FOSTER CHILDREN

HHS Guidance Could 

Help States Improve 

Oversight of 

Psychotropic 

Prescriptions 

Report to Congressional Requesters

December 2011 

GAO-12-201 

United States Government Accountability Office

GAO 

This report was revised on December 15, 2011, to insert the 

third page of the comments from the Department of Health 

and Human Services, which was inadvertently left out of the 

original report. It has been added at page 86. 
United States Government Accountability Office

Highlights of GAO-12-201, a report to 

congressional requesters

December 2011

FOSTER CHILDREN

HHS Guidance Could Help States Improve Oversight 

of Psychotropic Prescriptions

Why GAO Did This Study

Foster children have often been 

removed from abusive or neglectful 

homes and tend to have more mental 

health conditions than other children. 

Treatment of these conditions may 

include psychotropic drugs, but the 

risks these drugs pose specifically to 

children are not well understood. 

Medicaid, which is administered by 

states and overseen by the 

Department of Health and Human 

Services (HHS), provides prescription 

drug coverage to foster children.

For selected states, GAO examined (1) 

2008 rates of psychotropic 

prescriptions for foster and nonfoster 

children and (2) state oversight of 

psychotropic prescriptions for foster 

children through October 2011. GAO 

selected Florida, Maryland, 

Massachusetts, Michigan, Oregon, and 

Texas primarily for geographic diversity 

and size of the foster care population, 

and analyzed state Medicaid fee-forservice and foster care data from 

selected states for 2008. 2008 was the 

most recent year of prescription data 

available at the start of the audit. 

Maryland’s 2008 foster care data were 

unreliable and could not be analyzed. 

GAO contracted with expert child 

psychiatrists to provide a clinical 

perspective on our methodology and 

analysis, reviewed regulations and 

state policies, and interviewed federal 

and state officials. Results cannot be 

generalized to other states.

What GAO Recommends

GAO recommends that HHS consider 

endorsing guidance for states on best 

practices for overseeing psychotropic 

prescriptions for foster children. HHS 

agreed with our recommendation.

What GAO Found

Foster children in the five states GAO analyzed were prescribed psychotropic 

drugs at higher rates than nonfoster children in Medicaid during 2008. The higher 

rates do not necessarily indicate inappropriate prescribing practices, but 

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

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

exposure to traumatic experiences, and the challenges of coordinating their 

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

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

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

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

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

nonfoster children were prescribed doses higher than the maximum levels cited 

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

experts said increases the potential for adverse side effects and does not 

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

foster and nonfoster children under 1 year old were prescribed psychotropic 

drugs, which GAO’s experts said have no established use for mental health 

conditions in infants and could result in serious adverse effects. 

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

0

20

40

60

80

100

MAFL TXORMI

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

% of foster children

Prescribed at least one

psychotropic medication:

% of nonfoster children

The six selected states’ monitoring programs for psychotropic drugs provided to 

foster children fall short of best principles guidelines published by the American 

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

states are not required to follow, cover four categories. 

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

guidelines, such as identifying caregivers empowered to give consent. 

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

oversight guidelines, which include monitoring rates of prescriptions. 

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

which include providing consultations by child psychiatrists by request. 

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

clinicians, foster parents, and other caregivers. 

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

endorsed specific measures for state oversight of psychotropic prescriptions for 

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

psychotropic prescriptions and increase protections for these vulnerable children.

View GAO-12-201. For more information, 

contact Gregory D. Kutz at (202) 512-6722 or 

kutzg@gao.gov.
Page i GAO-12-201 Foster Children

Letter 1 

Background 5

Foster Children Have Higher Rates of Psychotropic Drug 

Prescriptions and Indicators of Potential Health Risks 7

Selected States’ Psychotropic Drug Monitoring Programs Fall Short 

of AACAP-Best Principles Guidelines 18

Conclusions 29

Recommendation for Executive Action 30

Agency Comments and Our Evaluation 30

Appendix I Objectives, Scope, and Methodology 34

Appendix II Uses and Side Effects of Psychotropic Drugs 41

Appendix III List of Psychotropic Drugs Used in Analysis 45

Appendix IV Rates of Psychotropic Prescription Usage by Length of Time in 

Medicaid Fee-for-service 48

Appendix V Additional Data on Children with Prescriptions of at Least One 

Psychotropic Drug 49

Appendix VI Additional Data on Concomitant Prescriptions 51

Appendix VII Additional Data on Psychotropic Drug Prescriptions Exceeding 

Maximum Recommended Doses 59

Contents
Page ii GAO-12-201 Foster Children

Appendix VIII Additional Data on Psychotropic Prescriptions to Children Under 

1 Year Old 62

Appendix IX Additional Data on Psychotropic Drugs with Gaps in Prescriptions of 

7 to 29 Days 64

Appendix X Selected States’ Implementation of AACAP’s Best Principles 

Guidelines 70

Appendix XI Comments from the Department of Health and Human Services 83

Appendix XII Comments from the Florida Agency for Health Care Administration 87

Appendix XIII Comments from the Massachusetts Executive Office of Health and 

Human Services 91

Appendix XIV Comments from the Oregon Health Authority 93

Appendix XV Comments from the Texas Health and Human Services Commission 96

Appendix XVI GAO Contact and Staff Acknowledgments 100

Appendix XVII Print-Friendly Version of Figure 1, Psychotropic Prescription Rates

for Children in Five States 101
Page iii GAO-12-201 Foster Children

Appendix XVIII Print-Friendly Version of Figure 2, Psychotropic Drug Potential 

Health Risk Indicators for Five Selected States 106

Tables

Table 1: Psychotropic Drug Classes 6

Table 2: Children Age 0-1 Year Old Prescribed Psychotropic Drugs 

in Five Selected States 16

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

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

in Five States 18

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

Best Principles Guidelines 20

Table 5: State Oversight Laws and Policies Compared with 

AACAP’s Best Principles Guidelines 23

Table 6: State Consultation Programs Compared with AACAP’s

Best Principles Guidelines 26

Table 7: State Information-sharing Laws and Policies Compared 

with AACAP’s Best Principles Guidelines 28

Table 8: Psychotropic Drugs Used in Analysis 45

Table 9: Rates of Psychotropic Prescriptions by Length of Medicaid 

Fee-for-service Coverage in Florida during 2008 48

Table 10: Rates of Psychotropic Prescriptions in Florida during 

2008 by Age of Child and Foster Care Status 49

Table 11: Rates of Psychotropic Prescriptions in Massachusetts 

during 2008 by Age of Child and Foster Care Status 49

Table 12: Rates of Psychotropic Prescriptions in Michigan during 

2008 by Age of Child and Foster Care Status 49

Table 13: Rates of Psychotropic Prescriptions in Oregon during 

2008 by Age of Child and Foster Care Status 50

Table 14: Rates of Psychotropic Prescriptions in Texas during 2008 

by Age of Child and Foster Care Status 50

Table 15: Rates of Concomitant Psychotropic Prescriptions in 

Florida during 2008 by Number of Drugs 51

Table 16: Rates of Concomitant Psychotropic Prescriptions in 

Massachusetts during 2008 by Number of Drugs 53

Table 17: Rates of Concomitant Psychotropic Prescriptions in 

Michigan during 2008 by Number of Drugs 54

Table 18: Rates of Concomitant Psychotropic Prescriptions in 

Oregon during 2008 by Number of Drugs 55
Page iv GAO-12-201 Foster Children

Table 19: Rates of Concomitant Psychotropic Prescriptions in 

Texas during 2008 by Number of Drugs 57

Table 20: Rates of Children Prescribed Psychotropic Drugs Outside 

FDA-Approved Doses or Standards Published in Medical 

Literature in Florida during 2008 59

Table 21: Rates of Children Prescribed Psychotropic Drugs Outside 

FDA-Approved Doses or Standards Published in Medical 

Literature in Massachusetts during 2008 60

Table 22: Rates of Children Prescribed Psychotropic Drugs Outside 

FDA-Approved Doses or Standards Published in Medical 

Literature in Michigan during 2008 60

Table 23: Rates of Children Prescribed Psychotropic Drugs Outside 

FDA-Approved Doses or Standards Published in Medical 

Literature in Oregon during 2008 61

Table 24: Rates of Children Prescribed Psychotropic Drugs Outside 

FDA-Approved Doses or Standards Published in Medical 

Literature in Texas during 2008 61

Table 25: Prescriptions of Psychotropic Drugs to Foster and 

Nonfoster Children Age 0-1 in Five Selected States 62

Table 26: Rates of Psychotropic Drugs with Three or More Gaps of 

7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Florida during 2008 64

Table 27: Average Gaps of 7-29 Days in Psychotropic Drug 

Prescriptions to Foster and Nonfoster Children in Florida 

during 2008 64

Table 28: Rates of Psychotropic Drugs with Three or More Gaps of 

7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Massachusetts during 2008 65

Table 29: Average Gaps of 7-29 Days in Psychotropic Drug 

Prescriptions to Foster and Nonfoster Children in 

Massachusetts during 2008 65

Table 30: Rates of Psychotropic Drugs with Three or More Gaps of 

7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Michigan during 2008 66

Table 31: Average Gaps of 7-29 Days in Psychotropic Drug 

Prescriptions to Foster and Nonfoster Children in 

Michigan during 2008 66

Table 32: Rates of Psychotropic Drugs with Three or More Gaps of 

7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Oregon during 2008 67
Page v GAO-12-201 Foster Children

Table 33: Average Gaps of 7-29 Days in Psychotropic Drug 

Prescriptions to Foster and Nonfoster Children in Oregon 

during 2008 67

Table 34: Rates of Psychotropic Drugs with Three or More Gaps of 

7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Texas during 2008 68

Table 35: Average Gaps of 7-29 Days in Psychotropic Drug 

Prescriptions to Foster and Nonfoster Children in Texas 

during 2008 68

Table 36: State Consent Laws and Policies Compared with AACAP 

Best Principle Guidelines 70

Table 37: State Oversight Laws and Policies Compared with 

AACAP’s Best Principle Guidelines 72

Table 38: State Consultation Programs Compared with AACAP’s 

Best Principle Guidelines 78

Table 39: State Information-Sharing Laws and Policies Compared 

with AACAP’s Best Principle Guidelines 80

Figures

Figure 1: Psychotropic Drug Prescription Rates for Five Selected 

States 9

Figure 2: Psychotropic Drug Potential Health Risk Indicators for 

Five Selected States 13
Page vi GAO-12-201 Foster Children

Abbreviations

AACAP American Academy of Child and Adolescent 

 Psychiatry

ACF Administration for Children and Families

ADHD Attention Deficit Hyperactivity Disorder

BPCA Best Pharmaceuticals for Children Act

CFSR Child and Family Services Review

CMS Centers for Medicare & Medicaid Services

CWS Child Welfare Services

DFPS Texas Department of Family and Protective 

 Services

FDA Food and Drug Administration

HHS Department of Health and Human Services

HMO Health Maintenance Organization

MCPAP Massachusetts Child Psychiatry Access Project

MMIS Medicaid Management Information System

MMPP Maryland Medicaid Pharmacy Program

NIMH National Institute of Mental Health

NSCAW National Survey of Child and Adolescent 

 Well-Being

OBRA Omnibus Budget Reconciliation Act

PA Prior Authorization

PREA Pediatric Research Equity Act

SSRI Selective Serotonin Reuptake Inhibitors

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Page 1 GAO-12-201 Foster Children

United States Government Accountability Office

Washington, DC 20548

December 14, 2011

Congressional Requesters

Children placed in foster care are among our nation’s most vulnerable 

populations. Often having been removed from abusive or neglectful 

homes, they tend to have more numerous and serious medical and 

mental health conditions than do other children.1 Treatment of mental 

illness may include prescribing psychotropic drugs, such as 

antidepressants and antipsychotics. Because foster children are under 

state care, they typically receive prescription drugs and other medical 

services through Medicaid, a joint federal-state program that finances 

health care coverage for certain low-income populations.2

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

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

disorder, depression, and schizophrenia. While many psychotropic drugs 

that have been approved by the Food and Drug Administration (FDA) as 

safe and effective in adults have not been similarly approved for children 

of all ages, prescribing them to children is legal and common medical 

practice in many instances. According to the National Institute of Mental 

Health (NIMH), some children with severe mental health conditions would 

suffer serious consequences without such medication.3 However, 

psychotropic drugs can also have serious side effects in adults, including 

irreversible movement disorders, seizures, and an increased risk for 

diabetes over the long term. Further, additional risks these drugs pose 

specifically to children are not well understood.4

 

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

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

2 Medicaid programs vary from state to state.

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

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

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

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

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

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

 
 

Page 2 GAO-12-201 Foster Children

States are responsible for running their Medicaid and foster care 

programs, but the programs are administered at the federal level by the 

Department of Health and Human Services (HHS) through the Centers for 

Medicare & Medicaid Services (CMS) and the Administration for Children 

and Families (ACF), respectively. HHS may issue regulations, provide 

guidance on some issues, or simply provide informational resources for 

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

psychotropic drugs provided to children in state custody. Among these 

resources are best principles developed by the American Academy of 

Child and Adolescent Psychiatry (AACAP), a nonprofit professional 

association. While HHS does not require states to follow these guidelines, 

AACAP developed them as a model to help inform state monitoring 

programs for youth in state custody. AACAP guidelines point out that “as 

a result of several highly publicized cases of questionable inappropriate 

prescribing, treating youth in state custody with psychopharmacological 

agents has come under increasingly intense scrutiny,” leading to state 

implementation of consent, authorization, and monitoring procedures.5

More recently, Congress enacted the Child and Family Services 

Improvement and Innovation Act in September 2011, requiring states that 

apply for certain federal child welfare grants to establish protocols for the 

appropriate use and monitoring of psychotropic drugs prescribed to foster 

children.6

You requested that we examine psychotropic drugs prescribed to foster 

children. In this report, for selected states we (1) compared rates of 

psychotropic drug prescriptions for foster children and nonfoster children 

covered by Medicaid in 2008, including indicators of potential health risks, 

and (2) examined federal and state oversight policies in effect for 

psychotropic drugs prescribed to foster children through October 2011. 

Our full scope and methodology is provided in appendix I.

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

we contracted with two child psychiatrists with clinical and research 

expertise in the use of psychotropic drugs in children. Dr. Jon McClellan 

is an attending psychiatrist at the Seattle Children’s Hospital; a professor 

at the University of Washington School of Medicine; and the medical 

 

5 AACAP guidelines are available at 

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

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

Page 3 GAO-12-201 Foster Children

director at Washington’s Child Study and Treatment Center, the children’s 

psychiatric hospital for the state of Washington. He is board certified in 

psychiatry and child and adolescent psychiatry. Dr. Michael Naylor is an 

associate professor at the University of Illinois at Chicago, School of 

Medicine, and the director of the Behavioral Health and Welfare Program, 

which was formed to address the mental health needs of the most 

severely disturbed children in state care. He directs the Clinical Services 

in Psychopharmacology program, which provides an independent review 

of all psychotropic medication consent requests for foster children in 

Illinois. He is board certified in child and adolescent psychiatry, general 

psychiatry, and sleep disorders medicine.

To compare rates of psychotropic drug prescriptions in foster children and 

nonfoster children covered by Medicaid, we reviewed calendar year 2008 

fee-for-service prescription claims and foster care data for Florida, 

Maryland, Massachusetts, Michigan, Oregon, and Texas.7

 

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

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

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

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

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

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

care. In Florida, about 60 percent of foster children and 45 percent of nonfoster children 

had their prescriptions covered only on a fee-for-service basis during 2008. In 

Massachusetts, the percentages were about 72 percent for foster children and about 42 

percent for nonfoster children. For these two states, our analysis is not applicable to the 

entire state’s foster care or Medicaid program. In these states, since we examined only 

fee-for-service data, we were more likely to identify psychotropic prescriptions for foster 

children during calendar year 2008 than for nonfoster children. Appendix IV shows how 

rates of psychotropic prescriptions are affected by the length of time a child is covered 

under a Medicaid fee-for-service program.

 At the start of 

our audit, 2008 data were the most recent calendar year prescription 

claims data available from CMS. These states were selected primarily for 

geographic diversity and the size of their foster care populations. 

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

unreliability of its foster care data. Because the audit was limited to 

children in these nonrandomly selected states, the results cannot be 

generalized to other states or populations. In consultation with our 

experts, we developed a list of psychotropic drugs likely to be prescribed 

in the six selected states by reviewing each state’s list of approved drugs, 

and a list of psychotropic drugs published by NIMH. Based on our 

experts’ recommendations, we excluded some drugs likely to be for 
 

Page 4 GAO-12-201 Foster Children

nonmental health purposes (such as anticonvulsants) from our overall 

analysis of psychotropic prescription rates, but included them in our 

analysis of concomitant prescriptions—that is, prescriptions for multiple 

drugs to be taken concurrently—and our analysis of gaps in medications.8

To identify prescribed drug regimens that have potential health risk 

indicators, we, among other things, consulted with our experts, performed 

literature searches, and reviewed state guidelines. Based on this, our final 

indicators of potential health risks were: concomitant prescriptions of five 

or more drugs, prescriptions exceeding dosage guidelines in the 

Psychotropic Medication Utilization Parameters for Texas Foster 

Children, and psychotropic prescriptions for children under 1 year old. In 

addition, we evaluated gaps of 7 to 29 days in prescriptions of a drug to 

identify nonadherence to drug regimens, which can pose significant risks 

to a patient. Because prescription claims do not include diagnosis data, 

we were not able to examine the clinical indications used to justify 

psychotropic prescriptions. Further, prescribers should weigh the benefits 

and drawbacks of drug regimens on a case-by-case basis. As such, 

determining the appropriateness of prescriptions without patient-level 

reviews by medical experts is impossible.

As such, we are likely understating the percentage of children prescribed 

psychotropic drugs for mental health purposes. See appendix III for the 

listing of psychotropic drugs used in our overall analysis.

To determine federal and state oversight policies in effect for prescribing 

psychotropic drugs to foster children through October 2011, we 

interviewed officials from CMS, ACF, and the six selected states’ 

Medicaid and foster care agencies. We also reviewed policies, statutes,

and regulations related to the prescribing of psychotropic drugs to foster 

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

HHS, we selected AACAP’s guidelines as a basis for assessing the 

extent to which selected states were implementing recommended 

practices.

We performed this audit from February 2010 through November 2011 in 

accordance with generally accepted government auditing standards. 

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

 

8 According to our experts, these medications, such as anticonvulsants, are likely being 

prescribed to treat mental health conditions when combined with another psychotropic 

medication. 
 

Page 5 GAO-12-201 Foster Children

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.

