 

physician follow-up for ADHD medications is one of several standardized health 

performance measures set by the National Committee for Quality Assurance under the 

Healthcare Effectiveness Data and Information Set (HEDIS). The committee is a non-profit 

organization that works to improve health care quality. It developed HEDIS as a tool for 

health organizations to measure performance on dimensions of care and service. HEDIS 

consists of 81 measures across 5 domains of care, including effectiveness of care. These 

measures are specifically defined to allow for comparisons of performance across health 

organizations. The measure examining physician follow-up for ADHD medications is also 

included as part of CMS’s Core Set of Children’s Health Care Quality Measures. These 

measures were established in response to the Children’s Health Insurance Program 

Reauthorization Act of 2009, which requires HHS to identify and publish a core set of 

children’s health care quality measures for voluntary use by state Medicaid and other 

children’s health programs.
Page 29 GAO-17-129 Foster Care

us they examine data on the number of children in foster care who 

received such services. Officials in four of these states told us their

state has increased the use of psychosocial services. For example, a 

2013 study on physicians’ use of Washington’s telephone line for 

mental health consultations between 2008 and 2011 found a 132 

percent increase in outpatient mental health visits for children 

currently or previously in foster care after a consultation.63 However, 

as mentioned earlier, child welfare and Medicaid officials in most of 

the selected states—as well as multiple studies—have noted 

continuing challenges with access to psychosocial services.

While we did not assess states’ implementation of specific practices to 

oversee the use of psychotropic medications, findings from a 2016 

California State Auditor report highlight the importance of having 

measures in place to ensure that state practices are followed.64

Specifically, the report found multiple cases where children in foster 

care received prescriptions for psychotropic medications without court 

authorization or parental consent, which, according to the report, is a 

violation of state law.

• Child placement, health, education, and juvenile justice 

outcomes. Most of the seven selected states collect data to monitor 

outcomes for children on psychotropic medications. For example, 

child welfare and Medicaid officials in four selected states told us they 

monitor information on whether a child in foster care on psychotropic 

medications experiences a placement disruption (the child is moved 

from one placement to another). Multiple studies have shown that 

placement disruptions are associated with increased mental health 

needs65 and poor social-emotional outcomes,66 and that problem 

 63R. Hilt, M. Romaire, M. McDonell, J. Sears, A. Krupski, J. Thompson, J. Myers, E. 

Trupin, “The Partnership Access Line: Evaluating a Child Psychiatry Consult Program in 

Washington State,” JAMA, vol. 167, no. 2 (2013).

64California State Auditor, California’s Foster Care System: The State and Counties Have 

Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in 

Foster Care, Report 2015-131 (Sacramento, CA: Aug. 23, 2016). The report findings are 

based on 80 case file reviews conducted by state auditors in four counties, including two 

that we reviewed, among other methods.

65See, for example, S. James, J. Landsverk, D. Slymen, and L. Leslie, “Predictors of 

Outpatient Mental Health Service Use—the Role of Foster Care Placement Change,”

Mental Health Services Research, vol. 6, no. 3 (2004) and D. Rubin, E. Alessandrini, C. 

Feudtner, D. Mandell, A.R. Localio, and T. Hadley, “Placement Stability and Mental Health 

Costs for Children in Foster Care,” Pediatrics, vol. 113, no. 5 (2004).
Page 30 GAO-17-129 Foster Care

behavior can be an indicator of risk for future placement disruptions.67

Since children may be prescribed psychotropic medications to help 

treat problem behaviors, examining data on disruptions can help 

states better understand whether children with problem behaviors on 

medications are improving or are still having serious behavioral 

problems. Some states also examine health, education, and juvenile 

justice outcome measures for children in foster care on psychotropic 

medications. Child welfare and Medicaid officials in a few states said 

such measures can help them determine whether the care and 

services provided to children in foster care are helping these children 

lead healthy and productive lives.68 For example, Illinois child welfare 

officials told us they examine whether a child under the age of 6 on a 

psychotropic medication has symptoms of self-harm or is hospitalized. 

In addition, Maryland child welfare officials told us they examine data 

on school enrollment and academic performance for children in foster 

care on psychotropic medications, whereas Washington officials told 

us they examine data on whether children in foster care with mental 

health needs, including those on psychotropic medications, have any 

involvement in the juvenile justice system.

Child welfare and Medicaid officials in most of the seven selected states 

discussed common challenges in their efforts to collect data needed to 

oversee the use of medications by children in foster care and to monitor 

outcomes for these children. In five of the seven states, officials 

discussed technical issues with obtaining reliable data. They said data on 

psychotropic medications and other mental health services for children in 

foster care can involve data systems from state child welfare, Medicaid, 

 66See, for example, E. Lewis, M. Dozier, J. Ackerman, and S. Sepulveda-Kozakowski, 

“The Effect of Placement Instability on Adopted Children’s Inhibitory Control Abilities and 

Oppositional Behavior,” Developmental Psychology, vol. 43, no. 6 (2007) and J. Ryan and 

M. Testa, “Child Maltreatment and Juvenile Delinquency: Investigating the Role of 

Placement and Placement Instability,” Children and Youth Services Review, vol. 27 

(2005).

67See, for example, P. Fisher, M.Stoolmiller, A. Mannering, A. Takahashi, and P. 

Chamberlain, “Foster Placement Disruptions Associated With Problem Behavior: 

Mitigating a Threshold Effect,” Journal of Consulting and Clinical Psychology, vol. 79, no. 

4 (2011) and S. Leathers, “Placement Disruption and Negative Placement Outcomes 

among Adolescents in Long-term Foster Care: The Role of Behavior Problems,” Child 

Abuse and Neglect, vol. 30 (2006).

68Several research and advocacy organizations also examine similar outcome measures 

for children in the general population. For example, the Annie E. Casey Foundation’s 

KIDS COUNT Data Center is an online resource that provides data on the educational, 

social, economic, and physical well-being of children over time at the national and local 

levels. See http://www.aecf.org/work/kids-count/.
Page 31 GAO-17-129 Foster Care

and mental health agencies. In addition, they said data needed to gauge 

whether a child’s life improves with treatment—such as the child’s living 

situation and their health, education, and juvenile justice outcomes—can 

involve many other data systems, including those from state education 

and juvenile justice agencies.69 Because some of these agencies may not 

collect information specifically on the foster care population, officials said 

gathering these data may require data matching across these systems. In 

some selected states, officials said this information may also involve 

county-level agencies that can vary in the types of data they collect as 

well as one or more third-party managed care organizations that report to 

state Medicaid agencies. These officials said matching such data can be 

difficult and time-consuming, and state child welfare and Medicaid 

officials in three selected states discussed limitations with data gathering 

due to resource and time constraints, given other competing priorities.