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

guardians and placed under the responsibility of a state child welfare 

agency. Removal from the home can occur because of reasons such as 

physical abuse or neglect. It can also occur when a child’s own behavior 

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

their community. As we have previously reported, children in foster care 

exhibit more numerous and serious medical conditions, including mental 

health conditions, than do other children.9

Foster care may be provided by a family member, caregivers previously 

unknown to the child, or a group home or institution. Ideally, foster care is 

an intermediate step towards a permanent family home. When reuniting 

the child with his or her parents or guardian is not in the child’s best 

interest, caseworkers seek a new permanent home for the child, such as 

an adoptive home or guardianship. However, some children remain in 

foster care until they reach adulthood.

Psychotropic drugs affect brain activity associated with mental processes 

and behavior. These drugs are also called psychotherapeutic drugs. 

While psychotropic drugs can have significant benefits for those with 

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

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

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

conditions treated and possible side effects. Specific information about 

each drug can be found in appendix II.

 

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

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

Background 
 

Page 6 GAO-12-201 Foster Children

Table 1: Psychotropic Drug Classes 

Drug class Examples of drugs

Types of conditions

treated by drug class

Examples of possible 

adverse side effects

ADHD drugs Atomoxetine (Strattera)

Lisdexamfetamine dimesylate (Vyvanse)

Methylphenidate (Ritalin, Concerta)

Amphetamine (Adderall)

Dextroamphetamine (Dexedrine, Dextrostat)

Attention deficit hyperactivity 

disorder

Decreased appetite

Tics

Psychosis

Anti-anxiety Clonazepam (Klonopin)

Lorazepam (Ativan)

Alprazolam (Xanax) 

Generalized anxiety disorder

Post-traumatic stress disorder

Social phobias

Dependence

Drowsiness and dizziness

Blurred vision

Nightmares

Antidepressants Fluoxetine (Prozac)

Citalopram (Celexa)

Sertraline (Zoloft)

Paroxetine (Paxil)

Escitalopram (Lexapro)

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Bupropion (Wellbutrin)

Depression

Generalized anxiety disorder

Obsessive-compulsive disorder

Social phobia

Suicidal thoughts

Sleeplessness or drowsiness

Agitation

Sexual dysfunction

Antipsychotics Chlorpromazine (Thorazine)

Haloperidol (Haldol)

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Aripiprazole (Abilify)

Bipolar disorder

Schizophrenia

Tourette’s syndrome

Rigidity (muscular tension)

Tremor

Tardive Dyskinesia 

(uncontrollable movements)

Diabetes

High cholesterol

Weight gain

Neuroleptic malignant 

syndrome (a life-threatening 

neurological disorder most 

often caused by an adverse 

reaction to antipsychotic drugs)

Hypnotics Quazepam (Doral)

Zolpidem (Ambien)

Eszopiclone (Lunesta)

Insomnia

Anxiety

Dependence

Sleep walking

Mood stabilizers Lithium

Divalproex sodium (Depakote)

Carbamazepine (Tegretol)

Lamotrigine (Lamictal)

Oxcarbazepine (Trileptal)

Bipolar disorder Suicidal thoughts

Loss of coordination

Hallucinations

Kidney, thyroid, liver, and 

pancreas damage

Polycystic ovarian syndrome

Weight gain

Source: NIMH, NIH, and our experts.
 

Page 7 GAO-12-201 Foster Children

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

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

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

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

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

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

Foster children in each of the five selected states were prescribed 

psychotropic drugs at higher rates than were nonfoster children in 

Medicaid during 2008.10 These states spent over $375 million for 

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

nonfoster children.11 The higher rates do not necessarily indicate 

inappropriate prescribing practices, as they could be due to foster 

children’s greater exposure to traumatic experiences and the unique 

challenges of coordinating their medical care.12

 

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

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

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

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

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

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

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

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

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

corrective actions as of March 2011.

However, psychotropic 

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

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

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

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

nonfoster children were prescribed such a medication regimen. Similarly, 

thousands of foster and nonfoster children were prescribed doses 

exceeding maximum levels cited in guidelines based on information in 

FDA-approved drug labels, which our experts said increases the potential 

for adverse side effects, and does not typically increase the efficacy of the 

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

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

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

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

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

organization (HMO)).

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

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

Foster Children Have 

Higher Rates of 

Psychotropic Drug 

Prescriptions and 

Indicators of Potential 

Health Risks
 

Page 8 GAO-12-201 Foster Children

drugs to any significant extent.13 Further, foster and nonfoster children 

under 1 year old were prescribed psychotropic drugs, which our experts 

said have no established use for mental health conditions in infants and 

could result in serious adverse effects.

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

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

were nonfoster children in Medicaid in 2008.14 The rates were higher 

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

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

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

psychotropic drug prescriptions compared with nonfoster children, the 

vast majority of children receiving psychotropic drug prescriptions in these 

states were nonfoster children because the population of nonfoster 

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

rates of psychotropic drug prescriptions among foster children do not 

necessarily mean that the prescriptions were inappropriate; determining 

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

history.15 Figure 1 shows prescription rates for children in each state for 

various age ranges. See appendix V for more information on psychotropic 

prescriptions to foster and nonfoster children in Medicaid.

 

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

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

effective. 

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

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

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

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

psychotropic prescriptions are not comparable across states, they are comparable 

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

prescriptions to foster children to prescriptions to nonfoster children are comparable 

across states.

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

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

prescriptions may be understated.

Higher Rates of 

Psychotropic Drug 

Prescriptions among 

Foster Children
Page 9 GAO-12-201 Foster Children

Figure 1. Psychotropic Drug Prescription Rates for Five Selected States

Rollover the shaded states for more information Print-friendly version

$

State:

Medicaid amount paid for 

psychotropic medications

prescribed to foster and

nonfoster children 

during 2008:

Percentage of children

prescribed psychotropic

medication age:

0–17 years old

13–17 years old

6–12 years old

0–5 years old

Ratio of foster to 

nonfoster children

Foster children Nonfoster children

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

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

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

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

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

rounded percentages.

Interactive Graphic
 

Page 10 GAO-12-201 Foster Children

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

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

contribute to these higher rates of prescribed psychotropic drug regimens. 

These factors included greater exposure to trauma before entering state 

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

policies. However, our literature search identified a relatively small 

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

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

additional factors are involved.

Greater exposure to trauma. Research and interviews with certain state 

officials suggest that children entering foster care have more emotional 

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

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

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

that of nonfoster children receiving Medicaid assistance. ADHD, 

depression, and developmental disorders were the most common 

diagnoses.16 According to the National Survey of Child and Adolescent 

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

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

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

serious form of recorded maltreatment.17 According to another study 

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

with completed child welfare investigations had clinically significant 

emotional or behavioral problems.18

State officials and our contracted child psychiatrists stated that higher 

levels of psychotropic drug prescriptions may be appropriate to deal with 

 

16 S. dosReis et al., Mental Health Services for Youths in Foster Care and Disabled 

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

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

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

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

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

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

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

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

al., Mental Health Need and Access to Mental Health Services by Youths Involved with 

Child Welfare: A National Survey, Journal of the American Academy of Child and 

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

Page 11 GAO-12-201 Foster Children

the increased prevalence and greater severity of mental health conditions 

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

unique treatment challenges for those with multiple severe symptoms. In 

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

which may cause them to receive multiple diagnoses that change with 

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

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

in foster children with severe symptoms. This limits the information 

available to providers on how best to treat their conditions.19

Frequent changes in foster placements. Foster children who change 

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

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

changes in placement pose significant challenges for agencies, foster 

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

services and maintaining uninterrupted information on children’s medical 

needs and courses of treatment.20 Several studies of the use of 

psychotropic drugs have also noted that multiple foster care placements 

over short periods prevent an individual familiar with the child from 

coordinating and overseeing his or her long-term medical care.21

 

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

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

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

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

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

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

Two Related Laws, but Improved Tracking Needed by FDA, 

Children 

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

with prior medical care may have experienced disruptions in care and 

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

states oversees psychotropic drug prescriptions in the next section that 

discusses federal and state oversight of psychotropic drugs prescribed to 

foster children.)

GAO-11-457 (Washington, 

D.C.: May 2011).

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

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

21 For example, see Leslie et al., Multi-State Study on Psychotropic Medication Oversight 

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

Page 12 GAO-12-201 Foster Children

Varying state oversight policies. States surveyed by the Tufts Clinical 

and Translational Science Institute in 2010 reported on several 

challenges that may affect prescribing patterns for foster children. These 

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

organizations responsible for the care of foster children; the consent 

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

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

guidelines on clinical practices regarding psychotropic prescriptions for 

foster children across stakeholder groups, including caregivers, child 

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

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

prescriptions with dosages exceeding current maximum 

recommendations set by the product manufacturer, professional or 

federal standards, or state expert panels.22

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

for foster children showed higher rates of potential health risk indicators 

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

following three prescribing practices carry increased levels of risk for 

children; concomitant prescriptions of five or more medications,23 doses 

exceeding maximum levels in FDA-approved drug labels, and 

prescriptions for infants.24

 

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

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

Figure 2 provides more information on these 

indicators by state.

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

serious, complex mental health issues.

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

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

Higher Rates of Potential 

Health Risk Indicators 

among Foster Children
Page 13 GAO-12-201 Foster Children

Figure 2. Psychotropic Drug Potential Health Risk Indicators for Five Selected States

Rollover the shaded states for more information Print-friendly version

State:

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

medications concomitantly

Children 0–17 with a dosage exceeding maximum

guidelines based on FDA-approved labels

Children under 1 year old prescribed a 

psychotropic drug

Percentage of 

foster children

Percentage of 

nonfoster children

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

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

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

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

HMO prescription coverage. 

Interactive Graphic
 

Page 14 GAO-12-201 Foster Children

Concomitant psychotropic drug prescriptions.25 Across the five 

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

concomitantly ranged from 0.11 to 1.33 percent among foster children 

compared with a lower 0.01 to 0.07 percent rate among nonfoster 

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

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

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

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

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

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

Increasing the number of drugs used concurrently increases the likelihood 

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

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

related to a particular treatment goal.26

Doses Exceeding Maximum Levels in FDA-Approved Drug Labels.

The rate of children prescribed medications exceeding maximum doses 

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

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

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

0.56 percent rate among nonfoster children.

See appendix VI for more 

information on concomitant prescription rates.

27

 

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

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

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

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

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

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

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

drug. See app. I for more details explaining how the concomitant analysis was conducted 

to eliminate cases in which a patient began taking a new drug without finishing the 

previous supply, thereby creating the appearance of concurrent use.

A total of 20,965 children in 

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

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

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

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

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

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

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

Heiligenstein, Psychotropic Medication Utilization Parameters for Foster Children, Office 

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

December 2010).
 

Page 15 GAO-12-201 Foster Children

children and 0.05 to 0.16 percent of nonfoster children were prescribed

dosages that exceeded the maximum standards published in the medical 

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

levels recommended by the FDA and medical literature increases the 

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

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

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

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

than the more moderate recommended dose.28

Psychotropic prescriptions for infants. The rate of children under 1 

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

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

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

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

prescriptions.

See appendix VII for 

information on rates of prescriptions above maximum doses for the child’s 

age as cited in the Texas Utilization Parameters.

29

 

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

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

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

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

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

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

Our experts said that there are no established mental 

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

providing them these drugs could result in serious adverse effects. 

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

nonfoster infants were prescribed clonidine—with dosages generally used 

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

sedation and potential cardiac problems including, on rare occasions, 

sudden death. Fewer than 10 infants in foster care were prescribed an 

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

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

antipsychotics have significant potential side effects, including 

cardiovascular and metabolic problems. Anti-anxiety drugs such as 

antihistamines and benzodiazepines accounted for the vast majority of 

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

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

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

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

resulting from data entry errors. See app. I on our assessment of data reliability.
 

Page 16 GAO-12-201 Foster Children

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

have been prescribed for nonmental health conditions.30

Table 2: Children Age 0-1 Year Old Prescribed Psychotropic Drugs in Five Selected 

States 

For example, the 

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

conditions such as eczema, the benzodiazepines for seizures or as 

sedation for a medical procedure. While physicians may use their 

discretion to prescribe these drugs to infants, these nonmental health 

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

antihistamines, diminished mental alertness and excitation in young 

children. According to our experts, because infants are at a stage in their 

development where they are potentially more vulnerable to the effect of 

psychotropic drugs, these cases raise significant concerns and warrant 

further review. See table 2 and appendix VIII for more information.

Drug category (subclass) Foster children Nonfoster children

Anti-anxiety (antihistamines)a 55 3,454

Anti-anxiety (benzodiazepines) 17 254

Other anti-anxiety drugs 0 <10

ADHD drugs <10 37

Antidepressants <10 44

Antipsychotics <10 12

Hypnotic 0 <10

Mood stabilizer 0 <10

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

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

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

infants were prescribed more than one psychotropic drug.

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

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

represents a nonmental health use, such as for allergies or rashes.

Claims data also raise concerns about patient adherence to prescribed 

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

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

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

 

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

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

data whether this was the case.
 

Page 17 GAO-12-201 Foster Children

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

psychotropic prescriptions. When comparing only those prescribed 

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

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

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

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

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

manner or a lack of consistent access to care.31 Gaps in drug claims do 

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

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

patient, such as reduced efficacy from undertreatment, rebound of 

symptoms, and withdrawal symptoms. For example, the sudden 

discontinuation of benzodiazepines such as alprazolam can cause 

seizures32 and the sudden discontinuation of SSRIs33 such as paroxetine 

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

and nausea.34 Nonadherence to a drug regimen can cause the drug to 

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

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

effect on the patient’s symptoms.35

 

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

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

because of side effects.

Failure to take the antidepressant 

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

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

addition of other drugs. Table 3 and appendix IX provide more information 

on gaps in prescriptions for foster and nonfoster children by state.

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

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

33 SSRIs are antidepressants.

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

Syndrome in Children and Adolescents, J Can Acad Child Adolesc Psychiatry (February 

2011) 20(1): pp. 60-67.

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

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

Page 18 GAO-12-201 Foster Children

Table 3: Percentage of Children Age 0-17 Prescribed a Psychotropic Drug with Three or More Gaps of 7-29 Days in Drug 

Claims in Five States 

State 

Percent of children who had

three or more gaps in drug claims

Percent of children

prescribed a psychotropic drug who had

three or more gaps in drug claimsa

Foster children Nonfoster children Foster children Nonfoster children

Florida 1.8 1.1 7.8 12.1

Massachusetts 3.4 1.8 8.4 16.4

Michigan 1.7 0.9 7.9 11.3

Oregon 1.6 0.5 7.7 9.5

Texas 2.2 0.7 6.6 8.6

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

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

psychotropic drug is slightly higher than reported in our overall prescription rates, which were based on primary drugs only.

Comparing the selected states’ monitoring programs for psychotropic 

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

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

comprehensive oversight as defined by AACAP. Though states are not 

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

monitoring programs that satisfied some of AACAP’s best principles 

guidelines to varying degrees. Such variation is expected because states 

set their own oversight guidelines and have only recently been required, 

as a condition of receiving certain federal child welfare grants, to establish 

protocols for the appropriate use and monitoring of psychotropic drugs 

prescribed to foster children.36

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

control measures to monitor psychotropic drug prescriptions to foster 

children. Without formally endorsing specific oversight measures for 

states to implement, HHS conducts state reviews and provides other 

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

their programs. ACF performs child and family services reviews of states 

to ensure conformity with federal child welfare requirements—which 

include provisions for safety, permanency, and family and child wellbeing—and to assist states as they enhance their capacity to help 

 

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

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

Selected States’ 

Psychotropic Drug 

Monitoring Programs 

Fall Short of AACAPBest Principles 

Guidelines 
 

Page 19 GAO-12-201 Foster Children

families achieve positive outcomes.37 These reviews included the 

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

determine whether the state foster care agency conducted assessments 

of children’s mental health needs and provided appropriate services to 

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

identify specific potential health risk indicators related to psychotropic 

medications, and since they occur every 2 to 5 years, states cannot rely 

on these reviews to actively monitor prescriptions. In addition, ACF 

operates technical assistance centers and provides online resources such 

as links to state guidance on psychotropic drug oversight, academic 

studies on psychotropic drugs, and recordings of teleconferences related 

to the oversight of psychotropic drugs.38

The AACAP guidelines are arranged into four categories, including 

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

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

describes the extent to which the selected states’ monitoring programs 

cover these areas. See appendix X for the full text of the AACAP 

guidelines and additional information on the selected states’ practices 

consistent with these guidelines.

While HHS makes a variety of 

resources available to states developing oversight programs for 

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

absence of HHS-endorsed guidance, states have developed varied 

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

recommended guidelines.

Consent: According to interviews and documentation provided by state 

Medicaid and foster care officials, all six selected states have 

 

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

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

comprehensive component of federal efforts to determine state compliance with federal 

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

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

generally on an annual basis.

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

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

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

Medicaid agency, pediatricians, other health care experts, and child welfare experts. See 

42 U.S.C. § 622(b)(15). Among other things, the state plans must also include the 

oversight of prescription drugs, and how the agency actively consults and involves 

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

foster care in determining appropriate medical treatment for the children.
 

Page 20 GAO-12-201 Foster Children

implemented some practices consistent with AACAP guidelines for 

consent procedures, though in varying scope and application. According 

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

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

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

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

incorporate consent procedures similar to AACAP’s guidelines may 

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

benefits associated with the decision to medicate with psychotropic drugs, 

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

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

relative to consent and illustrates the extent to which states have 

implemented those guidelines.

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

Florida and Michigan provide examples of how states vary in their 

approach to monitoring consent procedures used for psychotropic drugs 

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

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

Page 21 GAO-12-201 Foster Children

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

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

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

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

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

and obtains assent for psychotropic drug management from minors when 

age and developmentally appropriate. Florida provides required training 

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

prescribed psychotropic drugs are not included.

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

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

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

requires that caseworkers maintain in their files the consent forms used 

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

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

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

parents become more effective advocates for children in their custody. 

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

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

September 2011. Michigan does not have policies for obtaining assent 

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

for consent procedures.

Oversight procedures: Each of the six states has developed some 

procedures similar to AACAP’s guidelines for overseeing psychotropic 

drug prescriptions for foster children, as evidenced by interviews and 

documentation provided by state Medicaid and foster care officials.39

 

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

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

abuse as required by the Omnibus Budget Reconciliation Act (OBRA) of 1990 (Pub. L. No. 

101-508, § 4401, 104 Stat. 1388, § 1388-143. (1990)). States were encouraged by 

enhanced federal funding to design and install point-of-sale electronic claims management 

systems that interface with their Medicaid Management Information Systems (MMIS) 

operations. The annual report requirement is used to assess patient safety, provider 

prescribing habits, and dollars saved by avoidance of problems such as drug-drug 

interactions, drug-disease interactions, therapeutic duplication, and overprescribing by 

providers. However, the extent to which a state’s DUR process included reviews of 

psychotropic drugs varied across our states and the DUR process is not focused on the 

foster child population specifically. 

According to one study, states that implement standards to improve 

oversight of the use of psychotropic drugs may create enhanced 
 

Page 22 GAO-12-201 Foster Children

continuity of care, increased placement stability, reduced need for 

psychiatric hospitalization, and decreased incidence of adverse drug 

reactions.40 As such, states that do not incorporate oversight procedures 

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

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

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

illustrates the extent to which selected states have implemented those 

guidelines.

 

40 M.W. Naylor, et al., Psychotropic Medication Management for Youth in State Care: 

Consent, Oversight, and Policy Considerations, Child Welfare V 86, 5 (2007) pp.175-192.
 

Page 23 GAO-12-201 Foster Children

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

Page 24 GAO-12-201 Foster Children

Texas and Maryland provide examples of how states vary in their 

approach to oversight of psychotropic drug use among foster children.

For example, the Texas Department of Family and Protective Services 

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

assembled an advisory committee that included child and adolescent 

psychiatrists, psychologists, pediatricians, and other mental health 

professionals to develop psychotropic drug use parameters for foster 

children. These parameters are used to help identify cases requiring 

additional review. Factors that trigger additional reviews include dosages 

exceeding usual recommended levels, prescriptions for children of very 

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

prescriptions by a primary care provider lacking specialized training.41

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

procedures and partially applies others. Maryland provides foster children 

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

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

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

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

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

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

released these guidelines in 2005, psychotropic drug use among Texas 

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

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

claims data to monitor psychotropic drug prescriptions for foster children 

and to identify any unusual prescribing behaviors. Texas provides 

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

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

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

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

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

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

recommended dose for some medications, while allergy information may 

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

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

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

reactions at the macro level among youth in state custody.

 

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

uncomplicated depression, and uncomplicated anxiety disorders.
 

Page 25 GAO-12-201 Foster Children

and maintained electronically. However, Maryland has not produced any 

specific guidelines for the use of all psychotropic prescriptions among 

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

prescribing practices for the foster child population.42

Consultation program: According to interviews and documentation 

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

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

one of the six selected states has implemented a consultation program 

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

from child and adolescent psychiatrists before making consent decisions 

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

link consent-givers and prescribers with child and adolescent psychiatrists 

may reduce the extent to which prescribers and consent-givers are 

informed about the expected benefits and risks of treatments, alternative 

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

AACAP guidelines relative to consultation programs and illustrates the 

extent to which selected states have implemented those guidelines.

Without guidelines 

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

monitor the appropriateness of prescriptions. Moreover, Maryland does 

not review Medicaid claims data statewide specifically for foster children, 

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

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

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

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

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

and missing data for foster children.

 

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

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

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

children younger than the FDA-approved age require prior authorization (PA) based on 

the peer-review assessment. The MMPP’s board-certified child psychiatrist oversees the 

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

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

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

this practice is not statewide.
 

Page 26 GAO-12-201 Foster Children

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

Massachusetts and Oregon provide examples of how states vary their 

approach in providing expert consultations to caregivers. For example, 

Massachusetts’ foster care agency started an initiative to connect child 

welfare staff to Medicaid pharmacists who can provide information on 

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

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

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

access to the state-funded Massachusetts Child Psychiatry Access 

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

designed to help pediatricians find and consult with child psychiatrists. 

Massachusetts has six child psychiatrists who are available to provide 

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

consultations are not available for other consent-givers such as foster 
 

Page 27 GAO-12-201 Foster Children

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

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

concerned about a child’s treatment. 

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

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

agency shifted the responsibility for all consent decisions where the 

agency has legal custody or is the legal guardian of the child from foster 

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

and adolescent psychiatrist and can seek consultations before making 

consent decisions. However, the consultation program does not conduct 

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

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

prescribing physicians to consult with child and adolescent psychiatrists. 

Oregon has plans for the development of the Oregon Psychiatric Access 

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

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

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

Information sharing: Four of the six selected states have created 

websites with information on psychotropic drugs for clinicians, foster 

parents, and other caregivers. Access to comprehensive information 

could help ensure that clinicians, foster parents, and other interested 

parties are fully informed about the use and management of psychotropic 

drugs. Table 7 lists AACAP’s guidelines relative to information sharing 

and illustrates the extent to which selected states have implemented 

those guidelines.
 

Page 28 GAO-12-201 Foster Children

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

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

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

Advancement of Child Welfare Practice to provide needed information 

and support to Florida’s professional child welfare stakeholders.43

 

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

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

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

development to child welfare and child protection stakeholders throughout Florida.

The 

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

Page 29 GAO-12-201 Foster Children

information sharing. For example, the website includes policies and 

procedures governing psychotropic drug management, staff publications 

and educational materials about psychotropic drugs, consent forms, and 

links to other informative publications and news stories related to foster 

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

reports on prescription patterns for psychotropic drugs or adverse effect 

rating forms.

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

includes information regarding psychotropic medication, but the website is 

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

website currently has information on state policies and procedures 

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

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

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

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

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

other informative websites. States with less accessibility to 

comprehensive information may limit the extent to which physicians, 

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

and management of psychotropic drugs.

The higher rates of psychotropic drug prescriptions among foster children 

may be explained by their greater mental health needs and the 

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

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

have prescriptions that carry potential health risks. While doctors are 

permitted to prescribe these drugs under current laws, increasing the 

number of drugs used concurrently and exceeding the maximum 

recommended dosages for certain psychotropic drugs have been shown 

to increase the risk of adverse side effects in adults. Psychotropic 

prescriptions for infants are also of concern, due to the potential for 

serious adverse effects even when these drugs are used for nonmental 

health purposes. Comprehensive oversight programs would help states 

identify these and other potential health risks and provide caregivers and 

prescribers with the information necessary to weigh drug risks and 

benefits. The recently enacted Child and Family Services Improvement 

and Innovation Act requires states that apply for certain child welfare 

grants to establish protocols for monitoring psychotropic drugs prescribed 

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

own monitoring protocols, but HHS-endorsed, nationwide guidelines for 

consent, oversight, consultation, and information sharing could help 

Conclusions 
 

Page 30 GAO-12-201 Foster Children

states close the oversight gaps we identified and increase protections for 

this vulnerable population.

To improve the comprehensiveness of oversight of psychotropic drugs 

prescribed to foster children, we recommend that the Secretary of HHS 

evaluate our findings and consider endorsing guidance to state Medicaid 

and child welfare agencies on best practices for monitoring psychotropic 

drug prescriptions for foster children, including guidance that addresses, 

at minimum, informed consent, oversight, consultation, and information 

sharing.

We provided a draft copy of this report to HHS and the state foster care 

and Medicaid agencies of the six selected states for their review. Letters 

with comments from HHS, the Florida Agency for Health Care 

Administration, the Massachusetts Executive Office of Health and Human 

Services, the Oregon Health Authority, and the Texas Health and Human 

Services Commission are reprinted and discussed in further detail, when 

applicable, in appendices XI through XV. We also received e-mails with 

comments from officials from Florida Department of Children and Families

(DCF), Maryland Department of Human Resources (DHR), and Michigan 

Department of Community Health (DCH), which we describe below. HHS 

and certain states also provided technical comments, which we 

incorporated as appropriate. 

HHS agreed with our recommendation and stated that ACF will issue 

guidance to the states on best practices for monitoring psychotropic drug 

prescriptions for foster children. In addition, ACF will disseminate to 

states the current best practices for use in developing their approaches 

and protocols. We strongly support these steps and encourage HHS to 

follow through on these actions. The comment letters from the states 

generally provided clarifications or further information on specific aspects 

of each state program, which we incorporated, as appropriate.

In an e-mail response from the Chief of Quality Assurance, the Florida 

DCF, which administers the state’s foster care program, stated that our 

report appeared factually correct based on the data sources. Florida DCF 

stated that our statement that thousands of foster and nonfoster infants 

were prescribed psychotropic medications seemed inflammatory, given 

that the number of infants in foster care represented was less than 100 

and the report is focused on foster children. Florida DCF also noted that 

the state has very few cases of foster children under 1 year old 

Recommendation for 

Executive Action

Agency Comments 

and Our Evaluation
 

Page 31 GAO-12-201 Foster Children

prescribed a psychotropic drug, and stated that they had confirmed that 

all but one had a documented medical reason for the prescription. We 

continue to believe that the inclusion of both foster and nonfoster children 

in our total is appropriate, given the serious adverse effects these drugs 

may have in infants. We did not review case records for these children as 

part of this review, and thus cannot conclude whether there is a medical 

justification for these prescriptions. 

In an e-mail response from the deputy executive director of operations of 

the Maryland DHR, the agency stated that it regretted that its foster care 

data had not been usable for this report. Maryland DHR stated that it 

engaged in data cleanup and improvement following the 2007 launch of 

its new information system. The agency also stated that it would be 

helpful to Maryland, and perhaps other states, to make use of our

methodology and tools for further analysis. Maryland DHR would like to 

make use of our analysis tools for its 2010 or 2011 foster care data, which 

Maryland stated have much higher accuracy than the data available in 

2008. The agency agreed with the need to have comprehensive oversight 

programs and established protocols for monitoring psychotropic drugs 

prescribed to foster children, but the costs of implementing oversight 

mechanisms must be supported in order for these new guidelines to be 

effective. We would be willing to share our methodology with Maryland 

and any other state to help them improve the monitoring of children using 

psychotropic medications. We also agree that additional oversight 

mechanisms may require additional resources to be effective.

In an e-mail response from the director of the office of audit, Michigan 

DCH agreed with the recommendation and anticipated additional federal 

resources to be able to comply with future requirements.

We are sending copies of this report to the Secretary of Health and 

Human Services, cognizant state agencies, and interested congressional 

committees. In addition, this report is also available at no charge on the 

GAO website at http://www.gao.gov. If you have any questions 
 

Page 32 GAO-12-201 Foster Children

concerning this report, please contact Gregory D. Kutz at (202) 512-6722 

or kutzg@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report.

Key contributors to this report are listed in appendix XVI.

Gregory D. Kutz

Director

Forensic Audits and Investigative Service
 

Page 33 GAO-12-201 Foster Children

List of Requesters

The Honorable Thomas R. Carper

Chairman

Subcommittee on Federal Financial Management, Government

 Information, Federal Services, and International Security

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Susan M. Collins

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Scott P. Brown

Ranking Member

Subcommittee on Federal Financial Management, Government

 Information, Federal Services, and International Security

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Charles E. Grassley

Ranking Member

Committee on the Judiciary

United States Senate

The Honorable John McCain

United States Senate
Appendix I: Objectives, Scope, and 

Methodology

Page 34 GAO-12-201 Foster Children

Our objectives were to: (1) compare rates of psychotropic drug 

prescriptions in foster children and nonfoster children covered by 

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

examine federal and state oversight policies in effect for psychotropic 

drugs prescribed to foster children through October 2011.

To determine the rate of psychotropic drug prescriptions to foster and 

nonfoster children enrolled in Medicaid, we obtained Medicaid Statistical 

Information System (MSIS) claims data for prescriptions adjudicated 

between January 1 and December 31, 2008, for six selected states—

Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas.1 At the 

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

prescription claims data available from Centers for Medicare & Medicaid 

Services (CMS). We selected these states based on the following factors: 

(1) existence of a fee-for-service prescription or carve-out program 

reporting psychotropic drug prescription data to CMS,2

We obtained data on persons enrolled in Medicaid and/or receiving 

Medicaid services during calendar year 2008, and children in foster care 

during calendar year 2008, from the respective agencies in each of the 

six selected states. We identified psychotropic prescription claims for 

foster children and nonfoster children by matching the MSIS claims data 

with the Medicaid and foster care files and using national drug code 

information in the Medicaid data. For the purpose of our analysis, we 

defined foster children as any child under age 18 as of July 1, 2008, and 

in foster care for a period of 30 or more consecutive days during calendar 

year 2008, and excluded children in foster care less than 30 days during 

2008 from our analysis. We included only claims filled while the child was 

(2) geographic 

diversity, and (3) state foster care program size. The audit was limited to 

data on children in a Medicaid fee-for-service prescription or carve-out 

program for psychotropic drugs and may not generalize to other states or 

populations.

 

1 However, we determined through data tests, interviews, and reviews of state audit 

reports that data on children in Maryland foster care during 2008 were unreliable. 

Maryland data were not included in the data analysis portion of this report.

2 States with fee-for-service carve outs for psychotropic medications pay providers directly 

for these medications, and manage the resulting claims in a centralized data set. States 

without prescription carve outs used managed care organizations to oversee and pay for 

prescriptions, resulting in numerous, noncentralized data sets that would have inhibited 

our ability to identify psychotropic drugs for this analysis.

Appendix I: Objectives, Scope, and 

Methodology 
Appendix I: Objectives, Scope, and 

Methodology

Page 35 GAO-12-201 Foster Children

in foster care. We defined nonfoster children as any child under age 18 as 

of July 1, 2008, not in foster care at any time during calendar year 2008. 

Due to a small percentage of missing or incorrect identifiers in the foster 

care data, some children from the Medicaid files could not be correctly 

matched to foster care records. The result is an underestimate of the 

number of foster children and an overestimate of nonfoster children.

We developed a list of psychotropic drugs likely to be prescribed in the six 

selected states by reviewing each state’s list of approved drugs, and a list 

of psychotropic drugs published by the National Institute of Mental Health 

(NIMH).3 We verified the active ingredient for each drug in databases 

published by the Food and Drug Administration (FDA) or Thomson 

Reuters. The list was then reviewed by our two contracted child 

psychiatrists with clinical and research experience in the prescription of 

psychotropic drugs to children. Based on their recommendations, we 

developed a primary list of psychotropic drugs comprised of attention 

deficit hyperactivity disorder (ADHD) drugs, antidepressants, certain antianxiety drugs, antipsychotics, combination drugs, hypnotics, and mood 

stabilizers for our analysis of prescription rates of at least one 

psychotropic medication, and dosages exceeding FDA maximum 

recommended therapeutic doses. We counted a prescription for any 

primary drug in our analysis of prescription rates; we did not require that 

the prescription cover a minimum number of days.4 We also developed a 

secondary list of drugs—anticonvulsants, antiparkinson drugs, antienuretics, sleep aids, and certain anti-anxiety drugs—for our analysis of 

concomitant prescriptions. When paired with a primary psychotropic drug, 

these medications counted toward the total number of drugs prescribed 

concomitantly. When used alone or in combination with other secondary 

medications, they did not count as concomitant prescriptions.5

 

3 Approved drugs lists were either the state’s formulary or preferred drug list.

This may 

result in a slight underestimate of the prescription of concomitant 

psychotropic drugs; however, this should not differ between the foster and 

4 Although some medications may be prescribed on an “as needed” basis, these types of 

prescriptions are not distinguished in the data. In our analysis of doses exceeding levels 

recommended by the FDA and medical literature, we count all medications as though they 

were taken on a daily basis.

5 According to one of our experts, these secondary medications are likely used to treat 

physical symptoms when prescribed alone, but when paired with another psychotropic 

medication, they are likely used for mental health.
Appendix I: Objectives, Scope, and 

Methodology

Page 36 GAO-12-201 Foster Children

nonfoster care populations. These MSIS prescription claims data do not 

include diagnosis codes, and therefore, we cannot be sure that all the 

drugs in our analysis were prescribed for mental health purposes. By 

eliminating secondary drugs such as anticonvulsants from our analysis of 

prescription rates for one or more drugs, we likely understate the 

percentage of children prescribed psychotropic drugs for mental health 

purposes. We used both our primary and secondary lists when examining 

gaps in medications.

The five states differed in the types of prescriptions included in the claims 

data we analyzed. Because Medicaid is a state-administered program, 

each state has its own formulary of the drugs that it covers, including 

which drugs are covered by its fee for service or through its managed 

care. Generally, prescription claims paid for on a fee-for-service basis 

were reported to CMS by the five states during 2008, and therefore were 

included in the data we obtained from CMS and analyzed. In Florida and 

Massachusetts, prescriptions for those individuals not enrolled in a health 

maintenance organization (HMO) were reported to CMS, and we 

analyzed only these children.6

We used MSIS prescription claims data to calculate the total amount paid 

by state Medicaid programs for prescriptions on the primary list of 

psychotropic drugs used in our analysis for children in foster care for 30 

days or more and nonfoster children in Medicaid during 2008. This 

amount paid includes only claims paid for by a fee-for-service program 

and does not include manufacturer rebates or other costs such as 

managed care. We obtained additional information about drug dosages 

and administration routes from Thomson Reuters’ Red Book.

In addition, we found certain states through 

their formularies and prescription drug carve outs covered more drugs 

from our psychotropic list than other states. As such, while rates of 

psychotropic prescriptions are not comparable across states, they are 

comparable between foster and nonfoster children within the same state.

Similarly, the ratio of prescriptions to foster children to prescriptions to 

nonfoster children is comparable across states.

7

 

6 In Florida, about 60 percent of foster children and 45 percent of nonfoster children had 

their prescriptions covered only on a fee-for-service basis during 2008. In Massachusetts, 

the percentages were about 72 percent for foster children and about 42 percent for 

nonfoster children. For these two states, our analysis is not applicable to the entire state’s 

foster care or Medicaid program.

We did not 

7 Thomson Reuters’ Red BookTM is a medical resource for healthcare professionals for 

current information on medications.
Appendix I: Objectives, Scope, and 

Methodology

Page 37 GAO-12-201 Foster Children

evaluate relative rates of usage for brand name and generic drugs in our 

analysis.

We examined the concomitant prescription of five or more drugs with 

unique active ingredients. We did not allow for overlapping prescriptions 

of the same drug. We counted a drug as prescribed continuously if within 

3 consecutive calendar months, the prescription(s) had at least 84 days 

supply within that time period. Requiring a minimum of 84 days resulted in 

a more conservative estimate of concomitant prescriptions by eliminating 

cases in which a patient was prescribed a new drug without finishing the 

previous supply, thereby creating the appearance of concurrent use. For 

example, when one or more prescriptions for the same drug were filled 

before the days’ supply of the previous prescription had elapsed, we 

assumed that the subsequent prescriptions had been saved and used in 

sequence, with no overlapping days. Where the total days supply 

exceeded 84 days for a 3-month consecutive period, we counted this as 

continuous use.8

We developed indicators of potential health risks based on input from our 

child psychiatrists; a literature review; state guidelines; and interviews 

with officials from CMS, state Medicaid and foster care offices, NIMH, and 

professional medical associations. The final indicators of potential health 

risks were: concomitant prescriptions of five or more drugs, prescriptions 

exceeding dosage guidelines in the Psychotropic Medication Utilization 

Parameters for Texas Foster Children, and psychotropic prescriptions to 

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

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

which can pose significant risks to a patient. Analysis of only 1 year of 

claims data prevented us from determining whether a single drug was 

tried before adding additional drugs in all cases. Additionally, data 

limitations prevented us from comparing prescribing patterns for foster 

youth in different settings, and lack of pharmacy claims for hospitalized 

We added the number of unique active ingredients 

prescribed continuously for each 3-month period (i.e., two kinds of the 

same drug counted as one active ingredient). We did not count 

concomitant prescriptions of a brand name and generic drug with the 

same active ingredient.