State child welfare and Medicaid officials in five selected states also 

discussed privacy concerns related to data sharing. For example, officials 

in two of these states said state agencies are reluctant to share sensitive 

data on individuals due to their concerns about privacy protections under 

the Health Insurance Portability and Accountability Act of 1996 for health 

information70 and the Family Educational Rights and Privacy Act for 

 69Specifically, child welfare and Medicaid officials in three selected states discussed the 

importance of data on a child’s stability in their living situation, including information on 

placement disruptions, whether the child returns home, and whether the child becomes 

homeless; officials in two selected states discussed the need for health outcomes data for 

children in foster care, including rates of hospitalizations, emergency room visits, and 

relapses; officials in six states discussed the need for information on education outcomes 

for these children, including enrollment and graduation rates; officials in one state 

expressed interest in whether these children become involved in the juvenile justice 

system; and officials in another state were interested in whether a child is able to obtain 

employment after leaving the foster care system. As discussed earlier, some selected 

states may already be collecting data on these measures. 

70The Health Insurance Portability and Accountability Act of 1996 required HHS to 

promulgate regulations addressing the privacy and security of health information. Pub. L. 

No. 104-191, tit. II, subtit. F, 110 Stat. 1936, 2021-34 (codified at 42 U.S.C. §§ 1320d–

1320d-8). HHS has published Standards for Privacy of Individually Identifiable Health 

Information (the Privacy Rule) and Security Standards for the Protection of Electronic 

Protected Health Information (the Security Rule). See 45 C.F.R. pts. 160 and 164. The 

Privacy Rule establishes national standards for safeguarding individually identifiable 

health information that is transmitted or maintained in any form or medium (protected 

health information). The Security Rule establishes nationwide standards for safeguarding 

protected health information that is held or transferred electronically.
Page 32 GAO-17-129 Foster Care

education information.71 Similarly, officials in two other states expressed 

uncertainty over the types of data they were able to share under state and 

federal laws.72 Child welfare and Medicaid officials in three of the five 

counties where we conducted interviews discussed similar privacy 

concerns with data sharing among county-level agencies. Child welfare 

and Medicaid officials in two of the five states that expressed privacy 

concerns also discussed concerns about sharing data with managed care 

organizations. They said they were in the process of determining how to 

share information specifically on the foster care population with these 

organizations as well as what data to collect from them.

State child welfare and Medicaid officials in some selected states that

were able to share data said they overcame privacy concerns through 

negotiating written agreements and educating stakeholders about sharing 

data consistent with state and federal privacy requirements. For example, 

Maryland child welfare and Medicaid officials said their agencies each 

formed an agreement to share data with the same contractor, who 

matched data on children in foster care with Medicaid data on claims for 

psychotropic medications and mental health services, and reported the 

 71The Family Educational Rights and Privacy Act requires educational agencies and 

institutions that receive U.S. Department of Education funds—such as schools, school 

districts, colleges, and universities—to provide parents and eligible students with access 

to education records and generally prohibits the disclosure of education records without 

the prior written consent of the parent or eligible student, unless an exception to the 

general consent requirement applies. See 20 U.S.C. § 1232g and 34 C.F.R. pt. 99.

72Various GAO reports have outlined challenges states have faced in navigating federal 

privacy and security protections for health, child welfare, education, and other data. See, 

for example, GAO, Prescription Drug Data: HHS Has Issued Health Privacy and Security 

Regulations but Needs to Improve Guidance and Oversight, GAO-12-605 (Washington, 

D.C.: June 22, 2012); Human Services: Sustained and Coordinated Efforts Could 

Facilitate Data Sharing While Protecting Privacy, GAO-13-106 (Washington, D.C.: Feb 8, 

2013); and Postsecondary Education: Many States Collect Graduates’ Employment 

Information, but Clearer Guidance on Student Privacy Requirements Is Needed, 

GAO-10-927 (Washington, D.C.: Sept. 27, 2010). In response to GAO recommendations 

from these reports, HHS issued guidance in November 2012 to assist entities covered by 

the Health Insurance Portability and Accountability Act of 1996 in ensuring that protected 

health information, such as Medicaid beneficiaries’ use of prescription drugs, could not be 

linked to a particular individual when used for purposes other than directly providing 

clinical care to an individual. HHS published a “Confidentiality Toolkit” in August 2014 that 

aims to support state and local data sharing efforts by bringing greater clarity to the rules 

governing confidentiality in certain human services programs, and the Department of 

Education revised its Family Educational Rights and Privacy Act regulations in December 

2011 to, among other things, clarify the means by which states can collect and share 

graduates’ employment information consistent with federal requirements. The Department 

of Education also published a “Data Sharing Toolkit” for states and other community 

leaders in March 2016. 
Page 33 GAO-17-129 Foster Care

information to state agencies without providing personal data. In addition, 

Maryland child welfare officials said their agency entered into an 

agreement with their state education agency to share education 

information for children in foster care. This agreement granted certain 

officials access to personal information, and these officials assigned 

anonymous identifiers to each child to protect their privacy while 

facilitating data sharing. California child welfare officials told us they 

recently worked with their state education and juvenile justice agencies to 

issue a letter that summarizes existing state and federal laws that pertain 

to the sharing of information and records between local education 

agencies, county child welfare agencies, and caregivers for children in 

foster care. In addition, Washington child welfare officials discussed data 

sharing agreements among multiple state agencies that allowed the state 

to match and share client-level information across more than 30 state 

data systems.73 These officials attributed the success of their agreements 

to strong state leadership and the development of trust and buy-in among 

the stakeholders involved.

 73Examples of state agencies contributing to this database include Washington’s 

Department of Social and Health Services for data on child welfare services, Health Care 

Authority for data on Medicaid and health benefits, Department of Corrections for data on 

incarcerations, Education Research Data Center for data on school outcomes, and 

Department of Commerce for data on housing assistance and homelessness.