 

8 Calculating the number of prescriptions on a monthly rather than daily basis may result 

in an underestimate of concomitant prescriptions for individuals with continuous 

prescriptions that did not cover 84 days during 3 calendar months.
Appendix I: Objectives, Scope, and 

Methodology

Page 38 GAO-12-201 Foster Children

youth prevented us from examining prescribing patterns for these children 

or comparing hospitalized foster and nonfoster youth.

To determine whether children were prescribed psychotropic drugs 

exceeding FDA maximum recommended therapeutic doses for their age 

or standards published in medical literature for their age, we used the 

dosage guidelines in the 2010 Texas Utilization Parameters. We excluded 

anticonvulsants and dosages based on the child’s weight from our 

analysis. To identify children for whom there was no FDA-recommended 

dose and who exceeded the next relevant standard, we defined the next 

relevant standard as the published guidelines for the child’s age or next 

highest age range, the FDA-recommended dose for the next highest age 

range, or the published standards for a different version of the drug (i.e., 

standards for the extended release version of the drug). We calculated 

rates of psychotropic prescriptions to children age 0 to 1 in the same way 

that we calculated psychotropic prescription rates for other age groups.

See discussion above for definition of foster children and nonfoster 

children and the kinds of drugs included in this analysis.

We also examined drugs prescribed to foster or nonfoster children to 

identify gaps in the dispensing of the drugs. In consultation with our 

experts, we defined a gap in prescriptions as 7 to 29 days between the 

last day of the first prescription and the fill date of the next prescription. 

We examined gaps across prescriptions for the same active ingredient, 

regardless of dosage. Similar to our concomitant analysis, when one or 

more prescriptions for the same drug were filled before the days supply of 

the previous prescription had elapsed, we assumed that the subsequent 

prescriptions had been saved and used in sequence, with no overlapping 

days. This methodology may understate gaps for patients with two 

prescriptions for different versions of the same medication, such as a 

drug and its extended release version. In this case, a break in one of the 

medications would not appear as a gap if the prescription for the other 

drug continued to be filled. Conversely, prescribers may reduce the 

dosage of a medication without writing a new prescription, which could 

appear as a gap in prescriptions. For example, if a patient had been 

prescribed two 10 mg doses per day, and was adjusted down to a single 

dose of 10 mg per day, the next prescription would be filled later than 

expected, appearing as a gap. Finally, children who exited and reentered 

Medicaid in a 30-day period during the course of the year would appear to 

have a gap in their prescriptions. If a child had three such gaps, he or she 

would have been included in the rate of children with three or more gaps 

in a medication, although it is not possible to know from prescription 
Appendix I: Objectives, Scope, and 

Methodology

Page 39 GAO-12-201 Foster Children

claims data whether the child had other prescription coverage during the 

time he or she was not in Medicaid.

To identify federal requirements and guidance related to the oversight of 

psychotropic drugs, we interviewed officials from CMS and the 

Administration for Children and Families (ACF), and reviewed laws and 

regulations. To determine the design of controls over psychotropic 

medications prescribed to foster children in each of the six selected 

states, we reviewed state statutes and policies or regulations related to 

the prescription of psychotropic drugs to foster children, and interviewed 

officials from the six selected states’ Medicaid and child welfare agencies. 

Finally, we interviewed officials from the American Academy of Child and 

Adolescent Psychiatry (AACAP) to obtain an understanding of their 

methods for developing best practice guidelines for providing 

psychotropic drugs to foster children. We selected AACAP’s “Position 

Statement on Oversight of Psychotropic Medication Use for Children in 

State Custody: A Best Principles Guideline” as a standard against which 

to compare state program frameworks based on a literature review and 

our discussions with officials from NIMH and CMS. However, states have 

legal discretion to administer Medicaid and foster care programs, and are 

not required to implement controls based on these best principles 

guidelines.

We performed this audit from February 2010 through November 2011 in 

accordance with generally accepted government auditing standards. 

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

sufficient, appropriate evidence to provide a reasonable basis for our 

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

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

We performed data checks to determine the reliability of the MSIS 

prescription claims data provided by CMS, state Medicaid files provided 

by Medicaid agencies in the six selected states, databases of children in 

foster care provided by child welfare agencies in the six selected states, 

and Thomson Reuters Red Book. While a small number of Medicaid and 

foster care records may contain inaccurate personal data or prescription 

information likely resulting from data entry errors, based on our 

discussions with agency officials and our own testing, we concluded that 

the data elements in five of the six states used for this report were 

sufficiently reliable to address our audit objectives. However, we 

determined through data tests, interviews, and reviews of state audit 

reports that data on children in Maryland foster care during 2008 were 
Appendix I: Objectives, Scope, and 

Methodology

Page 40 GAO-12-201 Foster Children

unreliable. For example, our electronic tests of Maryland data found 8,869 

children in foster care as of September 30, 2008—16 percent more than 

the 7,613 children that Maryland reported to ACF for that year. In 

addition, state audits in 2008 reported duplicate records with different 

identifying numbers for the same child, records showing children who had 

exited foster care as still enrolled in the program, and personal 

information for the parent recorded as that of the child. We therefore 

concluded that the Maryland foster care data were unreliable and 

excluded Maryland from our analysis of rates of psychotropic 

prescriptions. 
Appendix II: Uses and Side Effects of 

Psychotropic Drugs51F

Page 41 GAO-12-201 Foster Children

Psychotropic drugs are used to treat the symptoms of mental health 

conditions such as schizophrenia, depression, bipolar disorder 

(sometimes called manic-depressive illness), anxiety disorders, and 

ADHD. These drugs cannot cure mental disorders, but they can treat the 

symptoms to help people feel better so they can function. For our 

analyses, we included drugs in the following categories: (1) ADHD, (2) 

anti-anxiety, (3) antidepressants, (4) antipsychotics, (5) hypnotics, and (6) 

mood stabilizers and any medications that combine two or more of these 

categories.2 The following information was taken primarily from NIMH’s

2008 Mental Health Medications guide, and provides the common uses 

and potential side effects for each type of psychotropic drug:3

Attention Deficit Hyperactivity Disorder (ADHD) drugs are prescribed 

to individuals who are hyperactive, impulsive, and easily distracted. 

These drugs are used to help individuals focus, work, and learn, and may 

also improve physical coordination. These drugs include nonstimulant 

drugs such as atomoxetine (Strattera), guanfacine (Intuniv), and clonidine 

(Kapvay), and stimulant drugs such as methylphenidate (Ritalin, 

Metadate, Concerta, Daytrana), amphetamine (Adderall), and 

lisdexamfetamine dimesylate (Vyvanse). Stimulants can cause side 

effects such as decreased appetite and sleep problems, and less 

frequently, tics or personality changes. Most minor side effects can be 

eliminated by lowering the drug dosage. More seriously, there are 

possible rare side effects associated with the use of ADHD drugs. ADHD 

patients also have a slightly higher risk for drug-related psychiatric side 

effects, such as hearing voices, having hallucinations, becoming 

paranoid, or becoming manic.

 

1 For a comprehensive list of mental health medication categories, uses, and side effects, 

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

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

2 For our analysis of concomitant use, we also included several drugs from the following 

categories: certain anti-anxiety drugs, anticonvulsants, anti-enuretics, antiparkinson drugs, 

and sleep aids. 

3 Combination drugs have two different classes of drugs in a single dose. For example, 

Symbyax contains olanzepine and fluoxetine, an antipsychotic and an antidepressant. 

This medication is used to treat depression with bipolar I disorder or depression that does 

not respond to other medicines. These drugs have side effects similar to their component 

medications.

Appendix II: Uses and Side Effects of 

Psychotropic Drugs1
Appendix II: Uses and Side Effects of 

Psychotropic Drugs51F

Page 42 GAO-12-201 Foster Children

Anti-anxiety drugs are prescribed to individuals to treat post-traumatic 

stress disorder, generalized anxiety disorder, obsessive compulsive 

disorder, panic disorder, and social phobias. Benzodiazepines, one type 

of anti-anxiety drug, include drugs such as clonazepam (Klonopin), 

lorazepam (Ativan), and alprazolam (Xanax).4 The most common side 

effects for benzodiazepines are drowsiness and dizziness. Other side 

effects include upset stomach, blurred vision, headache, confusion, 

grogginess, and nightmares. Another anti-anxiety drug used to treat 

generalized anxiety disorders is buspirone (Buspar).5

Antidepressants are prescribed to treat individuals who suffer from 

depression. All antidepressants contain an FDA box warning—the most 

serious type of warning—to alert users to the increased risk of suicidal 

thinking or attempts in children, adolescents, and young adults taking this 

type of drug.

Unlike 

benzodiazepines, however, it takes at least 2 weeks for buspirone to 

begin working. Possible side effects of buspirone include dizziness, 

headaches, nausea, nervousness, lightheadedness, excitement, and 

trouble sleeping.

Older antidepressant medications cause more side effects than newer 

classes of antidepressants, but they may be the best medication for some 

people. Older generations of antidepressants include tricyclics and 

tetracyclics, such as protriptyline (Vivactil) and trimipramine (Surmontil), 

and monoamine oxidase inhibitors (MAOIs), such as isocarboxazid 

(Marplan) and phenelzine (Nardil). These drugs can cause side effects 

such as dry mouth, constipation, bladder problems, sexual problems, 

blurred vision, and drowsiness. MAOIs can interact with various foods or 

drugs high in tyramine—including certain cheeses, wines, pickles, and 

over-the-counter medications—to produce severe hypertension.

Other types of antidepressants include selective serotonin reuptake 

inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft), and 

serotonin and norepinephrine reuptake inhibitors (SNRIs) such as 

venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs can 

 

4 Some benzodiazepines may be prescribed for insomnia, and therefore may also be 

considered hypnotics.

5 Some medications developed to treat depression, such as selective serotonin reuptake 

inhibitors and tricyclic antidepressants may also be used to treat anxiety disorders.
Appendix II: Uses and Side Effects of 

Psychotropic Drugs51F

Page 43 GAO-12-201 Foster Children

cause side effects such as agitation, serotonin syndrome, and sexual 

dysfunction, as well as headache, nausea, and sleeplessness or 

drowsiness when the patient first begins taking the drugs. Another type of 

antidepressant that acts on the neurotransmitter dopamine is called 

bupropion (Wellbutrin). Bupropion can cause side effects such as 

drowsiness, dry mouth, dizziness, headache, nausea, seizures, chest 

pain, and confusion.

Antipsychotic drugs are used to treat schizophrenia, bipolar disorders, 

irritability in autism, and depression. The first generation of 

antipsychotics, also known as “typical” antipsychotics, includes 

chlorpromazine (Thorazine) and haloperidol (Haldol). Typical 

antipsychotics can cause side effects such as rigidity, persistent muscle 

spasms, tremors, and restlessness and, with long-term use, tardive 

dyskinesia. The second generation of antipsychotics, or “atypical” 

antipsychotics, includes risperidone (Risperdal), quetiapine (Seroquel), 

and aripiprazole (Abilify). While typical antipsychotics are more likely to 

cause movement disorders, such as uncontrollable muscle spasms that in 

some cases cannot be cured , atypical antipsychotics can cause weight 

gain and changes in metabolism, potentially leading to an increased risk 

of diabetes and high cholesterol. Both typical and atypical antipsychotics 

can also cause drowsiness, dizziness when changing positions, blurred 

vision, rapid heartbeat, sensitivity to the sun, skin rashes, and menstrual 

problems.

Hypnotics cause sleep or partial loss of consciousness, and are used to 

treat insomnia and some anxiety disorders. Benzodiazepine hypnotics 

include drugs such as flurazepam (Dalmane), quazepam (Doral), and 

triazolam (Halcion).6

 

6 Some anti-anxiety medications may also be considered hypnotics. For example, in this 

report we categorize clonazepam (Klonopin), lorazepam (Ativan), and alprazolam (Xanax) 

as anti-anxiety medications, but they may also be used for insomnia.

Benzodiazepine hypnotics can be addictive and are 

associated with side effects such as daytime drowsiness, a hungover 

feeling, and the worsening of certain breathing problems. 

Nonbenzodiazepine hypnotics include drugs such as Zaleplon (Sonata), 

Zolpidem (Ambien), and Eszopiclone (Lunesta). These hypnotics may be 

less addictive than benzodiazepines but can cause side effects such as 

driving, making phone calls, or eating while asleep.
Appendix II: Uses and Side Effects of 

Psychotropic Drugs51F

Page 44 GAO-12-201 Foster Children

Mood stabilizers are drugs used to treat individuals with bipolar disorder 

(also known as manic-depressive illness). Lithium and anticonvulsant 

drugs can both be used as mood stabilizers.

Lithium was the first mood stabilizer approved by the FDA in the 1970s 

for treating both manic and depressive episodes. Lithium can cause 

several side effects, and some of them may become serious. These side 

effects include: loss of coordination, excessive thirst, frequent urination, 

blackouts, seizures, slurred speech, irregular or pounding heartbeat, 

hallucinations, changes in vision, rashes, swelling of the face or limbs, 

and low thyroid function (hypothyroidism). 

Anticonvulsant drugs are also used as mood stabilizers. These drugs 

were originally developed to treat seizures, but they were found to help 

control moods as well. One anticonvulsant commonly used as a mood 

stabilizer is divalproex sodium (Depakote). Other anticonvulsants used as 

mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) 

and oxcarbazepine (Trileptal). Like antidepressants, these drugs also 

have an FDA warning to alert users to the increased risk of suicidal 

thinking or behaviors in individuals taking this type of drug. Some other 

serious side effects of these drugs include damage to the liver and 

pancreas (divalproex sodium), polycystic ovarian syndrome (divalproex 

sodium), and serious skin rash (lamotrigine).
Appendix III: List of Psychotropic Drugs Used 

in Analysis

Page 45 GAO-12-201 Foster Children

The following table lists the type of psychotropic drug and drug 

ingredients for all drugs used in the analysis.

Table 8: Psychotropic Drugs Used in Analysis

Type of psychotropic drug Psychotropic drug ingredient

ADHD Drugs Amphetamine aspartate, Amphetamine 

sulfate, Dextroamphetamine saccharate, 

Dextroamphetamine sulfatea

ADHD Drugs Atomoxetine hydrochloride

ADHD Drugs Clonidine

ADHD Drugs Dexmethylphenidate hydrochloride

ADHD Drugs Dextroamphetamine sulfate

ADHD Drugs Guanfacine hydrochloride

ADHD Drugs Lisdexamfetamine dimesylate

ADHD Drugs Methamphetamine

ADHD Drugs Methylphenidate hydrochloride

ADHD Drugs Pemoline

Anti-anxiety Alprazolam

Anti-anxiety Buspirone hydrochloride

Anti-anxiety Chlordiazepoxide hydrochloride

Anti-anxiety Clonazepam

Anti-anxiety Clorazepate dipotassium

Anti-anxiety Diazepam

Anti-anxiety Diphenhydramine hydrochloride

Anti-anxiety Hydroxyzine

Anti-anxiety Lorazepam

Anti-anxiety Meprobamate

Anti-anxiety Oxazepam

Anti-anxiety Prazosin hydrochloride

Anti-anxiety Propranolol hydrochloride

Anti-anxiety Quazepam

Anticonvulsant Carbamazepine

Anticonvulsant Divalproex sodium

Anticonvulsant Gabapentin

Anticonvulsant Lamotrigine

Anticonvulsant Oxcarbazepine

Anticonvulsant Topiramate

Anticonvulsant Valproate sodium

Appendix III: List of Psychotropic Drugs 

Used in Analysis
Appendix III: List of Psychotropic Drugs Used 

in Analysis

Page 46 GAO-12-201 Foster Children

Type of psychotropic drug Psychotropic drug ingredient

Anticonvulsant Valproic acid

Antidepressants Amitriptyline hydrochloride

Antidepressants Amoxapine

Antidepressants Bupropion hydrochloride

Antidepressants Citalopram hydrobromide

Antidepressants Clomipramine hydrochloride

Antidepressants Desipramine hydrochloride

Antidepressants Desvenlafaxine succinate

Antidepressants Doxepin hydrochloride

Antidepressants Duloxetine hydrochloride

Antidepressants Escitalopram oxalate

Antidepressants Fluoxetine hydrochloride

Antidepressants Fluvoxamine maleate

Antidepressants Imipramine

Antidepressants Isocarboxazid

Antidepressants Maprotiline hydrochloride

Antidepressants Mirtazapine

Antidepressants Nefazodone hydrochloride

Antidepressants Nortriptyline hydrochloride

Antidepressants Paroxetine

Antidepressants Phenelzine sulfate

Antidepressants Protriptyline hydrochloride

Antidepressants Selegiline

Antidepressants Sertraline hydrochloride

Antidepressants Tranylcypromine sulfate

Antidepressants Trazodone hydrochloride

Antidepressants Trimipramine maleate

Antidepressants Venlafaxine

Anti-enuretic Desmopressin acetate

Antiparkinson Amantadine hydrochloride

Antiparkinson Benztropine mesylate

Antiparkinson Trihexyphenidyl hydrochloride

Antipsychotics Aripiprazole

Antipsychotics Chlorpromazine

Antipsychotics Clozapine

Antipsychotics Droperidol

Antipsychotics Fluphenazine
Appendix III: List of Psychotropic Drugs Used 

in Analysis

Page 47 GAO-12-201 Foster Children

Type of psychotropic drug Psychotropic drug ingredient

Antipsychotics Haloperidol

Antipsychotics Loxapine

Antipsychotics Mesoridazine besylate

Antipsychotics Molindone hydrochloride

Antipsychotics Olanzapine

Antipsychotics Paliperidone

Antipsychotics Perphenazine

Antipsychotics Pimozide

Antipsychotics Quetiapine fumarate

Antipsychotics Risperidone

Antipsychotics Thioridazine

Antipsychotics Thiothixene

Antipsychotics Trifluoperazine hydrochloride

Antipsychotics Ziprasidone

Combination anti-anxiety and 

antidepressant

Amitriptyline and Chlordiazepoxide

Combination antipsychotic and 

antidepressant

Amitriptyline and Perphenazine

Combination antipsychotic and 

antidepressant

Olanzapine and Fluoxetine hydrochloride

Hypnotic Estazolam

Hypnotic Eszopiclone

Hypnotic Flurazepam hydrochloride

Hypnotic Midazolam hydrochloride

Hypnotic Ramelteon

Hypnotic Temazepam

Hypnotic Triazolam

Hypnotic Zaleplon

Hypnotic Zolpidem tartrate

Mood stabilizer Lithium

Sleep aid Melatonin

Source: GAO.

a

Amphetamine aspartate, amphetamine sulfate, dextroamphetamine saccharate, and 

dextroamphetamine sulfate are medications indicated for treatment of ADHD and, as such, were 

considered as a single ingredient for purposes of our review.
Appendix IV: Rates of Psychotropic 

Prescription Usage by Length of Time in 

Medicaid Fee-for-service

Page 48 GAO-12-201 Foster Children

This appendix presents detailed information on rates of psychotropic 

prescriptions by the length of time a child was in a Medicaid fee-forservice program. In Michigan, Oregon, and Texas, psychotropic 

prescriptions were always covered by a fee-for-service program; in 

Florida and Massachusetts, prescriptions were covered by either 

Medicaid fee-for-service or a managed care program. In our analysis of 

Florida’s Medicaid program, we found that children in foster care for 30 

days or more averaged 7.47 months of fee-for-service coverage 

compared to 5.02 months for nonfoster children. To determine the impact 

of different lengths of time in fee-for-service on rates of psychotropic 

prescription usage, we conducted an analysis that adjusted for length of 

time in fee-for-service in Florida. Table 9 shows the rates of psychotropic 

prescription usage for children under 18 by length of time in fee-forservice.

Table 9: Rates of Psychotropic Prescriptions by Length of Medicaid Fee-for-service Coverage in Florida during 2008

Length of time in

Medicaid fee-for-service

Foster children age 0-17,

in care for 30 or more days Nonfoster children age 0-17 Ratio of percentage 

with 1 or more 

psychotropic 

prescriptions

of foster to

Population nonfoster children

Percentage 

with 1 or more 

psychotropic 

prescription Population

Percentage with 

1 or more 

psychotropic 

prescription

3-5 months 899 6.7 87,161 2.8 2.4

6-8 months 1,338 11.8 71,505 4.1 2.9

9-12 months 16,817 24.1 456,219 11.0 2.2

1-12 months 19,484 22.0 686,103 8.2 2.7

Children enrolled in Medicaid 

fee-for-service or managed 

care organization during 

2008 32,806 1,526,020 

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

Appendix IV: Rates of Psychotropic 

Prescription Usage by Length of Time in 

Medicaid Fee-for-service
Appendix V: Additional Data on Children with 

Prescriptions of at Least One Psychotropic 

Drug

Page 49 GAO-12-201 Foster Children

This appendix presents detailed information on rates of foster and 

nonfoster children prescribed at least one psychotropic drug in the five

states during 2008. In the tables below, rates for foster and nonfoster 

children can be compared within the same state and the ratio of 

prescriptions to foster children to prescriptions to nonfoster children can 

be compared across states. However, prescription rates cannot be 

compared across states. Percentages and ratios are rounded to the 

nearest tenth, and therefore the reported ratio may be slightly different 

than the ratio of the rounded percentages.

Table 10: Rates of Psychotropic Prescriptions in Florida during 2008 by Age of Child and Foster Care Status

Age

Foster children Nonfoster children Ratio of foster to 

Number Percent Number Percentage nonfoster children

Children 0-17 (Under 18) 4,281 22.0 56,408 8.2 2.7

Children 13-17 2,093 36.8 17,549 11.9 3.1

Children 6-12 1,758 31.2 28,690 12.3 2.5

Children 0-5 (Under 6) 430 5.3 10,169 3.3 1.6

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

Table 11: Rates of Psychotropic Prescriptions in Massachusetts during 2008 by Age of Child and Foster Care Status

Age

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17 (Under 18) 3,814 39.1 22,041 10.2 3.8

Children 13-17 2,599 53.4 10,265 14.7 3.6

Children 6-12 1,095 44.8 10,455 12.1 3.7

Children 0-5 (Under 6) 120 4.9 1,321 2.2 2.2

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

Table 12: Rates of Psychotropic Prescriptions in Michigan during 2008 by Age of Child and Foster Care Status

Age

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17 (Under 18) 4,360 21.0 74,188 7.9 2.7

Children 13-17 2,220 35.0 30,118 13.1 2.7

Children 6-12 1,802 26.7 39,917 11.5 2.3

Children 0-5 (Under 6) 338 4.4 4,153 1.1 3.8

Appendix V: Additional Data on Children with 

Prescriptions of at Least One Psychotropic 

Drug
Appendix V: Additional Data on Children with 

Prescriptions of at Least One Psychotropic 

Drug

Page 50 GAO-12-201 Foster Children

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

Table 13: Rates of Psychotropic Prescriptions in Oregon during 2008 by Age of Child and Foster Care Status

Age

Foster children Nonfoster children Ratio of foster to

Number Percentage Number Percentage nonfoster children

Children 0-17 (Under 18) 2,119 19.7 11,731 4.8 4.1

Children 13-17 1,177 43.3 5,991 12.0 3.6

Children 6-12 831 23.4 5,022 6.2 3.8

Children 0-5 (Under 6) 111 2.5 718 0.6 3.9

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

Table 14: Rates of Psychotropic Prescriptions in Texas during 2008 by Age of Child and Foster Care Status

Age

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17 (Under 18) 11,699 32.2 185,329 7.1 4.5

Children 13-17 4,740 58.2 53,142 11.4 5.1

Children 6-12 5,488 45.8 93,466 10.6 4.3

Children 0-5 (Under 6) 1,471 9.1 38,721 3.1 2.9

Source: GAO analysis of Texas Medicaid and foster care data.
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 51 GAO-12-201 Foster Children

This appendix presents detailed information on rates of psychotropic 

drugs prescribed concomitantly to foster and nonfoster children under 18 

years old during 2008. We considered two or more drugs with unique 

active ingredients to be prescribed concomitantly if each prescription was 

filled with a 3-month overlap, defined as 84 days to account for 

prescriptions that are filled late and 28-day prescriptions. We did not 

count two drugs with the same active ingredient such as a brand name 

drug and its generic equivalent. We did count combination drugs, which 

have two active ingredients in a single dose, as concomitant 

prescriptions.1

In the tables below, rates for foster and nonfoster children can be 

compared within the same state and the ratio of prescriptions to foster 

children to prescriptions to nonfoster children can be compared across 

states. However, prescription rates cannot be compared across states. 

Percentages and ratios are rounded to the nearest tenth, and therefore 

the reported ratio may be slightly different than the ratio of the rounded 

percentages.

Table 15: Rates of Concomitant Psychotropic Prescriptions in Florida during 2008 by Number of Drugs

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17

1 (combination drug) - 0.0 - 0.0 - 

2 715 3.7 4,689 0.7 5.4

3 323 1.7 1,863 0.3 6.1

4 93 0.5 564 0.1 5.8

5 18 0.1 137 0.0 4.6

6 <10 0.0 37 0.0 3.8

7 - 0.0 11 0.0 - 

8 - 0.0 <10 0.0 - 

9 - 0.0 <10 0.0 - 

10 - 0.0 - 0.0 - 

Total >1149 5.9 >7,301 1.1 5.6

Children 13-17

 

1 For example, Symbyax contains olanzapine and fluoxetine, an antipsychotic and an 

antidepressant, in a single dose.

Appendix VI: Additional Data on 

Concomitant Prescriptions
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 52 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

1 (combination drug) - 0.0 - 0.0 - 

2 376 6.6 1,727 1.2 5.6

3 182 3.2 819 0.6 5.7

4 55 1.0 307 0.2 4.6

5 11 0.2 74 0.1 3.8

6 <10 0.0 22 0.0 2.4

7 - 0.0 <10 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 <10 0.0 - 

10 - 0.0 - 0.0 - 

Total >624 11.0 >2,949 2.0 5.5

Children 6-12

1 (combination drug) - 0.0 - 0.0 - 

2 315 5.6 2,680 1.1 4.9

3 138 2.4 988 0.4 5.8

4 37 0.7 249 0.1 6.2

5 <10 0.1 62 0.0 4.7

6 <10 0.0 15 0.0 5.5

7 - 0.0 <10 0.0 - 

8 - 0.0 <10 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >490 8.9 >3994 1.7 5.2

Children 0-5 

1 (combination drug) - 0.0 - 0.0 - 

2 24 0.3 282 0.1 3.2

3 <10 0.0 56 0.0 2.0

4 <10 0.0 <10 0.0 4.7

5 - 0.0 <10 0.0 - 

Total >24 0.3 >338 0.1 3.0

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

Note: Percentages are rounded to the nearest tenth.
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 53 GAO-12-201 Foster Children

Table 16: Rates of Concomitant Psychotropic Prescriptions in Massachusetts during 2008 by Number of Drugs 

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17

1 (combination drug) - 0.0 - 0.0 - 

2 711 7.3 2,586 1.2 6.1

3 558 5.7 1,171 0.5 10.6

4 249 2.5 430 0.2 12.8

5 97 1.0 118 0.1 18.2

6 26 0.3 31 0.0 18.6

7 <10 0.1 <10 0.0 12.3

8 <10 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 <10 0.0 - 

Total >1641 16.9 >4,336 2.0 8.4

Children 13-17

1 (combination drug) - 0.0 - 0.0 - 

2 473 9.7 1,103 1.6 6.2

3 368 7.6 588 0.8 9.0

4 176 3.6 258 0.4 9.8

5 76 1.6 84 0.1 13.0

6 19 0.4 22 0.0 12.4

7 <10 0.1 <10 0.0 9.0

8 <10 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 <10 0.0 - 

Total >1,112 23.0 >2,055 3.0 7.8

Children 6-12

1 (combination drug) - 0.0 - 0.0 - 

2 228 9.3 1,413 1.6 5.7

3 184 7.5 563 0.7 11.5

4 73 3.0 170 0.2 15.1

5 21 0.9 34 0.0 21.8

6 <10 0.3 <10 0.0 27.4

7 - 0.0 <10 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 54 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

10 - 0.0 - 0.0 - 

Total >506 21.0 >2,180 2.5 8.3

Children 0-5 

1 (combination drug) - 0.0 - 0.0 - 

2 10 0.4 70 0.1 3.5

3 <10 0.2 20 0.0 7.4

4 - 0.0 <10 0.0 - 

5 - 0.0 - 0.0 - 

Total >10 0.7 >90 0.2 4.3

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

Note: Percentages are rounded to the nearest tenth.

Table 17: Rates of Concomitant Psychotropic Prescriptions in Michigan during 2008 by Number of Drugs

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17

1 (combination drug) - 0.0 <10 0.0 - 

2 620 3.0 5,659 0.6 5.0

3 332 1.6 1,951 0.2 7.7

4 134 0.6 608 0.1 10.0

5 50 0.2 152 0.0 14.9

6 10 0.0 34 0.0 13.3

7 <10 0.0 10 0.0 4.5

8 - 0.0 <10 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >1,146 5.5 >8,414 0.9 6.2

Children 13-17

1 (combination drug) - 0.0 <10 0.0 - 

2 367 5.8 2,435 1.1 5.5

3 234 3.7 1,045 0.5 8.1

4 97 1.5 378 0.2 9.3

5 38 0.6 95 0.0 14.5

6 <10 0.1 25 0.0 13.1
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 55 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

7 <10 0.0 <10 0.0 6.1

8 - 0.0 <10 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >736 11.8 >3,978 1.7 6.8

Children 6-12

1 (combination drug) - 0.0 - 0.0 - 

2 236 3.5 3,044 0.9 4.0

3 95 1.4 877 0.3 5.6

4 37 0.5 228 0.1 8.3

5 12 0.2 57 0.0 10.8

6 <10 0.0 <10 0.0 5.7

7 - 0.0 <10 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >380 5.6 >4,206 1.2 4.6

Children 0-5 

1 (combination drug) - 0.0 - 0.0 - 

2 17 0.2 180 0.0 4.5

3 <10 0.0 29 0.0 4.9

4 - 0.0 <10 0.0 - 

5 - 0.0 - 0.0 - 

Total >17 0.3 >209 0.1 4.5

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

Note: Percentages are rounded to the nearest tenth.

Table 18: Rates of Concomitant Psychotropic Prescriptions in Oregon during 2008 by Number of Drugs

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17

1 (combination drug) - 0.0 <10 0.0 - 

2 330 3.1 980 0.4 7.6

3 131 1.2 317 0.1 9.4
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 56 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

4 31 0.3 91 0.0 7.7

5 11 0.1 19 0.0 13.1

6 <10 0.0 <10 0.0 4.5

7 <10 0.0 - 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >503 4.7 >1,407 0.6 8.1

Children 13-17

1 (combination drug) - 0.0 <10 0.0 - 

2 214 7.9 488 1.0 8.0

3 90 3.3 172 0.3 9.6

4 24 0.9 58 0.1 7.6

5 <10 0.3 <10 0.0 20.9

6 - 0.0 <10 0.0 - 

7 <10 0.1 - 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >328 12.4 >718 1.5 8.5

Children 6-12

1 (combination drug) - 0.0 - 0.0 - 

2 109 3.1 473 0.6 5.3

3 40 1.1 137 0.2 6.7

4 <10 0.2 33 0.0 4.9

5 <10 0.1 12 0.0 5.8

6 <10 0.0 <10 0.0 7.7

7 - 0.0 - 0.0 - 

8 - 0.0 - 0.0 - 

9 - 0.0 - 0.0 - 

10 - 0.0 - 0.0 - 

Total >149 4.5 >655 0.8 5.6

Children 0-5 

1 (combination drug) - 0.0 - 0.0 - 

2 <10 0.2 19 0.0 9.3

3 <10 0.0 <10 0.0 3.1
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 57 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

4 - 0.0 - 0.0 - 

5 - 0.0 - 0.0 - 

Total >0 0.2 >19 0.0 7.4

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

Note: Percentages are rounded to the nearest tenth.

Table 19: Rates of Concomitant Psychotropic Prescriptions in Texas during 2008 by Number of Drugs

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

Children 0-17

1 (combination drug) <10 0.0 14 0.0 5.1

2 2,483 6.8 11,002 0.4 16.2

3 1,672 4.6 4,518 0.2 26.5

4 839 2.3 1,549 0.1 38.8

5 301 0.8 415 0.0 52.0

6 60 0.2 126 0.0 34.1

7 18 0.0 21 0.0 61.4

8 <10 0.0 10 0.0 14.3

9 <10 0.0 - 0.0 - 

10 - 0.0 <10 0.0 - 

Total >5,373 14.8 >17,655 0.7 21.8

Children 13-17

1 (combination drug) - 0.0 13 0.0 - 

2 1,044 12.8 3,652 0.8 16.4

3 758 9.3 1,792 0.4 24.3

4 422 5.2 692 0.1 35.0

5 128 1.6 206 0.0 35.7

6 38 0.5 78 0.0 28.0

7 14 0.2 15 0.0 53.6

8 <10 0.0 <10 0.0 11.5

9 - 0.0 - 0.0 - 

10 - 0.0 <10 0.0 - 

Total >2,404 29.5 >6,448 1.4 21.4

Children 6-12
Appendix VI: Additional Data on Concomitant 

Prescriptions

Page 58 GAO-12-201 Foster Children

Medications prescribed 

concomitantly

Foster children Nonfoster children Ratio of foster to 

Number Percentage Number Percentage nonfoster children

1 (combination drug) <10 0.0 <10 0.0 73.3

2 1,245 10.4 6,504 0.7 14.0

3 820 6.8 2,552 0.3 23.6

4 403 3.4 822 0.1 36.0

5 171 1.4 206 0.0 60.9

6 22 0.2 48 0.0 33.6

7 <10 0.0 <10 0.0 48.9

8 <10 0.0 <10 0.0 14.7

9 <10 0.0 - 0.0 - 

10 - 0.0 <10 0.0 - 

Total >2,661 22.3 >10,132 1.2 19.3

Children 0-5 

1 (combination drug) - 0.0 - 0.0 - 

2 194 1.2 846 0.1 17.8

3 94 0.6 174 0.0 41.9

4 14 0.1 35 0.0 31.0

5 <10 0.0 <10 0.0 51.7

Total >302 1.9 >1,055 0.1 22.3

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

Note: Percentages are rounded to the nearest tenth.
Appendix VII: Additional Data on Psychotropic 

Drug Prescriptions Exceeding Maximum 

Recommended Doses

Page 59 GAO-12-201 Foster Children

This appendix presents detailed information on rates of psychotropic 

drugs prescribed for foster and nonfoster children that exceeded the 

maximum dose for the child’s age cited in the Texas Utilization 

Parameters, which includes doses based on information in the FDAapproved drug label and published in medical literature for the child’s age.

Based on these parameters, we also analyzed prescriptions where there 

was no FDA-approved dose or published dose in medical literature for the 

child’s age. Finally, for those prescriptions that had no FDA-approved 

doses for the child’s age, we determined whether the prescription dosage 

exceeded the next most relevant standard: dosages published in medical 

literature for the same age group, dosages published in medical literature 

for an older age group, or the FDA-approved dose for an older age group 

or similar version of the same drug. These dosages were drawn from the 

Texas Utilization Parameters or, in limited cases, FDA-approved drug 

labels.

In the tables below, rates for foster and nonfoster children can be 

compared within the same state and the ratio of prescriptions to foster 

children to prescriptions to nonfoster children can be compared across 

states. However, prescription rates cannot be compared across states. 

Percentages and ratios are rounded to the nearest tenth, and therefore 

the reported ratio may be slightly different than the ratio of the rounded 

percentages.

Table 20: Rates of Children Prescribed Psychotropic Drugs Outside FDA-Approved Doses or Standards Published in Medical 

Literature in Florida during 2008

Category

Foster Nonfoster Ratio of foster to 

nonfoster 

Number Percentage Number Percentage children

Prescription exceeding FDA maximum dose for age 

group 292 1.5 3,005 0.4 3.4

Prescription exceeding maximum dose published in 

medical literature for age group 423 2.2 3,566 0.5 4.2

Prescription with no FDA-approved dose for child’s age, 

exceeding dosages for the next most relevant standard 101 0.5 586 0.1 6.1

Prescription for medication with no FDA-approved dose 

for age group 1,628 8.4 15,282 2.2 3.8

Prescription for medication with no published dose in 

medical literature for age group 71 0.4 828 0.1 3.0

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

Note: The data contained for each category in this table are not mutually exclusive.

Appendix VII: Additional Data on 

Psychotropic Drug Prescriptions Exceeding 

Maximum Recommended Doses
Appendix VII: Additional Data on Psychotropic 

Drug Prescriptions Exceeding Maximum 

Recommended Doses

Page 60 GAO-12-201 Foster Children

Table 21: Rates of Children Prescribed Psychotropic Drugs Outside FDA-Approved Doses or Standards Published in Medical 

Literature in Massachusetts during 2008

Category

Foster Nonfoster Ratio of foster to 

nonfoster 

Number Percentage Number Percentage children

Prescription exceeding FDA maximum dose for age 

group 216 2.2 1,214 0.6 3.9

Prescription exceeding maximum dose published in 

medical literature for age group 367 3.8 1,590 0.7 5.1

Prescription with no FDA-approved dose for child’s age, 

exceeding dosages for the next most relevant standard 116 1.2 336 0.2 7.7

Prescription for medication with no FDA-approved dose 

for age group 2,199 22.5 8,287 3.8 5.9

Prescription for medication with no published dose in 

medical literature for age group 88 0.9 433 0.2 4.5

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

Note: The data contained for each category in this table are not mutually exclusive.