HHS Assists States in 

Addressing 

Medication Use and 

the Mental Health 

Needs of Children, 

Though More Could 

Be Done to Support 

Collaboration across 

State Agencies
Page 34 GAO-17-129 Foster Care

Since our 2014 review of psychotropic medications for children in foster 

care,74 ACF, CMS, and SAMHSA have continued to provide support to 

states—generally in the form of funding and technical assistance—to 

assist with oversight of these medications. Specifically, these efforts aim 

to support states’ practices for prescribing medications, for diagnosis and 

treatment options, and for implementing measures to assess the quality 

of health care delivery to children in foster care.

Through funding and information sharing, SAMHSA, CMS, and ACF help

state agencies with practices related to prescribing medication and their 

oversight efforts. For example, SAMHSA partly funded AACAP’s 

development of voluntary recommendations for states on the use of 

psychotropic medications for children and adolescents.75 As discussed 

earlier, these recommendations emphasize that holistic mental health 

treatment can include medication, but that medication should be only one 

part of the overall plan. State officials in most of our selected states said 

they reviewed AACAP recommendations when developing their own 

guidelines and oversight practices for children in foster care. For 

example, child welfare officials in Illinois said they worked with a 

representative of their state AACAP branch, among others, to develop 

guidelines on prescribing medications, which, according to these officials, 

were included in their state law. In addition, Ohio’s medication 

management and oversight program included clinical resources and 

prescribing guidelines for physicians based on AACAP’s 

recommendations.

SAMHSA also supports child welfare agency staff and mental health 

stakeholders seeking to ensure the appropriate use of psychotropic 

medications for children in foster care through a contract with the 

Technical Assistance Network at the University of Maryland’s School of 

Social Work. SAMHSA funds a medical director position at the network, 

and that director works with 55 child and adolescent psychiatrists in state 

and county governments to address issues regarding psychotropic 

medication, including strategies to help ensure children receive 

 74GAO-14-362.

75Recommendations about the Use of Psychotropic Medications for Children and 

Adolescents Involved in Child-Serving Systems, 2015. These recommendations apply to 

all children and adolescents, including those in foster care. They cover three areas—

clinical practice, psychotropic medication oversight, and research. In addition to these 

recommendations, AACAP developed several other resources that address these and 

other related topics. 

HHS Supports States in 

Overseeing Medication 

Use and Determining 

Children’s Mental Health 

Needs and Treatment 

Options

States’ Practices to Oversee 

Medication Use
Page 35 GAO-17-129 Foster Care

appropriate treatment. Specifically, the director created a community 

listserv of child and adolescent psychiatrists to disseminate best practices 

and developed webinars on medication oversight. According to SAMHSA 

officials, the medical director, with input from the listserv community, is 

developing guidance on how to take youth off medication, an issue that 

child welfare officials in one selected state said can be a challenge. As 

these officials explained, psychiatrists generally are reimbursed more for 

medication management than psychotherapy, which can create a 

disincentive for keeping children off medication.76 Through the network’s 

Clinical Distance Learning Series, SAMHSA also developed webinars and 

issue briefs on the oversight of psychotropic medications for children on 

Medicaid, including one on developing performance measures. According 

to SAMHSA officials, the technical assistance network has also begun 

planning for a multi-year collaborative for residential treatment centers 

that have an interest in addressing the use of antipsychotic medications 

among the youth they serve.77 As they explained, the goal of this group is 

to increase best practices related to the use of antipsychotic medications 

for youth in residential care and reduce outlier practices, such as 

prescribing children too many medications or at dosages exceeding 

maximum levels based on labels approved by the Food and Drug 

Administration. Through funding, SAMHSA has continued to support a 

multi-year virtual learning community in which community participants 

receive technical assistance, including monthly e-newsletters, webinar 

invitations, and access tools and resources.78 SAMHSA-funded webinars 

 76Researchers in one study noted that a significant decline in the provision of 

psychotherapy by psychiatrists in the United States was attributed to a decrease in the 

number of psychiatrists specializing in psychotherapy and a corresponding increase in 

those specializing in pharmacotherapy. Further, it was noted that changes were likely 

motivated by financial incentives—that is, reimbursement policies favoring brief 

medication management visits rather than psychotherapy—and the introduction of newer 

psychotropic medications with fewer adverse effects. R. Motjabai and M. Olfsen. “National 

Trends in Psychotherapy by Office-Based Psychiatrists” Archive of General Psychiatry, 

vol. 65, no. 8 (2008): 962-970.

77As discussed earlier, residential treatment facilities are for youth who may require

intervention to address emotional or behavioral challenges and are generally established 

by state agencies or private companies.

78The virtual learning community was developed by the non-profit organization Center for 

Health Care Strategies as part of its initiative on “Improving the Use of Psychotropic 

Medications among Children and Youth in Foster Care.” The center conducted a threeyear quality improvement collaborative that included participation by Illinois, New Jersey, 

New York, Oregon, Rhode Island, and Vermont. Each state convened a cross-agency 

team, including state Medicaid, child welfare, and mental health agencies as well as 

families, youth, and physicians, to develop and implement new approaches to 

psychotropic medication use for children. 
Page 36 GAO-17-129 Foster Care

have included issues such as cross-system data sharing, education and 

engagement of key stakeholders, phone psychiatric consultation models, 

and red flag and response systems for medication oversight.

CMS, in its 2015 Quality Conference, hosted a Medicaid Track that 

included a session for Medicaid and health care professionals on 

physician prescribing patterns considered high risk because of the 

adverse side effects, including the use of antipsychotic medications. The 

National Committee for Quality Assurance, a nationally recognized quality 

improvement entity, presented the results of its efforts to develop 

measures to oversee medication use at the conference.79 According to 

CMS officials, this session prompted formation of a group for interested 

state Medicaid agencies and their partners on the use of antipsychotic 

medications for children. Eights states are participating in the group as of 

October 2016. These states are working on various projects to improve 

appropriate medication use and monitoring for possible side effects.80 In 

addition, in February 2016, CMS collaborated with the National 

Association of Medicaid Directors and the American Drug Utilization 

Review Society to host a national call for 12 Medicaid drug utilization 

review program directors to share their strategic efforts on their child 

antipsychotic monitoring programs with all other states and the District of 

Columbia.