Table 22: Rates of Children Prescribed Psychotropic Drugs Outside FDA-Approved Doses or Standards Published in Medical 

Literature in Michigan during 2008

Category

Foster Nonfoster Ratio of foster to 

nonfoster 

Number Percentage Number Percentage children

Prescription exceeding FDA maximum dose for age 

group 346 1.7 4,592 0.5 3.4

Prescription exceeding maximum dose published in 

medical literature for age group 412 2.0 4,660 0.5 4.0

Prescription with no FDA-approved dose for child’s age, 

exceeding dosages for the next most relevant standard 70 0.3 492 0.1 6.4

Prescription for medication with no FDA-approved dose 

for age group 1,411 6.8 14,026 1.5 4.6

Prescription for medication with no published dose in 

medical literature for age group 186 0.9 1,750 0.2 4.8

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

Note: The data contained for each category in this table are not mutually exclusive.
Appendix VII: Additional Data on Psychotropic 

Drug Prescriptions Exceeding Maximum 

Recommended Doses

Page 61 GAO-12-201 Foster Children

Table 23: Rates of Children Prescribed Psychotropic Drugs Outside FDA-Approved Doses or Standards Published in Medical 

Literature in Oregon during 2008

Category

Foster Nonfoster Ratio of foster to 

nonfoster

Number Percentage Number Percentage children

Prescription exceeding FDA maximum dose for age 

group 121 1.1 399 0.2 6.9

Prescription exceeding maximum dose published in 

medical literature for age group 180 1.7 539 0.2 7.6

Prescription with no FDA-approved dose for child’s age, 

exceeding dosages for the next most relevant standard 43 0.4 115 0.1 8.5

Prescription for medication with no FDA-approved dose 

for age group 726 6.8 3,063 1.3 5.4

Prescription for medication with no published dose in 

medical literature for age group 61 0.6 334 0.1 4.1

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

Note: The data contained for each category in this table are not mutually exclusive.

Table 24: Rates of Children Prescribed Psychotropic Drugs Outside FDA-Approved Doses or Standards Published in Medical 

Literature in Texas during 2008

Category

Foster Nonfoster Ratio of foster to 

nonfoster 

Number Percentage Number Percentage children

Prescription exceeding FDA maximum dose for age 

group 1,190 3.3 9,590 0.4 8.9

Prescription exceeding maximum dose published in 

medical literature for age group 1,773 4.9 11,033 0.4 11.5

Prescription with no FDA-approved dose for child’s age, 

exceeding dosages for the next most relevant standard 554 1.5 1,849 0.1 21.5

Prescription for medication with no FDA-approved dose 

for age group 6,060 16.7 42,328 1.6 10.3

Prescription for medication with no published dose in 

medical literature for age group 861 2.4 4,232 0.2 14.6

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

Note: The data contained for each category in this table are not mutually exclusive.
Appendix VIII: Additional Data on Psychotropic 

Prescriptions to Children Under 1 Year Old

Page 62 GAO-12-201 Foster Children

This appendix presents detailed information on psychotropic prescriptions 

to children under 1 year old in five selected states.

Table 25: Prescriptions of Psychotropic Drugs to Foster and Nonfoster Children Age 0-1 in Five Selected States

CATEGORY INGREDIENT

Foster children Nonfoster children

Children Prescriptions Children Prescriptions

ADHD Drugs

 

 

 

 

 

Clonidine <10 17 22 46

Guanfacine hydrochloride 0 0 <10 <10

Amphetamine aspartate, amphetamine 

sulfate, dextroamphetamine saccharate, 

dextroamphetamine sulfate

0 0 <10 <10

Lisdexamfetamine dimesylate 0 0 <10 <10

Methylphenidate hydrochloride 0 0 <10 12

Subtotal <10 17 40 76

Anti-anxiety

 

 

 

 

 

 

 

 

Diphenhydramine hydrochloride 

(antihistamine)

<10 <10 49 54

Hydroxyzine (antihistamine) 52 70 3,408 4,240

Alprazolam (benzodiazepine) 0 0 14 32

Clonazepam (benzodiazepine) <10 18 69 219

Clorazepate dipotassium (benzodiazepine) <10 14 <10 <10

Diazepam (benzodiazepine) <10 22 95 220

Lorazepam (benzodiazepine) <10 15 91 127

Buspirone hydrochloride 0 0 <10 <10

Subtotal 74 142 3,730 4,899

Antidepressants

 

 

 

 

 

 

 

 

 

 

Bupropion hydrochloride <10 <10 <10 <10

Trazodone hydrochloride 0 0 <10 16

Venlafaxine 0 0 <10 <10

Citalopram hydrobromide 0 0 <10 12

Escitalopram oxalate <10 <10 11 24

Fluoxetine hydrochloride 0 0 <10 <10

Paroxetine 0 0 <10 <10

Sertraline hydrochloride 0 0 12 16

Amitriptyline hydrochloride <10 <10 0 0 

Doxepin hydrochloride <10 <10 0 0 

Subtotal <10 18 49 87

Antipsychotics

 

 

Aripiprazole 0 0 <10 <10

Olanzapine 0 0 <10 <10

Quetiapine fumarate <10 <10 <10 <10

Appendix VIII: Additional Data on 

Psychotropic Prescriptions to Children 

Under 1 Year Old
Appendix VIII: Additional Data on Psychotropic 

Prescriptions to Children Under 1 Year Old

Page 63 GAO-12-201 Foster Children

CATEGORY INGREDIENT

Foster children Nonfoster children

Children Prescriptions Children Prescriptions

 

 

Risperidone 0 0 <10 <10

Ziprasidone 0 0 <10 <10

Subtotal <10 <10 12 15

Hypnotic

 

 

Triazolam 0 0 <10 <10

Zolpidem tartrate 0 0 <10 <10

Subtotal 0 0 <10 <10

Mood stabilizer Lithium 0 0 <10 <10

Totala 85 182 3,836 5,083

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

a

Note: These subtotals and total differ from those in table 2 because children prescribed multiple 

ingredients from the same category of drug are listed once for each ingredient in the table above, and 

therefore may be counted multiple times per category. In table 2, children are counted only once per 

category of drug.
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 64 GAO-12-201 Foster Children

This appendix presents detailed information on psychotropic drugs 

prescribed for foster and nonfoster children with gaps in prescriptions of 

7-29 days. While children in foster care had a higher rate of three or more 

gaps in prescriptions for a single active ingredient in all states, other 

differences between gaps in prescriptions for foster and nonfoster 

children varied by state.

In the tables below, rates for foster and nonfoster children can be 

compared within the same state. However, prescription rates cannot be 

compared across states. Since we used both primary and secondary lists 

in our gaps analysis, the number of foster and nonfoster children 

prescribed a psychotropic drug is slightly higher than reported in our 

overall prescription rates, which were based on primary drugs only. 

Table 26: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Florida during 2008

Age

Number of children who had three 

or more gaps in drug claims

Percentage of foster or 

nonfoster children who had 

three or more gaps in drug 

claims

Percentage of foster or nonfoster 

children prescribed a psychotropic 

drug who had three or more gaps in 

drug claims

Foster Children

Nonfoster 

children Foster children

Nonfoster 

children Foster children

Nonfoster 

children

0-17 355 7,381 1.8 1.1 7.8 12.1

13-17 159 2,379 2.8 1.6 7.2 12.6

6-12 167 4,489 3.0 1.9 9.1 14.5

0-5 29 513 0.4 0.2 5.9 4.6

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

Table 27: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions to Foster and Nonfoster Children in Florida during 

2008 

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

0-17 Average number of gaps per child 1.09 1.18 1.59 1.85

 Average length of gaps per child (days) 9.64 9.63 13.98 15.01

13-17 Average number of gaps per child 1.15 1.33 1.57 1.82

 Average length of gaps per child (days) 10.35 11.03 14.05 15.04

6-12 Average number of gaps per child 1.13 1.35 1.60 1.88

Appendix IX: Additional Data on 

Psychotropic Drugs with Gaps in 

Prescriptions of 7 to 29 Days
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 65 GAO-12-201 Foster Children

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

 Average length of gaps per child (days) 9.82 10.72 13.89 14.94

0-5 Average number of gaps per child 0.68 0.48 1.65 1.74

 Average length of gaps per child (days) 5.75 4.24 14.01 15.28

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

Table 28: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Massachusetts during 2008

Age

Number of children who had three 

or more gaps in drug claims

Percentage of foster or 

nonfoster children who had 

three or more gaps in drug 

claims

Percentage of foster or nonfoster 

children prescribed a psychotropic 

drug who had three or more gaps in 

drug claims

Foster Children

Nonfoster 

children Foster children

Nonfoster 

children Foster children

Nonfoster 

children

0-17 330 3,825 3.4 1.8 8.4 16.4

13-17 210 1,769 4.3 2.5 7.8 16.4

6-12 112 1,954 4.6 2.3 9.9 17.6

0-5 <10 102 0.3 0.2 6.2 6.9

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

Table 29: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions to Foster and Nonfoster Children in Massachusetts 

during 2008 

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

0-17 Average number of gaps per child 1.14 1.55 1.56 1.94

 Average length of gaps per child (days) 10.57 11.90 14.37 14.87

13-17 Average number of gaps per child 1.14 1.62 1.54 1.94

 Average length of gaps per child (days) 10.65 12.43 14.42 14.88

6-12 Average number of gaps per child 1.22 1.60 1.58 1.95
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 66 GAO-12-201 Foster Children

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

 Average length of gaps per child (days) 11.00 12.14 14.27 14.84

0-5 Average number of gaps per child 0.55 0.74 1.50 1.79

 Average length of gaps per child (days) 5.14 6.30 13.93 15.18

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

Table 30: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Michigan during 2008 

Age

Number of children who had three 

or more gaps in drug claims

Percentage of foster or 

nonfoster children who had 

three or more gaps in drug 

claims

Percentage of foster or nonfoster 

children prescribed a psychotropic 

drug who had three or more gaps in 

drug claims

Foster children

Nonfoster 

children Foster children

Nonfoster 

children Foster children

Nonfoster 

children

0-17 360 8,903 1.7 0.9 7.9 11.3

13-17 165 3,459 2.6 1.5 7.2 10.8

6-12 174 5,122 2.6 1.5 9.3 12.2

0-5 21 322 0.3 0.1 5.6 6.4

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

Table 31: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions to Foster and Nonfoster Children in Michigan during 

2008 

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

0-17 Average number of gaps per child 1.10 1.14 1.60 1.76

 Average length of gaps per child (days) 10.03 9.61 14.55 14.85

13-17 Average number of gaps per child 1.14 1.18 1.55 1.74

 Average length of gaps per child (days) 10.67 10.16 14.47 14.96

6-12 Average number of gaps per child 1.15 1.17 1.67 1.79
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 67 GAO-12-201 Foster Children

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

 Average length of gaps per child (days) 9.99 9.67 14.53 14.76

0-5 Average number of gaps per child 0.67 0.65 1.64 1.71

 Average length of gaps per child (days) 6.34 5.68 15.61 14.97

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

Table 32: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Oregon during 2008 

Age

Number of children who had three 

or more gaps in drug claims

Percentage of foster or 

nonfoster children who had 

three or more gaps in drug 

claims

Percentage of foster or nonfoster 

children prescribed a psychotropic 

drug who had three or more gaps in 

drug claims

Foster children

Nonfoster 

children Foster children

Nonfoster 

children Foster children

Nonfoster 

children

0-17 167 1,174 1.6 0.5 7.7 9.5

13-17 97 576 3.6 1.2 8.1 9.3

6-12 61 559 1.7 0.7 7.2 10.5

0-5 <10 39 0.2 0.0 7.1 4.7

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

Table 33: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions to Foster and Nonfoster Children in Oregon during 

2008 

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

0-17 Average number of gaps per child 0.96 0.95 1.63 1.79

 Average length of gaps per child (days) 8.31 7.70 14.15 14.53

13-17 Average number of gaps per child 1.06 0.95 1.62 1.77

 Average length of gaps per child (days) 9.06 7.75 13.88 14.46

6-12 Average number of gaps per child 0.88 1.01 1.64 1.81
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 68 GAO-12-201 Foster Children

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or

without a gap in prescriptions)

Children in Medicaid

with at least one gap in

psychotropic drug prescriptions

Foster Nonfoster Foster Nonfoster

 Average length of gaps per child (days) 7.75 8.12 14.51 14.55

0-5 Average number of gaps per child 0.57 0.52 1.71 1.72

 Average length of gaps per child (days) 5.08 4.63 15.37 15.15

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

Table 34: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 Days in Prescriptions to Foster and Nonfoster 

Children in Texas during 2008 

Age

Number of children who had three 

or more gaps in drug claims

Percentage of foster or 

nonfoster children who had 

three or more gaps in drug 

claims

Percentage of foster or nonfoster 

children prescribed a psychotropic 

drug who had three or more gaps in 

drug claims

Foster children

Nonfoster 

children Foster children

Nonfoster 

children Foster children

Nonfoster 

children

0-17 798 17,512 2.2 0.7 6.6 8.6

13-17 336 5,185 4.1 1.1 7.0 9.1

6-12 373 10,935 3.1 1.2 6.6 10.8

0-5 89 1,392 0.5 0.1 5.6 3.2

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

Table 35: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions to Foster and Nonfoster Children in Texas during 

2008 

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or without a 

gap in prescriptions)

Children in Medicaid with at least 

one gap in psychotropic drug 

prescriptions

Foster Nonfoster Foster Nonfoster

0-17 Average number of gaps per child 1.23 0.94 1.44 1.73

 Average length of gaps per child (days) 11.97 8.37 14.00 15.32

13-17 Average number of gaps per child 1.38 1.08 1.42 1.71

 Average length of gaps per child (days) 13.75 9.72 14.13 15.38

6-12 Average number of gaps per child 1.25 1.12 1.45 1.76
Appendix IX: Additional Data on Psychotropic 

Drugs with Gaps in Prescriptions of 7 to 29 

Days

Page 69 GAO-12-201 Foster Children

Age Category

Children in Medicaid with a 

psychotropic prescription 

(including those with or without a 

gap in prescriptions)

Children in Medicaid with at least 

one gap in psychotropic drug 

prescriptions

Foster Nonfoster Foster Nonfoster

 Average length of gaps per child (days) 11.92 9.73 13.85 15.26

0-5 Average number of gaps per child 0.74 0.36 1.54 1.62

 Average length of gaps per child (days) 6.77 3.44 14.09 15.52

Source: GAO analysis of Texas Medicaid and foster care data.
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 70 GAO-12-201 Foster Children

This appendix compares in detail selected states’ oversight of 

psychotropic drug prescriptions for foster children with the American 

Academy of Child and Adolescent Psychiatry (AACAP) Best Principles 

Guidelines. The processes were in place as of October 2011 unless 

otherwise noted. The tables are based on interviews and documentation 

provided by state Medicaid and foster care officials. With the exception of

table 39, the information below was not tested to ensure these principles 

are implemented effectively.

Table 36: State Consent Laws and Policies Compared with AACAP Best Principle Guidelines

State Extent Description

AACAP 

guideline

Identify the parties empowered to consent for psychotropic drug treatment for youth in state 

custody in a timely fashion [minimal].

FL Full The parent or legal guardian can consent for psychotropic drug treatment, or the foster care agency 

may seek court authorization. 

MD Full The parent, legal guardian, court-authorized foster care agency, or local social services director or 

designee can consent for psychotropic drug treatment. 

MA Full For children in the care of the Massachusetts Department of Children and Families (DCF) through a 

voluntary placement agreement, only parents may consent to the use of antipsychotic drugs. For 

children in the custody of the Massachusetts DCF through a court order or through adoption surrender, 

court approval is required for the use of antipsychotic drugs in all nonemergency cases. According to 

agency officials, parents whose rights have not been terminated, caseworkers, or foster parents can 

provide consent for all other psychotropic medications. 

MI Full For children in the care of the Michigan Department of Human Services (DHS) through a voluntary 

placement, or children who are temporary wards of the court, only parents or legal guardians may 

consent to the use of psychotropic drugs. For children who are permanent wards of the court, only the

court may consent to the use of psychotropic drugs. For children who are permanent wards of the state, 

only the Michigan DHS may consent to the use of psychotropic drugs.

OR Full For children in the care of the Oregon Department of Human Services (DHS) through a voluntary 

placement or custody agreement, parents or legal guardians must consent to the use of psychotropic 

drugs. However, if the parents have signed a release agreement, then the department may consent. 

For children placed in legal custody of the Oregon DHS, or where the department is the legal guardian, 

then child welfare agency officials may consent to the use of psychotropic drugs. In any case, children 

14 years or older may also consent themselves.

TX Full Any individual or state department designated by name in a court order (which may include parent, 

relative, foster parent, or others) can give consent for psychotropic drug treatment. If the Department of 

Family and Protective Services (DFPS) is named, the department designates both a primary medical 

consenter and a back-up medical consenter (typically emergency shelter employees, live-in caregivers, 

relatives, or caseworkers). Children at least 16 years old may also consent themselves, if the court 

determines the child has the capacity to consent.

AACAP

guideline

Establish a mechanism to obtain assent for psychotropic medication management from minors 

when possible [minimal].a

FL Full Since 2010, prescribers are required to determine if minor can give assent and records decision in 

child’s medical report. 

Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 71 GAO-12-201 Foster Children

State Extent Description

MD Full If a child is prescribed psychotropic medication and is developmentally able to understand the usage 

and effects of the medication, the child should be a part of the process and able to exercise their right 

to take the medication. If the child is not of age he or she can refuse medication—the assent or dissent 

to take medication is documented in the child’s case record 

MA No

MI No

OR No

TX Full DFPS policy requires all children’s medical consenters to discuss their medical care with them in a 

developmentally appropriate way and obtain their input.

AACAP

guideline

Obtain simply written psycho-educational materials and medication information sheets to 

facilitate the consent process [recommended].

FL Full Florida has an online guide to children’s mental health services and support which can facilitate the 

consent process. In addition, the child’s medical report contains drug information and is used during the 

consent process. The Florida Dependency Court Judges Bench-book includes a section on 

psychotropic drugs to help judges when reviewing cases during court hearings. 

MD Partial The caseworker must provide information, including reason prescribed and side effects, but no 

standard form is used.

MA Full There are two documents staff can use to assist in collecting information to make informed consent 

decisions. One form is specific to antipsychotic medications and the other form is for all other 

medications. The prescriber is asked to complete the form and give it to the social worker, who can 

then ask for a member of the Massachusetts DCF Health and Medical Services Team to assist in 

interpreting the information and if necessary, obtain additional information from the prescriber. An 

information form stating the risks and benefits of medications is available to caseworkers upon request. 

MI No Although there are no psycho-educational materials and medication information sheets to facilitate the 

consent process, Michigan policy requires that the caseworker maintain a copy of the consent form 

used by the prescriber. 

OR Full Since June 2010, the consent form allows prescribers to describe target symptoms, potential side 

effects, and alternative treatments. The Oregon DHS website also has a link to a medical chart that 

includes psychotropic drug benefits and side effects

TX Full Since February 2005, psycho-educational materials are available to consent-givers online through the 

Texas DFPS website. 

AACAP

guideline

Establish training requirements for child welfare, court personnel and/or foster parents to help 

them become more effective advocates for children in their custody [ideal].

FL Partial Florida DCF’s partnership with the University of South Florida provides online training, research articles, 

and child welfare resources to foster parents and caseworkers. Guidelines are also compiled 

specifically for court personnel. Content related to psychotropic drugs is included in each module of the 

three tiers of required caseworker training. However, the names and indications for use of commonly 

prescribed psychotropic medications are not included as part of the required training.

MD Partial As part of the foster parent training, some local departments of social services have begun offering 

training on psychotropic drugs and the behaviors associated with taking the medication. However, there 

is no statewide training.

MA Partial Caseworkers and attorneys who represent parents and children are trained on the court process for 

obtaining authorization for antipsychotic medication and general information on the use and effect of 

psychotropic medications. However agency officials did not confirm whether each of the elements listed 

in AACAP’s guidelines for training is included. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 72 GAO-12-201 Foster Children

State Extent Description

MI No Michigan has optional children’s mental health training for child welfare agency staff. There are plans to 

develop training, but the particulars of the trainings had not been completed as of September 2011. 

OR Partial Oregon required training as a one-time initiative in July 2010 for Child Welfare Supervisors that covered 

all of the AACAP best principle guidelines for training. The training was optional for nonsupervisory staff 

and a modified version of this course was provided at an annual conference for foster parents, Citizen 

Review Board, and other community partners. A webcast training has also been offered for foster 

parents and other child welfare staff and an updated version of the training is in the early development 

stages and will be provided as an ongoing training course once completed.

TX Full Since 2005, all consent-givers, except parents, must take training for informed consent and the 

provision of medical care which includes each of the training requirements listed in the AACAP best 

principle guidelines. The Minimum Standards for Residential Child Care Licensing requires that training 

for foster parents and other residential providers include these elements as well. DFPS has no authority 

to require court personnel to complete psychotropic medication training. However, DFPS is in the 

process of developing online training to include all of the training requirements noted in the AACAP 

guidelines and will be made available to children’s caregivers, staff, court personnel, and others in the 

child welfare system through an external website.

Source: GAO analysis of information collected through interviews with, and various documentation provided by, the selected states’ 

Medicaid and foster care officials, and the AACAP’s best principles guidelines. 

a

According to AACAP, consent is given by the person who has legal authority to make medical 

decisions, whereas assent is for the patient themselves if they are not legally able to make their own 

decisions.

b

AACAP Best Principles Guidelines state this training should include the names and indications for 

use of commonly prescribed psychotropic medications, monitoring for medication effectiveness and 

side effects, and maintaining medication logs. Materials for this training should include a written 

“Guide to Psychotropic Medications” that includes many of the basic guidelines reviewed in the 

psychotropic medication training curriculum.

Table 37: State Oversight Laws and Policies Compared with AACAP’s Best Principle Guidelines

State Extent Description

AACAP 

guideline

Establish guidelines for the use of psychotropic medications for children in state custody 

[minimal].

FL Partial Evidence-based Medication Drug Guidelines for Children were developed by the Florida Mental Health 

Institute with input from physician researchers and are updated biennially. However, these guidelines 

are not specifically targeted towards children in state custody. Since 2008, the prior authorization review 

process requires a clinical review or second medical opinion by a child and adolescent psychiatrist for 

children less than 6 years of age prescribed an antipsychotic medication, in order to be reimbursed by 

Medicaid. Since 2010 prior authorization reviews are conducted for any antipsychotic lacking an FDA 

indication or acceptable evidence-base for safety and efficacy for children less than 18 years of age, 

and any high dose of antipsychotic medication.

MD Partial Beginning October 2011, the Maryland Medicaid Pharmacy Program (MMPP) implemented a peerreview authorization process to ensure the safe and effective use of antipsychotic medications in 

children. Claims for antipsychotic medications for children younger than the FDA approved age require 

a prior authorization based on the peer-review assessment. The MMPP’s board-certified child 

psychiatrist oversees the peer-review project.
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 73 GAO-12-201 Foster Children

State Extent Description

MA Partial Massachusetts guidelines are specific only to antipsychotic drugs. However, the majority of children in 

state custody are members of MassHealth and are subjected to the requirements and clinical 

management principles of the MassHealth Drug List, but these principles are not specific to foster 

children.

MI Full As of April 2010 Michigan adopted the guidelines established by Texas for the use of psychotropic 

medication for children in state custody. 

OR No Since June 2010, annual reviews of psychotropic drugs must be conducted for all children under 6, or 

for any individual under 20 who remains in the care and custody of the state and who has more than two 

prescriptions for psychotropic drugs. The review must be performed by an individual other than the 

prescriber who is either a licensed medical professional, a qualified mental health professional with the 

authority to prescribe drugs, or a licensed pharmacist with the Drug Use Review Program. However, 

these are retrospective reviews that occur on an annual basis and do not take place at the time of 

prescription. 

TX Full Since 2005, the Psychotropic Medication Utilization Parameters for Foster Children have been in place 

to serve as guidelines for the use of psychotropic drugs for children in foster care. For a child being 

prescribed a psychotropic medication, any of the following suggests the need for additional review:

1. Absence of a thorough assessment of child’s mental health diagnosis in the child’s medical record

2. Five or more psychotropic medications prescribed concomitantly (side-effect medications are not 

included in this count)

3. Prescribing of:

(a) Two or more concomitant antidepressants (if an additional one is used, may be reviewed but will be 

allowed if reasonable for the indications)

(b) Two or more concomitant antipsychotic medications

(c) Two or more concomitant stimulant medications

(d) Three or more concomitant mood stabilizer medications

Note: Polypharmacy is defined here as the use of two or more medications for the same indication. The 

prescription of a long-acting stimulant and an immediate release stimulant of the same chemical entity 

does not constitute concomitant prescribing and when switching psychotropic drugs, medication overlap 

and lowering the dose of an old drug while increasing the dose of a new drug may be utilized before 

discontinuing the first medication.

4. The prescribed psychotropic medication is not consistent with appropriate care for the patient’s 

diagnosed mental disorder or with documented target symptoms usually associated with a therapeutic 

response to the medication prescribed.

5. Psychotropic polypharmacy for a given mental disorder is prescribed before utilizing psychotropic 

monotherapy.

6. The psychotropic medication dose exceeds usual recommended doses.

7. Psychotropic medications are prescribed for children of very young age, including children receiving 

the following medications with an age of:

Antidepressants: Less than four years of age

Antipsychotics: Less than four years of age

Psychostimulants: Less than three years of age

8. Prescribing by a primary care provider who has not documented previous specialty training for a 

diagnosis other than the following (unless recommended by a psychiatrist consultant):

Attention Deficit Hyperactive Disorder (ADHD)

Uncomplicated anxiety disorders

Uncomplicated depression
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 74 GAO-12-201 Foster Children

State Extent Description

AACAP

guideline

Oversight program includes an advisory committee to oversee a medication formulary and 

provide medication monitoring guidelines to practitioners who treat children in the child welfare 

system [ideal].a

 

FL Partial The Florida Medicaid Drug Therapy Management Program for Behavioral Health (MDTMP for BH) was 

created in 2004 to improve the quality of behavioral health drug prescribing, improve patient adherence 

to therapy, reduce clinical risks, and lower cost while providing appropriate therapy. In 2006, an expert 

panel of psychiatrists developed evidence-based best practice guidelines for the use of 

psychotherapeutic drugs in children and adolescents. The guidelines were published in October 2006 

and are reviewed and updated biennially. Members of the panel include a combination of pediatric, 

adolescent, and adult psychiatrists as well as primary care physicians, pediatricians, DCF members, 

Agency for Health Care Administration (AHCA) staff and clinical pharmacists. However, the advisory 

committee does not include other mental health providers, consulting clinical pharmacists, family 

advocates or parents, or state child advocates. The advisory committee does not oversee a medication 

formulary or provide medication monitoring guidelines specifically for practitioners who treat children in 

the child welfare system. The Florida MDTMP for BH does provider outreach and the guidelines are also 

accessible online. 

MD Partial The MMPP’s board-certified child psychiatrist oversees the peer-review project for antipsychotic 

medications. However, there are no medication-monitoring guidelines specific to practitioners who treat 

children in the child welfare system. 

MA No The Massachusetts Drug Utilization Review program’s goal is to ensure that prescribed drugs are 

appropriate, medically necessary, and not likely to result in medication-related problems. However, 

Massachusetts does not have an advisory committee that oversees a medication formulary and 

monitoring guidelines specific to practitioners who treat children in the child welfare system.

MI Partial Michigan DHS established a Child Welfare Health Advisory Board in June 2010 and a subcommittee

from that group meets to discuss the oversight of psychotropic medication including monitoring 

guidelines. Members of the subcommittee include agency and community child and adolescent 

psychiatrists, pediatricians, other mental health providers, and state child advocates. However, the 

subcommittee does not include consulting clinical pharmacists, and family advocates or parents. The 

group met in 2010, and it was determined that the pharmacy claims data were needed to move forward 

and that the group would not meet again until they were available. The advisory committee planned to 

meet again in October 2011 after receiving a second set of data. There is not a separate formulary for 

children in state custody.

OR No Oregon accesses the Drug Use Review (DUR) in the Division of Medical Assistance Programs. DUR is 

a program designed to measure and assess the proper utilization, quality, therapy, medical 

appropriateness, appropriate selection and cost of prescribed medication through evaluation of claims 

data. However, Oregon does not have an advisory committee that oversees a medication formulary and 

monitoring guidelines specific to practitioners who treat children in the child welfare system.

TX Partial In 2004, an advisory committee convened and issued a report recommending that parameters and 

oversight for psychotropic medications for children in foster care be put into place. In 2005 the 

Psychotropic Medication Utilization Parameters for Foster Children were released. The most recent 

update to the parameters was released in December 2010. Members of the advisory committee who 

update the parameters on a biennial basis as necessary include agency and community child and 

adolescent psychiatrists, pediatricians, other mental health providers, consulting clinical pharmacists, 

and family advocates or parents, but do not include state child advocates. However, according to 

agency officials Texas is initiating a new psychotropic medication workgroup that will include state child 

advocates and judges in addition to the current members. The Psychotropic Medication Monitoring 

Group, comprised of various health care professionals, reviews ongoing monitoring conducted by 

consulting child psychiatrists. An annual report on psychotropic medication utilization is posted online

and a panel of experts reviews and updates the parameters periodically based on the most current 

evidence-based literature available at the time of publication. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 75 GAO-12-201 Foster Children

State Extent Description

AACAP

guideline

Oversight program monitors the rate and types of psychotropic medication usage and the rate of 

adverse reactions among youth in state custody [ideal].

FL Partial Florida DCF has two recurring file exchanges with Florida’s Agency for Health Care Administration 

(AHCA). One file is used to identify and verify those children who are enrolled in the prepaid Mental 

health program. The second file exchange is a Psych Meds Match report that recurs monthly. This 

report is used to validate the recording of psychotropic medications. Florida DCF provides a list of all 

children who are active in in-home or out-of-home care to Florida’s third party vendor for pharmacy data. 

The third party matches against their pharmacy data and reports back all psychotropic medications 

prescribed for the last 3 months. This information is subsequently provided to the local agencies for 

monitoring. Florida DCF also provides a weekly report of all children prescribed psychotropic 

medications (according to the child welfare record) and a corresponding list report that includes every 

child by name so that regions and management can address individual cases as needed. Supervisors 

review cases every 30 days and may address issues at that time. The report is completed for all 

psychotropic medications for all children 0-17 years of age and supervisory reviews are done on all 

children. The Florida Mental Health Institute at the University of South Florida performs retrospective 

prescription claims reviews for AHCA to determine the rate and types of psychotropic drugs used for 

Medicaid eligible children in the child welfare system. However, Florida DCF does not monitor the rate 

and types of psychotropic medication in relation to the state guidelines and does not monitor and review 

adverse reactions at the aggregate level.

MD Partial According to an agency official, data on rate and types of psychotropic medication usage are gathered 

for all children in the child welfare system in a collaborative effort between the Departments of Human 

Resources (Child Welfare) and Health and Mental Hygiene, and the University of Maryland Schools of 

Pharmacy, Social Work and Medicine. However, there is not a uniform system in place among local 

departments of social services to monitor the rate of adverse reactions. 

MA Partial Unstable and medically complex children receive home visits from a pediatric nurse practitioner. Also, 

when a court authorizes antipsychotic medication, it appoints a Guardian ad Litem to monitor the use of 

the medication and it sets periodic—usually every 6 months—reviews of the usage and impact of the 

medication, including any adverse reactions. 

MI Partial Michigan DHS completed an interagency agreement for data sharing with the Michigan Department of 

Community Health (DCH) to review foster children’s prescription claims data on a quarterly basis. 

However, Michigan DHS was unable to build reliable reports with the first data set received April 2011 

and there is no process to monitor and review adverse reactions.

OR Partial As of June 2010, an annual review of psychotropic medications by an individual other than the 

prescriber is performed when:

(a) a child or young adult has more than two prescriptions for psychotropic medications; or

(b) a child is under 6 years of age.

The annual review guidelines have been used as a threshold for review or additional review on an 

individual basis. There is no macro level review of foster children’s claims data to track prescribing 

trends across the entire foster care population and no aggregate reviews of adverse reactions to 

medications. Prior to 2010 the department enacted a number of different informal strategies to better 

understand and inform the process which concluded with the development of the rules now in place.

TX Partial In June 2006, a report on the use of psychotropic medications in Texas foster children was released. 

This macro level analysis reports the rate and types of various psychotropic prescribing practices and is 

updated and reported on an annual basis. However, adverse reactions are not tracked and reviewed on 

a macro level. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 76 GAO-12-201 Foster Children

State Extent Description

AACAP

guideline

Oversight program establishes a process to review non-standard, unusual, and/or experimental 

psychiatric interventions with children who are in state custody [ideal].

FL Partial A preconsent review by a consultant child psychiatrist is obtained prior to the prescription of a 

psychotropic medication for any child under 11 years of age who is prescribed two or more psychotropic 

medications and who is in the custody of the department in out-of-home care. The results of the review 

by the consultant child psychiatrist are provided to the child and to the person who has legal authority to 

provide express and informed consent or the judge who is providing the court order for treatment with a 

psychotropic medication. Florida DCF may utilize the department’s pre-consent review contract with the 

University of Florida or may contract locally with a child psychiatrist. The University of Florida has at 

least two certified child psychiatrists on staff who review the medications identified by Florida DCF for 

additional review. The child psychiatrists can contact the prescriber and request more information or 

recommend alternative treatment options as necessary. However, the prescribing physician is permitted 

by law to fill the prescription using their own discretion regardless of the child psychiatrists’ 

recommendation.

MD Partial A child and adolescent psychiatrist who is on the faculty at Johns Hopkins University School of Medicine 

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

this practice is not statewide.

MA Partial For extraordinary, complex, risky, or novel treatment, Massachusetts DCF is required to get the consent 

of the parents (if the child is in the department’s care) or receive prior judicial approval (if the child is in 

the department’s custody). However, the only psychotropic medication regimen that has been defined to 

meet these criteria is antipsychotic medications. 

MI Full The Michigan DHS oversight program flags pharmacy claims when the prescribing of psychotropic 

medication falls outside of established guidelines. Current reviews are conducted on prescribing 

practices including: four or more psychotropic medications prescribed concomitantly; prescribing two or 

more concomitant antidepressant medications, two or more concomitant antipsychotic medications, two 

or more concomitant stimulant medications, or two or more concomitant mood stabilizer medications; 

psychotropic medication dose exceeds usually recommended dose; and psychotropic medications 

prescribed for children 5 years and under. In addition, Michigan DHS hired 25 health liaison officers to 

serve as health care advocates for foster children and help assist in the review and oversight process of 

psychotropic medications under the direction of the Michigan DHS medical consultant. 

OR Partial Oregon’s annual review guidelines have been used as a threshold for review or additional review on an 

individual basis. 

TX Full Since April 2008, State of Texas Access Reform (STAR) Health Service Managers perform health 

assessments on foster children to identify those who have medication regimens which appear to be 

outside the Psychotropic Medication Utilization Parameters. 

AACAP

guideline

Oversight program collects and analyzes data and makes quarterly reports to the state or county 

child welfare agency regarding the rates and types of psychotropic medication use. These data 

are made available to clinicians in the state to improve the quality of care provided [ideal].

FL Partial Florida DCF reports the number of children on psychotropic medications, the number of children who 

received informed consent, and the demographics of those cases on a weekly basis to management. 

Florida DCF monitors the number of children prescribed psychotropic medications and whether valid 

express and informed consent were obtained or court authorized, but does not monitor and report the 

rates and types of psychotropic medications prescribed. The state conducts quarterly quality assurance 

reviews of all community-based care agencies. Cases are randomly selected for a comprehensive 

quality assurance review and if the child is on psychotropic medications, the reviewer is required to 

determine if the case management organization complied with statute and Florida Administrative Code. 

All quality assurance reports are accessible online. Florida DCF also publishes an annual report of 

findings. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 77 GAO-12-201 Foster Children

State Extent Description

MD Partial The oversight program used in Baltimore City collects and analyzes data and makes reports to the state 

and the Baltimore City Child Welfare Department. However, this practice is not statewide. 

MA Partial Individual cases are reviewed quarterly, but macro-level reports are not done regularly. However, 

episodic reports have been issued on the rates and types of psychotropic medication for specific drug 

types and age ranges that include foster children.

MI No There is a plan to look at the claims data systemically, but it has not yet been determined how the 

reports will be developed or shared. Those decisions will be made by the Child Welfare Health Advisory 

Board’s subcommittee. 

OR No Medication logs are reviewed monthly on an individual basis by the caseworker, but no macro-level 

report is available to improve the quality of care.

TX Full Quarterly reports are reviewed by the Psychotropic Medication Monitoring Group, which is chaired by 

DFPS. These reports include the percentile of children in foster care on psychotropic medications and 

the percentile that are outside parameters (receiving any psychotropic medications under age 4 years, 

two of more of the same class and/or five or more of the same class). Annually, at the end of each state 

fiscal year, a report specific to foster children is generated from Medicaid prescription data and posted 

on the Texas Health and Human Services Commission website for use by clinicians and other 

stakeholders.

AACAP

guideline

Maintain an ongoing record of diagnoses, height and weight, allergies, medical history, ongoing 

medical problem list, psychotropic medications, and adverse medication reactions that are 

easily available to treating clinicians 24 hours a day [ideal].