ACF developed two guides related to psychotropic medication use for 

children in foster care. The first guide provides tools to help children ask 

questions about medications as they meet with physicians. The second 

publication is a companion guide for child welfare staff and foster parents 

on mental health issues, the impact of trauma, and psychotropic 

medications.81 According to ACF officials, both guides have been 

 79This collaborative was led by the Medicaid Medical Directors Network. The first data 

project began in 2007 and included 16 states. The follow-on project in 2011 involved nine 

states: Colorado, Maine, Missouri, New Hampshire, New York, Oklahoma, Pennsylvania, 

Tennessee, and Washington. 

80According to CMS officials, the working group includes a mix of large and small 

population states as well as those with fee-for-service and managed care delivery models.

81Children’s Bureau et al. Making Healthy Choices: A Guide on Psychotropic Medications 

for Youth in Foster Care (Washington, D.C.: Children’s Bureau, Administration for Children 

and Families, Department of Health and Human Services, 2012). Also, Children’s Bureau 

et al. Supporting Youth in Foster Care: Making Healthy Choices (Washington, D.C.: 

Children’s Bureau, Administration for Children and Families, Department of Health and 

Human Services, 2015).
Page 37 GAO-17-129 Foster Care

distributed nationally and are posted on ACF’s Child Welfare Information 

Gateway website.

HHS also helps states address mental health screenings for children—

which affects their diagnosis and treatment options—and increase 

awareness of and access to trauma-informed care services among the 

child welfare workforce.

Misdiagnosis and inappropriate medication use: ACF and the Centers 

for Disease Control and Prevention partnered to study the relationship 

between misdiagnosis and inappropriate medication use. Their study was 

spurred by prior research that examined a large sample of children in a 

child welfare population who underwent a comprehensive diagnostic 

evaluation. The prior study found that over 85 percent of children 

diagnosed with fetal alcohol spectrum disorder had never been previously 

diagnosed or had been misdiagnosed. For these children, the most 

common mental health diagnosis prior to the comprehensive evaluation 

was ADHD—a diagnosis that often leads to psychotropic medication 

prescriptions.82 ACF and the Centers for Disease Control and Prevention 

are currently completing a pilot study at a local child welfare agency to 

understand why a diagnosis of fetal alcohol spectrum disorder might be 

missed and what information agencies and families need in order to 

maximize outcomes for children and families. According to ACF officials, 

they also plan to gather information from other sites to understand this 

issue at a national level, and to develop training materials for 

caseworkers and caregivers on a child’s likely prenatal exposure to 

 82I. J. Chasnoff, A. M. Wells, and L. King “Misdiagnosis and Missed Diagnoses in Foster 

Care and Adopted Children with Prenatal Alcohol Exposure,” Pediatrics, vol. 135, no. 2, 

(2015): 264-270. Data were collected from a sample of 547 adopted children and those in 

foster care who underwent a comprehensive multidisciplinary diagnostic evaluation. 

Among 156 children and adolescents who met criteria for a diagnosis within the fetal 

alcohol spectrum disorder, 125 had never been diagnosed as affected by prenatal alcohol 

exposure, a missed diagnosis rate of 80.1 percent. Within this clinical sample, 86.5 

percent of youth with fetal alcohol spectrum disorder had never been previously 

diagnosed or had been misdiagnosed. According to the study, high rates of missed 

diagnoses and misdiagnosis have significant implications for intervention and therapeutic 

services. According to ACF officials, children with fetal alcohol spectrum disorder can 

present behaviors which often lead them to be incorrectly identified as having ADHD. 

Diagnosis and Treatment 

Options
Page 38 GAO-17-129 Foster Care

alcohol as well as the types of information that caseworkers and 

caregivers need to help these children.83

Trauma-informed care and evidence-based practices: ACF provides a 

variety of trauma-related grants, including grants focused on screening, 

assessment, treatment, and bridging the gaps between child welfare and 

mental health.84 Through support of another ACF grant, the National 

Center for Evidence Based Practice in Child Welfare provides training 

and capacity building for child welfare and mental health staff on traumafocused therapy and on improving access to mental health services.85 In 

Washington, the state used ACF’s informational briefs on trauma for its 

own training and ACF grant funds to develop a handbook on trauma for 

foster care families.86

SAMHSA also provided competitive grants to a cohort of states to help 

increase quality of care and access to trauma-related services.87 In 2014, 

 83The ACF and Centers for Disease Control and Prevention study indicated that foster 

parents and child welfare agency staff often do not understand that typical child rearing 

approaches are not effective with these children. Instead, they need training to learn the 

best approaches to improve children’s outcomes.

84These trauma-related discretionary grants were initially awarded in three clusters, in 

2011, 2012, and 2013, and include 20 grantees from local, county, or state governments. 

The first cluster focuses on screening and assessment upon entry into foster care. The 

second cluster focuses on determining the availability of evidence-based practices, in 

addition to screening and assessment. The third cluster focuses on transition services for 

children preparing for adoption. Grantees conduct an evaluation of child welfare 

outcomes. According to ACF officials, ACF is just beginning to see results. Among the 

recipients of these grants are university, hospital, and county government entities in three 

of the seven selected states we included in this review. These grants were made pursuant 

to HHS’s authority under section 203 of the Child Abuse Prevention and Treatment Act, 

codified as amended at 42 U.S.C. § 5113.

85The National Center for Evidence Based Practice in Child Welfare implemented a 

program called Partnering for Success, which began in 2014 and has been implemented 

in four states, according to ACF officials.

86The handbook was developed as part of Washington’s “Creating Connections” project, 

supported by one of ACF’s trauma-related grants.

87SAMHSA funded these competitive grants through the Donald J. Cohen National Child 

Traumatic Stress Initiative, authorized by the Children’s Health Act of 2000, as amended. 

Pub. L. No. 106-310, § 3101, 114 Stat. 1101, 1169-70 (codified as amended at 42 U.S.C. 