FL Partial Florida maintains a resource record as the child’s standardized record that contains copies of all 

available and accessible medical and psychological information—including behavioral health 

information—pertaining to the child. The resource record is a hard copy form maintained in the child’s 

foster home. However, the states Automated Child Welfare Information System includes medical 

information and most child welfare agencies store documents electronically to maintain copies of 

medical records. The electronic systems that store critical information such as immunizations and 

medical history are accessible 24 hours a day. However, Florida’s policy does not specify whether the 

record of diagnosis, height and weight, allergies, medical history, ongoing medical problem list, 

psychotropic medications, and adverse medication reactions are specifically required to be maintained. 

MD Full Each child that enters out-of-home placement is given a medical passport. This passport serves as a 

record of the child’s previous and current medical file. The passport is provided to the placement 

resource (e.g., foster parents or group home) and is carried to every medical appointment to be 

reviewed if necessary by the health care provider. Each medical visit, medication, and immunization is 

documented in the passport along with diagnoses, height and weight, allergies, medical history, ongoing 

medical problem list, psychotropic medications, and adverse medication reactions. An additional copy of 

the passport is kept in the child’s case record and also maintained electronically. Since the passport is 

maintained at the child’s placement it is available 24 hours a day for emergencies. 

MA Partial Massachusetts DCF requires the use of a “medical passport” for all children in substitute care. The 

medical passport records pertinent and available medical/dental/mental health and developmental data 

about the child. Department social workers and medical providers complete relevant portions of the 

passport. The passports are held by the substitute care provider and remain with the child for the 

duration of his or her placement. If a child moves to a new substitute care placement or returns home, 

the medical passport moves with the child. However, the medical passport does not include height and 

weight, adverse reactions, or an ongoing medical problem list. 

MI Full Each foster child is provided a medical passport that records all of the elements recommended by 

AACAP. The passport is a paper document and is provided to the foster parents to ensure health 

information is updated as necessary. The passport stays with the child over time, but it is the 

responsibility of the foster parents to make sure the passport stays updated and is made available to 

treating clinicians. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 78 GAO-12-201 Foster Children

State Extent Description

OR Partial Oregon has medical information and a health care record for the child in foster care. However, these 

records may not be inclusive of all the child’s health care information—which may be with other medical 

offices—and they are not accessible 24 hours a day to health care providers.

TX Partial As of April 2008, a web-based electronic health record system maintains health information for foster 

children and is available to treating clinicians 24 hours a day. The electronic health record system 

records an ongoing record of diagnoses, medical history, and psychotropic medications, but the adverse 

medication reactions, height and weight, and allergies are optional and not all health care providers 

enter this information. An ongoing medical problem list is not recorded in the electronic health record 

system. 

Source: GAO analysis of information collected through interviews with, and various documentation provided by, the selected states’ 

Medicaid and foster care officials, and the AACAP’s best principles guidelines. 

a

AACAP describes advisory committees as composed of agency and community child and adolescent 

psychiatrists, pediatricians, other mental health providers, consulting clinical pharmacists, family 

advocates or parents, and state child advocates.

Table 38: State Consultation Programs Compared with AACAP’s Best Principle Guidelines

State Extent Description

AACAP 

guideline

Design a consultation program administered by child and adolescent psychiatrists. This 

program provides consultation by child and adolescent psychiatrists to the persons or agency 

that is responsible for consenting for treatment with psychotropic medications [recommended].a

FL Full Starting in 2004, the MedConsult line was made available for families, guardians, and the courts to 

consult with board-certified child psychiatrists via telephone. The purpose of the MedConsult line is to 

assist decision makers who give express and informed consent for psychotropic medication for 

dependent children or children enrolled in the Behavioral Health Network. The MedConsult Line is 

available Monday through Friday 9:00 am until 5:00 pm. The court may order additional medical 

consultation, including consultation with the MedConsult line at the University of Florida, if available, or 

require the department to obtain a second opinion within a reasonable timeframe as established by the 

court, not to exceed 21 calendar days, after such order based upon consideration of the best interests of 

the child. The MedConsult line is not a second opinion and participation is voluntary. The kind of 

information provided include indicated uses, usual and customary practices, dose ranges, starting dose, 

FDA Box Warnings, on-or off-label use, any precautions such as EKGs, and lab work. 

MD No

MA Partial The Massachusetts Department of Mental Health (DMH) has six child psychiatrists who are available to 

provide consultations on a part-time basis. In addition, Massachusetts DCF has a part-time child 

psychiatrist on staff who is available for consultation on individual cases and provides consultation to the 

agency senior managers. Pharmacists are also available to consult with consent-givers if the child is 

enrolled on MassHealth. A pharmacist is available via phone to provide information regarding the child’s 

drug history, provide an opinion on proposed medications—including interactions between multiple 

medications—make consent recommendations, and/or call the prescriber to ask questions and seek 

additional information. 

MI No According to agency officials, Michigan DHS has set aside $1 million to develop a consultation program 

and is considering a line item for future fiscal years to continue the program if successful.

OR Partial As of February 2009, child welfare agency officials give consent for children placed in legal custody of 

Oregon DHS, or where the department is the legal guardian, and have access to a consulting child and 

adolescent psychiatrist on a part-time basis.
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 79 GAO-12-201 Foster Children

State Extent Description

TX Partial The DFPS Medical Director who is a board-certified child and adolescent psychiatrist, consults with CPS 

staff regarding policy, procedures, training materials and complex cases. Under the guidance of the 

DFPS Medical Director, the CPS Division Administrator for Medical Services and the Regional Nurse 

Consultants also provide guidance and education to staff that consent to a child’s treatment with 

psychotropic medications and consult on specific cases when necessary or when requested.

AACAP

guideline

The consultation program provides consultations by child and adolescent psychiatrists to, and 

at the request of, physicians treating this difficult patient population [recommended].

FL Full The MedConsult line is available to physicians who seek consultations by child and adolescent 

psychiatrists. 

MD Partial A child and adolescent psychiatrist consults with prescribers for youth entering Baltimore City Child 

Welfare. MMPP has contracted with the University of Maryland (UMD) Division of Child and Adolescent 

Psychiatry and School of Pharmacy to provide call center services. UMD utilizes psychiatrists and 

pharmacists to answer calls from Medicaid prescribers who prescribe antipsychotic medications off-label 

to children and provide reviews of patient profiles to determine if the program will approve or deny the 

claim. However, these reviews are only for antipsychotic drugs and do not include other psychotropic 

drugs. 

MA Full As of December 2005, the Massachusetts Child Psychiatry Access Project (MCPAP) was put in place, 

which allows pediatricians to have access to consultations with child and adolescent psychiatrists by 

phone on weekdays between 9 a.m. and 5 p.m., within 30 minutes of the request.

MI No

OR No The Oregon Psychiatric Access Line for Kids project is under development which would allow primary 

care physicians and nurse practitioners to consult with child psychiatrists as needed. Agency officials 

told us that future implementation is dependent on finding a long-term funding source. Neither the 

Oregon Foster children program nor the state Medicaid agency currently uses this program. 

TX No Child psychiatrists with Texas STAR health consult with prescribing physicians as part of the 

psychotropic medication utilization review process. However, these consultations are not conducted at 

the request of treating physicians as recommended by AACAP. 

AACAP

guideline

The consultation program conducts face-to-face evaluations of youth by child and adolescent 

psychiatrists at the request of the child welfare agency, the juvenile court, or other state or 

county agencies empowered by law to consent for treatment with psychotropic medications 

when concerns have been raised about the pharmacological regimen [recommended].

FL No

MD No

MA Full Massachusetts DCF mental health specialists are able to arrange consultations or evaluations if needed 

and the Juvenile Courts have access to Juvenile Court Clinics where evaluations can be conducted.

MI No

OR No

TX Full Since April 2008, the psychotropic medication utilization review process is triggered when a child’s 

medication regimens are outside the parameters or when certain criteria are met, including at the 

request of CPS nurse consultants, caseworkers, court appointed special advocates, foster parents, 

attorneys, residential child care providers, and at the request of the court. 

Source: GAO analysis of information collected through interviews with, and various documentation provided by, the selected states’ 

Medicaid and foster care officials, and the AACAP’s best principles guidelines. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 80 GAO-12-201 Foster Children

a

Massachusetts, Oregon, and Texas received a partial categorization because the consultation 

programs do not ensure all possible consent-givers have access to consultations with a child and 

adolescent psychiatrist. For example, when parent(s) have retained their rights to consent for their 

child’s medication and the child enters foster care through a voluntary placement agreement. In 

addition, consultations in Massachusetts and Oregon are only available to agency officials on a parttime basis.

Table 39. State Information-Sharing Laws and Policies Compared with AACAP’s Best Principle Guidelines 

State Extent Description

AACAP 

guideline

Create a website to provide ready access for clinicians, foster parents, and other caregivers to 

pertinent policies and procedures governing psychotropic medication management [ideal].

FL Full Florida DCF has partnered with the University of South Florida to implement Florida’s Center for the 

Advancement of Child Welfare Practice to provide needed information and support to Florida’s 

professional child welfare stakeholders. The website includes policies and procedures regulating 

psychotropic drug management. 

MD No

MA Full The official website of the Executive Office of Health and Human Services (EOHHS) includes policies 

and procedures governing psychotropic medication management. 

MI No

OR Full Oregon developed a website as a communication tool during the implementation of the agency’s recent 

2010 administrative rules, but the website is not an ongoing resource for information. The website 

currently has information on state policies and procedures governing the use of psychotropic drugs.

TX Full As of September 2005, DFPS posted the Psychotropic Medication Utilization Parameters for Foster 

Children on the agency’s website. Also, DFPS has incorporated requirements to follow the principles 

underlying the parameters into each residential child-care contract. The residential contract is revised 

each year and posted on the website.

AACAP

guideline

Website includes psycho-educational materials [ideal].

FL Full Florida’s Center for the Advancement of Child Welfare Practice website includes staff publications and 

educational materials about psychotropic drugs.

MD No

MA Full The official website of EOHHS includes web links to psycho-educational materials and publications. 

MI No According to an agency official, Michigan DHS added a Health Information and Resource page to its 

internal website that Michigan DHS staff can access. The website is updated by the Health, Education, 

and Youth Unit and was activated in January 2011. However, this information is not available to 

external caregivers such as clinicians.a

 

OR Full Oregon’s official website links to a medication chart that can be used as a psychotropic medication 

reference tool. 

TX Full As of February of 2005, DFPS posted the Psychotropic Medication Utilization Parameters for Foster 

Children on their website. The parameters describe appropriate practice for prescribers and literature 

references. Since the Summer of 2007, DFPS has posted tables addressing medication uses, dosages 

and possible side effects on the agency website.
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 81 GAO-12-201 Foster Children

State Extent Description

AACAP

guideline

Website includes consent forms [ideal].

FL Full Florida’s Center for the Advancement of Child Welfare Practice website includes a consent form. 

MD No

MA No

MI No

OR Full Oregon’s official website includes a consent form. 

TX No DFPS does not have a standardized form that all prescribing health care providers are required to use. 

Each health care provider documents consent in his or her office-based medical record.

AACAP

guideline

Website includes adverse effect rating forms [ideal].

FL No

MD No

MA No

MI No

OR No

TX No

AACAP

guideline

Website includes reports on prescription patterns for psychotropic medications [ideal].

FL No Although Florida’s Center for the Advancement of Child Welfare Practice website does not include 

prescribing patterns, Florida’s DCF website does post prescription patterns and tracks informed consent 

as of 2009. 

MD No

MA No

MI No

OR No

TX Full Annual outcomes regarding prescribing patterns are posted on the website.

AACAP

Guideline

Website includes links to helpful, accurate, and ethical websites about child and adolescent 

psychiatric diagnoses and psychotropic medications [ideal].

FL Full The website includes links to other informative publications and news stories related to foster children 

and psychotropic medications.

MD No

MA No

MI No Agency officials said that Michigan DHS has a draft policy to link publications from the National Institute 

of Mental Health to the Michigan DHS website to give workers up-to-date information about child and 

adolescent psychiatric diagnoses and psychotropic medications. 

OR No

TX Full The website includes links to state and national sites that have information on medication guidelines 

and diagnoses of psychotropic medications.

Source: GAO analysis of information collected through interviews with, and various documentation provided by, the selected states’ 

Medicaid and foster care officials, and the AACAP’s best principles guidelines. 
Appendix X: Selected States’ Implementation 

of AACAP’s Best Principles Guidelines

Page 82 GAO-12-201 Foster Children

a

This information was provided by Michigan state officials and was not tested to ensure effective 

implementation.
Appendix XI: Comments from the Department 

of Health and Human Services

Page 83 GAO-12-201 Foster Children

Appendix XI: Comments from the 

Department of Health and Human Services
Appendix XI: Comments from the Department 

of Health and Human Services

Page 84 GAO-12-201 Foster Children
Appendix XI: Comments from the Department 

of Health and Human Services

Page 85 GAO-12-201 Foster Children
Appendix XI: Comments from the Department 

of Health and Human Services

Page 86 GAO-12-201 Foster Children
Appendix XII: Comments from the Florida 

Agency for Health Care Administration

Page 87 GAO-12-201 Foster Children

Appendix XII: Comments from the Florida 

Agency for Health Care Administration

GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix.
Appendix XII: Comments from the Florida 

Agency for Health Care Administration

Page 88 GAO-12-201 Foster Children

See comment 2.

See comment 2.

See comment 1.
Appendix XII: Comments from the Florida 

Agency for Health Care Administration

Page 89 GAO-12-201 Foster Children

See comment 3.
Appendix XII: Comments from the Florida 

Agency for Health Care Administration

Page 90 GAO-12-201 Foster Children

The following are GAO’s comments on the Florida Agency for Health 

Care Administration letter dated November 21, 2011: 

1. We revised the report to reflect the prior authorization for children

under 18.

2. We believe that the report accurately summarizes Florida’s oversight 

program. 

3. Some states' prescription drugs are covered by Medicaid managed 

care plans in which drug payments are included in the capitated 

payments that plans receive from states. The scope of our review was 

fee-for-service. As such, we did not evaluate managed care 

organizations’ controls related to the prescribing of psychotropic drugs to 

foster children.
Appendix XIII: Comments from the 

Massachusetts Executive Office of Health and 

Human Services

Page 91 GAO-12-201 Foster Children

Appendix XIII: Comments from the 

Massachusetts Executive Office of Health 

and Human Services

Note: GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix.

See comment 1.
Appendix XIII: Comments from the 

Massachusetts Executive Office of Health and 

Human Services

Page 92 GAO-12-201 Foster Children

The following are GAO’s comments on the Massachusetts Executive Office of Health 

and Human Services letter dated November 18, 2011: 

1. We revised the report to reflect Massachusetts’ technical comments as 

appropriate.
Appendix XIV: Comments from the Oregon 

Health Authority

Page 93 GAO-12-201 Foster Children

Appendix XIV: Comments from the Oregon 

Health Authority

GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix.

See comment 2.

See comment 1.
Appendix XIV: Comments from the Oregon 

Health Authority

Page 94 GAO-12-201 Foster Children
Appendix XIV: Comments from the Oregon 

Health Authority

Page 95 GAO-12-201 Foster Children

The following are GAO’s comments on the Oregon Health Authority letter 

dated November 18, 2011: 

1. Our evaluation found that the prescriber field was not reliable for 

several states. As such, we did not use that field in our data analysis.

2. Some states' prescription drugs are covered by Medicaid managed 

care plans in which drug payments are included in the capitated 

payments that plans receive from states. Although Oregon states that 

eighty percent of its Medicaid population was served by a fully capitated 

plan, the majority of drugs on our list were covered by a fee-for-service 

carve out of Oregon managed care plans. The data included in the feefor-service carve out were reliable and the scope of our review was feefor-service. As such, we did not evaluate managed care organizations’ 

controls related to the prescribing of psychotropic drugs to foster children. 
Appendix XV: Comments from the Texas 

Health and Human Services Commission

Page 96 GAO-12-201 Foster Children

Appendix XV: Comments from the Texas 

Health and Human Services Commission

GAO comments 

supplementing those in 

the report text appear at 

the end of this appendix. 
Appendix XV: Comments from the Texas 

Health and Human Services Commission

Page 97 GAO-12-201 Foster Children

See comment 2.

See comment 1.
Appendix XV: Comments from the Texas 

Health and Human Services Commission

Page 98 GAO-12-201 Foster Children
Appendix XV: Comments from the Texas 

Health and Human Services Commission

Page 99 GAO-12-201 Foster Children

The following are GAO’s comments on the Texas Health and Human 

Services Commission letter dated November 18, 2011: 

1. The evaluation of psychotropic rates and potential health risks were 

based on 2008 data. As such, we agree that it would not reflect any 

changes that have been made by the state after this time period.

However, our review of state controls examined policies in place through 

October 2011.

2. Our analysis focused on foster and nonfoster Medicaid children who 

were prescribed a psychotropic drug during 2008. Our methodology 

accurately reflects the percentages of those children that received such 

prescriptions during that time period. 
Appendix XVI: GAO Contact and Staff 

Acknowledgments

Page 100 GAO-12-201 Foster Children

Gregory D. Kutz , 202-512-6722 or kutzg@gao.gov

In addition to the contact named above, Matthew Valenta, Assistant 

Director; Erika Axelson, Assistant Director; Gary Bianchi; Assistant 

Director; Luqman Abdullah; Scott Clayton; Matthew Harris; Maria 

Kabiling; Sandra Moore; James Murphy; Robert Rodgers; Barry Shillito; 

April Van Cleef; Timothy Walker; and Monique Williams made significant 

contributions to this report.

Appendix XVI: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Staff 

acknowledgements 
Appendix XVII: Print-Friendly Version of Figure 

1, Psychotropic Prescription Rates for 

Children in Five States

Page 101 GAO-12-201 Foster Children

Appendix XVII: Print-Friendly Version of 

Figure 1, Psychotropic Prescription Rates for 

Children in Five States 
Appendix XVII: Print-Friendly Version of Figure 

1, Psychotropic Prescription Rates for 

Children in Five States

Page 102 GAO-12-201 Foster Children
Appendix XVII: Print-Friendly Version of Figure 

1, Psychotropic Prescription Rates for 

Children in Five States

Page 103 GAO-12-201 Foster Children
Appendix XVII: Print-Friendly Version of Figure 

1, Psychotropic Prescription Rates for 

Children in Five States

Page 104 GAO-12-201 Foster Children
Appendix XVII: Print-Friendly Version of Figure 

1, Psychotropic Prescription Rates for 

Children in Five States

Page 105 GAO-12-201 Foster Children
Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States

Page 106 GAO-12-201 Foster Children

Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States 
Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States

Page 107 GAO-12-201 Foster Children
Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States

Page 108 GAO-12-201 Foster Children
Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States

Page 109 GAO-12-201 Foster Children
Appendix XVIII: Print-Friendly Version of 

Figure 2, Psychotropic Drug Potential Health 

Risk Indicators for Five Selected States

Page 110 GAO-12-201 Foster Children (192343)
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