§ 290hh-1). According to SAMHSA officials, funding opportunities have been issued in six 

cohorts since 2001. Fiscal year 2016 grant awards are currently under review. Through 

this initiative, SAMHSA created the National Child Traumatic Stress Network, a 

collaborative network of service providers, family and youth representatives, and 

researchers.
Page 39 GAO-17-129 Foster Care

SAMHSA initiated an online and television campaign to inform the public 

about efforts to treat child trauma and resources available through the 

National Child Traumatic Stress Initiative. SAMHSA has also formed a 

relatively new partnership with the National Center for Trauma-informed 

Care to develop coordinated networks focused on treatments shown to be 

effective in treating mental health conditions. In addition, SAMHSA has 

provided funding for webinars88 and a national technical assistance 

program that supports research and training centers focused on trauma.89

CMS added a measure on the use of multiple antipsychotic medications 

to the 2016 Core Set of Children’s Health Care Quality Measures for 

Medicaid and the State Children’s Health Insurance Program.90 The core 

set is a voluntary set of measures that states may use to monitor and 

improve the quality of health care delivery to children covered under 

Medicaid, including those in foster care. In addition to the measure added 

by CMS, other measures related to children’s use of antipsychotic 

medications include behavioral or mental health counseling services and 

metabolic monitoring.91 Through its group on antipsychotic medication 

use in children, CMS facilitates information sharing and provides technical 

assistance to help eight state Medicaid agencies improve their 

evaluations of state programs through the voluntary use of these 

measures. This will be the first year that states may voluntarily report on 

the measure for the use of multiple antipsychotic medications at the same 

time among children and adolescents. According to CMS officials, they 

provided a technical assistance webinar in August 2016 to help states 

determine how to measure this information. CMS officials said that a key 

CMS goal is to encourage and support national reporting by state 

 88Webinar topics ranged from facilitating cross-system data sharing for medication 

oversight to telephonic psychiatric consultation models.

89The Portland State University Pathways Research and Training Center publishes Focal 

Point. In 2015, an entire issue of Focal Point focused on trauma, including articles on the 

impact of trauma, implementation issues around trauma-informed care, organizational 

culture and policies, and evidence-based practices. Focal Point: Youth, Young Adults, & 

Mental Health, Trauma-Informed Care, 2015, v.29 (Portland, OR: Research and Training 

Center for Pathways to Positive Futures, Portland State University). 

90The Children’s Health Insurance Program Reauthorization Act of 2009 required HHS to 

identify and publish a core set of children’s health care quality measures for voluntary use 

by state Medicaid and Children’s Health Insurance programs, and beginning in January 

2013, to annually publish recommended changes to the core measures. Pub. L. No. 111-

3, § 401(a), 123 Stat. 8, 72-82 (codified as amended at 42 U.S.C. § 1320b-9a). 

91These three measures are in the Healthcare Effectiveness Data and Information Set 

(HEDIS) for quality monitoring. 

Health Care Quality Reporting 

Measures
Page 40 GAO-17-129 Foster Care

Medicaid agencies on a uniform set of measures to facilitate assessment 

of quality of care.92

Officials from most of the seven selected states we reviewed said they 

use or plan to use some or all of these measures. For example, in 

February 2017 California’s Medicaid agency will report to CMS measures 

on ADHD medication use and the use of multiple antipsychotic 

medications at the same time, among other things. The measures will 

include data on all children covered under their fee-for-service, managed 

care, and specialty mental health programs. In Ohio, state officials said 

they will build into managed care contracts two Healthcare Effectiveness 

Data and Information Set (HEDIS) measures as an oversight mechanism: 

the use of multiple antipsychotics at the same time in children and the first 

line psychosocial care for children and adolescents on antipsychotics.

Although HHS has a variety of efforts to assist states in overseeing 

psychotropic medication use among children, since 2014 the agency has 

not convened meetings with all the relevant stakeholder groups needed to 

share information and work together on these issues. Under title IV-B of 

the Social Security Act, states are required to develop their plans for 

oversight and coordination of health care services for children in foster 

care in collaboration with the state Medicaid agency, and in consultation 

with pediatricians, experts in health care, and experts in and recipients of 

child welfare services.93 HHS’s guidance on implementing this provision 

and overseeing psychotropic medication use notes that state oversight 

should include coordination among and mechanisms to actively engage 

with child welfare, Medicaid, and mental health stakeholders to improve 

outcomes for this population.94 This guidance also discussed HHS’s goal 

of facilitating cross-system collaborations for the purposes of promoting 

 92We previously reported that the core set of measures for children’s health care quality 

are voluntarily reported by states and provide CMS with information on whether children 

are receiving needed care. Although the numbers of states reporting these measures had 

increased in recent years, states varied considerably in the number of measures they 

reported. We noted that CMS’s ability to monitor children’s access to services is 

dependent on consistent, reliable, complete, and sufficiently detailed data from each state. 

GAO, Medicaid: Key Issues Facing the Program, GAO-15-677 (Washington, D.C.: July 30, 

2015). 

9342 U.S.C. § 622(b)(15). 

94Administration for Children and Families, Information Memorandum, ACYF-CB-IM-12-

03. 

HHS Has Supported 

Some State Collaboration 

on Medication Oversight, 

and Selected States Said 

More Federal Assistance 

Would Help
Page 41 GAO-17-129 Foster Care

improved behavioral health diagnosis, treatment, service delivery, and 

service tracking for children in foster care, which includes actions to 

increase oversight and monitoring of psychotropic medications. However, 

HHS’s assistance to states around collaboration has generally focused on 

a limited number of states or certain stakeholder groups. For example, 

SAMHSA hosted a day-long technical assistance meeting in 2015 for 

states with the capacity and commitment to implement improved crossagency oversight of medication use, however, the meeting was limited to 

five states.95 In addition, at its August 2016 National Conference on Child 

Abuse and Neglect, HHS held a breakout session which focused on a 

range of issues, including evaluation and oversight of medication, and 

how effective psychotropic medication oversight systems work in concert 

with efforts to ensure access to effective psychosocial services.96 While 

the conference included this session, ACF officials said it was limited in 

scope compared to previous events it hosted on this issue.

ACF also finalized regulations in June 2016 that established requirements 

for a new, optional comprehensive child welfare information system that 

states can use to maintain their child welfare data.97 If a state chooses to 

develop one, the new information system is required to support data 

exchanges with specified other systems, including Medicaid, court, and 

education systems, among other requirements. In the final rule, ACF 

stated that the new information system will provide child welfare agencies 

with the tools and flexibility to rapidly share data among multiple 

programs, including Medicaid and mental health. As discussed earlier, 

officials from child welfare and Medicaid agencies in most of the selected 

states spoke of challenges related to concerns about state and federal 

laws protecting individuals’ privacy. In 2013, we reported that state and 

local human services agencies, among others surveyed, identified 

 95These five states included Delaware, Hawaii, Kentucky, Mississippi, and Washington. 

States were selected based on a competitive application process that required articulation 

of existing goals related to medication oversight that would be advanced by participation in 

the technical assistance meeting. According to SAMHSA officials, they are planning 

follow-up with these states to assess their progress and develop training materials based 

on lessons learned and other resources. 

96The 20th National Conference on Child Abuse and Neglect in August 2016 included a 

variety of sessions over a 3-day period. Sessions focused on five core topic areas: 

promoting child and family well-being, shaping the workforce, building on strengths, 

leveraging community assets, and partnering for impact.

97Comprehensive Child Welfare Information System, 81 Fed. Reg. 35,450 (June 2, 2016). 

The final rule went into effect on August 1, 2016, but provides for a 24-month transition 

period.
Page 42 GAO-17-129 Foster Care

challenges related to the interpretation of federal privacy requirements as 

they balance the need to protect clients’ personal information while 

increasing the use of data sharing.98 These challenges included confusion 

or misperceptions about what agencies are allowed to share as well as a 

tendency to be risk averse and overly cautious in their interpretation of 

federal privacy requirements. ACF officials told us some states interpret 

federal laws on protecting confidentiality to have barriers when there often 

are not barriers at the federal level. They added that they have used their 

confidentiality toolkit to debunk myths and concerns with data sharing, 

though child welfare officials we interviewed in a few of the selected 

states said they were not aware of a federal toolkit on data sharing.99

State officials in all seven selected states spoke of the importance of 

collaboration, and some said successful cross-agency collaboration has 

helped them oversee the use of psychotropic medications more 

effectively. Further, officials in most of these states said they benefitted 

from HHS’s national convening in August 2012 of state directors of child 

welfare, Medicaid, and mental health agencies to address the use of 

psychotropic medications for children in foster care and their mental 

health needs. The meeting (“Because Minds Matter”), hosted by ACF, 

CMS, and SAMHSA, provided an opportunity for state leaders to enhance 

their collaboration on the appropriate use of psychotropic medications. 

Officials we spoke with said it helped them develop prescribing guidelines 

and expand reporting on psychotropic medications. According to officials 

in one selected state, their child welfare agency worked with its mental 

health agency partner at the HHS meeting to develop its informed 

consent process. Likewise, the meeting was the impetus for another 

selected state’s child welfare and Medicaid agency partnership and its 

quality improvement project, according to state officials. This project 

involved engaging with multiple stakeholders throughout the state, 

forming work groups to study psychotropic medication use, and 

developing training materials and guidance on the proper use of these 

medications. In a third selected state, three lead agency directors and 

medical directors formed a team to provide clinical oversight of their foster 

care population. In addition, officials in one selected state said their 

participation in the meeting, and in other collaborative efforts, helped 

 98GAO-13-106.

99As discussed earlier, HHS published a “Confidentiality Toolkit” in August 2014 that aims 

to support state and local data sharing efforts by bringing greater clarity to the rules 

governing confidentiality in certain human services programs.
Page 43 GAO-17-129 Foster Care

them learn about the work of other states in effective monitoring of mental 

health care for children in foster care, including an improved ability to 

monitor medication use.

State officials in three of the seven selected states said more federal 

government leadership could help them work through ongoing 

challenges, including (1) obtaining best practices in medication use 

concurrent with other treatments; (2) overcoming siloes across child 

welfare, Medicaid, and mental health systems serving the foster care 

population; and (3) enhancing access to child and adolescent psychiatric 

resources. In addition, officials in selected states transitioning their foster 

care populations into managed care expressed concern about the 

transition, and the need to manage the transition to ensure optimal care 

coordination. Some of the concerns identified include (1) ensuring state 

agencies share data with the managed care providers to facilitate 

continuity of care, (2) bringing all the necessary stakeholders onboard 

during the transition to ensure a common understanding of concepts and 

roles, and (3) ensuring managed care plans have the needed tools to 

accommodate non-traditionally served populations that have high medical 

needs.100

State child welfare, Medicaid, and mental health officials in three selected 

states said having other events similar to the one hosted by HHS in 2012 

could provide further support in addressing these challenges. While ACF, 

CMS, and SAMHSA have held various events with limited numbers of 

states or certain stakeholder groups, as mentioned above, they have not 

convened a 50-state meeting that includes child welfare, Medicaid, and 

mental health stakeholders since 2012 to continue discussions about how 

best to oversee psychotropic medications. ACF officials said they have no 

plans to hold a national convening of state agency stakeholders. They 

explained that, in response to recent mandates on efficient government, 

 100Our 2014 report on monitoring of psychotropic medications described similar transitions 

to managed care and limited planning among the states included in its review. 

GAO-14-362. We recommended HHS issue guidance to help states implement oversight 

strategies within a managed care environment. CMS officials said they were continuing to 

provide guidance to states through their working group on antipsychotic medications for 

children, which includes states that provide prescription drug benefits through a managed 

care delivery system. However, this effort reaches a select number of states and focuses 

on antipsychotic medications rather than the broader classes of psychotropic medications. 

As of December 2016, the recommendation remained open. 
Page 44 GAO-17-129 Foster Care

they have moved toward hosting more virtual meetings.101 While virtual 

meetings can be a useful and cost-effective tool in facilitating 

collaboration and information sharing, none of HHS’s virtual meetings on 

psychotropic medications have included most states and stakeholders 

across multiple services. HHS noted in its 2012 guidance to states on 

oversight of psychotropic medications that children in foster care are 

typically involved in multiple service delivery systems, and a coordinated, 

multi-system approach is necessary to meaningfully improve outcomes 

for this population. Additional efforts from HHS to include relevant 

stakeholders in collaborations to address continuing challenges can 

better position states in their work to improve practices to oversee 

medication use and effectively ensure appropriate treatments for the 

foster care population.

Though the benefits of using psychotropic medications have been 

documented, the health risks or side effects associated with certain 

prescribing patterns—such as the use of multiple psychotropic 

medications at the same time and the use of antipsychotics—make it 

important to ensure that a given treatment is appropriate for addressing a 

child’s condition. State agencies in our seven selected states have taken 

steps to curb inappropriate prescriptions of psychotropic medications 

among children in foster care, often by collaborating with each other and 

with other stakeholders involved in the child’s care. Officials in these 

states credited HHS with helping them jumpstart or further their efforts by 

fostering collaboration and providing forums to share information at 

HHS’s 2012 conference.

While the states included in our review have made efforts to improve 

medication oversight, selected state officials and their partners discussed 

a need for continued collaboration and information sharing to help 

effectively implement oversight practices, improve access to mental 

health services, share data, and monitor outcomes. Information on 

oversight practices can be especially important for states that may not be 

as far along in their efforts to oversee medication use as those selected 

 101Specifically, officials pointed to: (1) Executive Order 13589, Promoting Efficient 

Spending, 76 Fed. Reg. 70,863 (Nov. 15, 2011) and OMB Memorandum M-12-12; (2) 

Executive Order 13576, Delivering Efficient, Effective, and Accountable Government, 76 

Fed. Reg. 35,297 (June 16, 2011) and OMB Memoranda M-11-35; and (3) division E, title 

VII, sections 739 and division G, title V, section 527 of the Consolidated and Further 

Continuing Appropriations Act, 2015, Pub. L. No. 113-235, 128 Stat. 2130 (2014). 

Conclusions
Page 45 GAO-17-129 Foster Care

for this review, or for those experiencing a period of change as they 

transition their foster care populations into managed care. While HHS has 

made efforts to help support states in their oversight activities, additional 

support from HHS to convene state child welfare and Medicaid agencies 

and other stakeholders could create opportunities for state agencies to 

learn from one another’s experience, collaboratively develop solutions to 

mitigate common challenges, strengthen oversight practices for 

psychotropic medications, and more effectively ensure appropriate 

treatments for children in foster care.

To help states effectively address ongoing challenges related to ensuring 

the appropriate use of psychotropic medications for children in foster 

care, the Secretary of HHS should consider cost-effective ways to 

convene state child welfare, Medicaid, and other stakeholders to promote 

collaboration and information sharing within and across states on 

psychotropic medication oversight.

We provided a draft of this report to the Secretary of HHS for review and 

comment. HHS agreed with our recommendation and provided some 

examples of a virtual convening of select groups of professionals and 

agencies it employed to facilitate information sharing and collaboration 

around different issues. We believe that convening child welfare, 

Medicaid, and mental health stakeholders across all 50 states, in virtual 

or other settings, is an important step towards helping these stakeholders 

ensure the appropriate use of psychotropic medications for children in 

foster care. HHS also provided additional information on their efforts to 

date to help states address medical and mental health care for children in 

foster care. Finally, HHS provided technical comments, which we 

incorporated as appropriate. A letter conveying HHS’s formal comments 

is reproduced in appendix III.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of HHS and 

interested congressional committees. The report will also be available at 

no charge on the GAO website at www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7215 or Brownke@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

Recommendation for 

Executive Action

Agency Comments 

and Our Evaluation
Page 46 GAO-17-129 Foster Care

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix IV. 

Sincerely yours, 

Kay E. Brown, Director

Education, Workforce, and Income Security Issues
Appendix I: Objectives, Scope, and 

Methodology

Page 47 GAO-17-129 Foster Care

This appendix discusses in detail our methodology for addressing three 

research questions: (1) how child welfare and Medicaid agencies in 

selected states work to ensure the appropriate use of psychotropic 

medications for children in foster care; (2) what is known about the results 

of their efforts, and (3) the extent to which the Department of Health and 

Human Services (HHS) helps states support the appropriate use of 

psychotropic medications for children in foster care. To address these 

questions, we reviewed relevant federal laws, regulations, and guidance. 

We interviewed HHS officials, and state officials in seven selected states 

and county officials in two of those states as well as officials in nine 

national professional and research organizations. We reviewed national, 

state, and county guidance and other documents identified by our 

interview subjects, and analyzed available data from selected states on 

medication use in foster care over a 5-year period.

To address all objectives, we conducted in-person and telephone 

interviews with officials in seven selected states, including officials from 

child welfare and Medicaid agencies and other partners, and with nine 

national child welfare, Medicaid, and mental health professional and 

research organizations.1 The states we selected were Arizona, California, 

Illinois, Maryland, New Jersey, Ohio, and Washington. Our selection 

criteria included: (1) a high percentage of children in foster care and 

congregate care in the state when compared nationwide in fiscal year 

2014; (2) variation in the type of Medicaid delivery system covering 

psychotropic medications and other mental health services for children in 

foster care (i.e., fee-for-service versus single or multiple managed care 

organizations)2 and in the type of child welfare system (i.e., state- versus 

county-administered);3 (3) recommendations from national organizations 

 1

We interviewed additional stakeholders when referred to us by officials from the selected 

state child welfare and Medicaid agencies. Examples of additional stakeholders include 

state or county mental health agency officials, employees of partnering universities, and a 

state child welfare agency advisory committee made up of former foster youth.

2

Of our seven selected states, three states—Illinois, Maryland, and Ohio—use a fee-forservice system to deliver psychotropic medications and mental health services to children 

in foster care on Medicaid. Of the remaining four states, Arizona uses multiple managed 

care organizations to deliver these services, California may deliver these services under 

fee-for-service or managed care depending on the county, New Jersey uses multiple 

organizations to deliver psychotropic medications and a fee-for-service system for other 

mental health services, and Washington transitioned the delivery of these services from a 

fee-for-service system to a single managed care organization as of April 1, 2016.

3

Of our seven selected states, five states have state-administered child welfare systems 

(Arizona, Illinois, Maryland, New Jersey, and Washington) and two have countyadministered systems (California and Ohio). 

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 48 GAO-17-129 Foster Care

we interviewed for states that have or are in the process of implementing 

practices to oversee and monitor psychotropic medications; and (4) 

diversity in geographic location. In two states with county-administered 

child welfare systems, California and Ohio, we selected five counties and 

conducted interviews with officials from the respective county-level child 

welfare and Medicaid agencies, as appropriate.4 These counties were 

selected based on factors similar to those mentioned above as well as 

variation in population density (i.e., rural versus urban). Our findings 

cannot be generalized to states or counties outside our selection sample.

In the report we use qualifiers, such as “a few,” “some,” and “most” to 

quantify responses from officials across our interviews with state and 

county child welfare and Medicaid agencies and their partners, such as 

universities and state or county mental health agencies. We reported the 

total number of the seven selected states in which at least one official or 

partner gave the reported response. These qualifiers are defined as 

follows:

• “All” states represents seven

• “Most” states represents five to six

• “Some” states represents three to four

• “A few” states represents two

We interviewed representatives from nine national professional and 

research organizations selected to represent a variety of views on child 

welfare, Medicaid, and mental health-related policy and research. These 

organizations were: American Academy of Child & Adolescent Psychiatry, 

American Academy of Pediatrics, Center for Health Care Strategies, Child 

Welfare League of America, Medicaid and CHIP Payment and Access 

Commission, National Association of Medicaid Directors, National 

Association of Public Child Welfare Administrators, National Association 

of State Mental Health Program Directors, and National Alliance on 

Mental Illness.

For all our interviews, we used a semi-structured interview protocol that 

included open-ended questions about state child welfare and Medicaid 

delivery systems; state and county oversight practices, including related 

challenges and measurement of outcomes; and federal efforts to assist 

 4

The counties we selected are Fairfield, Lucas, and Perry counties in Ohio, and Los 

Angeles and Sonoma counties in California. 
Appendix I: Objectives, Scope, and 

Methodology

Page 49 GAO-17-129 Foster Care

states. Information was volunteered by officials in each interview in 

response to these open-ended questions. Thus, the counts of 

organizations citing such responses vary. We reviewed relevant 

documents to corroborate information obtained in our interviews, when 

possible.

To examine how state child welfare and Medicaid agencies work to 

ensure the appropriate use of psychotropic medications, we also 

reviewed guidance and other documents identified by officials from 

selected states and counties.5 While we identified selected states’

oversight and monitoring practices related to psychotropic medications 

based on interviews and these document reviews, we did not assess the 

effectiveness of states’ implementation of these practices, nor did we 

evaluate their compliance with state or federal requirements or whether 

there are controls in place to help ensure that required practices are 

followed. In addition, while we focused our review on children in foster 

care, state oversight practices may also pertain to other children on 

Medicaid. We also reviewed guidance on oversight and monitoring of 

psychotropic medications for children issued by national health care 

professional organizations.6 In addition, we reached out to selected 

states’ audit agencies and HHS’s Office of Inspector General to identify 

past, ongoing, or planned work in this area. We also conducted a review 

of selected literature, including reports from academic, professional, and 

governmental organizations, related to the use of psychotropic 

medications and published since GAO’s report in April 2014.7

To examine the results of state efforts to ensure the appropriate use of 

psychotropic medications, we gathered and analyzed available data from 

selected states on the use of these medications among children in foster 

care from 2011 through 2015.8 We selected this range in order to gather 

data on 5-year trends that included the most recent data available. To 

examine the reliability of these data, we interviewed and sent a 

 5

We did not conduct a review of state laws and regulations.

6

For example, we reviewed AACAP’s 2015 Recommendations about the Use of 

Psychotropic Medications for Children and Adolescents Involved in Child-Serving 

Systems, among other documents.

7

GAO-14-362. 

8

We analyzed data for six of our seven selected states. The remaining state—Ohio—was 

unable to provide data from 2011 through 2015; Ohio child welfare officials said they did 

not collect data on the use of medications in the past, but began to do so as of May 2016. 
Appendix I: Objectives, Scope, and 

Methodology

Page 50 GAO-17-129 Foster Care

questionnaire to relevant state child welfare and Medicaid officials and 

examined the data received to identify any obvious outliers. We 

determined that these data were sufficiently reliable for the purposes of 

describing trends in the percentage of children in foster care on 

psychotropic medications for each of the selected states. However, 

because these states use different methodologies to collect data (e.g., 

states collected data for different time periods and ages of children in 

foster care), the data are not comparable among them. In addition, the 

results of our analyses are not generalizable nationwide. Information 

collected from selected states, such as on their oversight practices and 

measures collected to examine the results of their efforts, was provided to 

officials in each selected state for their review and verification.

To examine HHS’s actions to support state efforts related to psychotropic 

medications, we interviewed officials from the Administration for Children 

and Families, Centers for Medicare & Medicaid Services, and Substance 

Abuse and Mental Health Services Administration, and reviewed relevant 

documents. In addition, we reviewed guidance on oversight and 

monitoring of psychotropic medications for children issued by HHS and 

used it as criteria for our recommendation.
Appendix II: Selected State Information

Page 51 GAO-17-129 Foster Care

Appendix II: Selected State Information
Appendix II: Selected State Information

Page 52 GAO-17-129 Foster Care
Appendix II: Selected State Information

Page 53 GAO-17-129 Foster Care
Appendix II: Selected State Information

Page 54 GAO-17-129 Foster Care
Appendix II: Selected State Information

Page 55 GAO-17-129 Foster Care
Appendix II: Selected State Information

Page 56 GAO-17-129 Foster Care
Appendix II: Selected State Information

Page 57 GAO-17-129 Foster Care
Appendix III: Agency Comments from the

Department of Health and Human Services

Page 58 GAO-17-129 Foster Care

Appendix III: Agency Comments from the 

Department of Health and Human Services
Appendix III: Agency Comments from the 

Department of Health and Human Services

Page 59 GAO-17-129 Foster Care
Appendix III: Agency Comments from the 

Department of Health and Human Services

Page 60 GAO-17-129 Foster Care
Appendix IV: Staff Acknowledgments

Page 61 GAO-17-129 Foster Care

Kay E. Brown, (202) 512-7215 or brownke@gao.gov

In addition to the contact named above, Elizabeth Morrison (Assistant 

Director), Claudine Pauselli (Analyst-in-Charge), Linda Collins, and Nhi

Nguyen made key contributions to this report. Also contributing to this 

report were Seto Bagdoyan, James Bennett, David Chrisinger, Sarah 

Cornetto, Celina Davidson, Sara Edmondson, Sandra George, Katherine 

Iritani, Angie Jacobs, Kirsten Lauber, Hannah Locke, Sheila McCoy, 

Jonathan McMurray, and Jennifer Whitworth.

Appendix IV: Staff Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 62 GAO-17-129 Foster Care

Foster Children: HHS Could Provide Additional Guidance to States 

Regarding Psychotropic Medications. GAO-14-651T. Washington, D.C.: 

May 29, 2014.

Foster Children: Additional Federal Guidance Could Help States Better 

Plan for Oversight of Psychotropic Medications Administered by 

Managed-Care Organizations. GAO-14-362. Washington, D.C.: April 28, 

2014.

Children’s Mental Health: Concerns Remain about Appropriate Services 

for Children in Medicaid and Foster Care. GAO-13-15. Washington, D.C.: 

December 10, 2012.

Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions. GAO-12-201. Washington, D.C.: December 

14, 2011.

Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions. GAO-12-270T. Washington, D.C.: December 

1, 2011.

Related GAO Products

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