CHILDREN’S 

MENTAL HEALTH

Concerns Remain 

about Appropriate 

Services for Children 

in Medicaid and 

Foster Care

Report to Congressional Requesters

December 2012

GAO-13-15

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-15, a report to 

congressional requesters

December 2012

CHILDREN’S MENTAL HEALTH

Concerns Remain about Appropriate Services for 

Children in Medicaid and Foster Care

Why GAO Did This Study

Experts have concerns that children 

with mental health conditions do not 

always receive appropriate treatment, 

including concerns about appropriate 

use of psychotropic medications (which 

affect mood, thought, or behavior) and 

about access to psychosocial therapies 

(sessions with a mental health 

provider). These concerns may be 

compounded for low-income children in 

Medicaid and children in foster care 

(most of whom are covered by 

Medicaid)—populations who may be at 

higher risk of mental health conditions. 

Within HHS, CMS oversees Medicaid, 

and ACF supports state child welfare 

agencies that coordinate health care 

for foster children.

GAO was asked to provide information 

on children’s mental health. This report 

examines (1) the use of psychotropic 

medications and other mental health 

services for children in Medicaid 

nationwide, and related CMS 

initiatives; (2) HHS information on the 

use of psychotropic medications and 

other mental health services for 

children in foster care nationwide, and 

related HHS initiatives; and (3) the 

amount HHS has invested in research 

on children’s mental health.

GAO analyzed data from HHS’s MEPS 

—a national household survey on use 

of medical services—from 2007 

through 2009 for children covered by 

Medicaid and private insurance. GAO 

reviewed two recent ACF foster care 

reports with data from a national 

survey conducted during 2008 through 

2011. GAO analyzed data from HHS 

agencies that conduct or fund research 

and interviewed HHS officials and 

children’s mental health providers, 

researchers, and advocates.

What GAO Found

An annual average of 6.2 percent of noninstitutionalized children in Medicaid 

nationwide and 4.8 percent of privately insured children took one or more 

psychotropic medications, according to GAO’s analysis of 2007-2009 data from 

the Department of Health and Human Services’ (HHS) Medical Expenditure 

Panel Survey (MEPS). MEPS data also showed that children in Medicaid took 

antipsychotic medications (a type of psychotropic medication that can help some 

children but has a risk of serious side effects) at a relatively low rate—1.3 percent 

of children—but that the rate for children in Medicaid was over twice the rate for 

privately insured children, which was 0.5 percent. In addition, MEPS data 

showed that most children whose emotions or behavior, as reported by their 

parent or guardian, indicated a potential need for a mental health service did not 

receive any services within the same year. The Centers for Medicare & Medicaid 

Services (CMS) and many states have initiatives under way to help ensure that 

children receive appropriate mental health treatments. However, CMS’s ability to 

monitor children’s receipt of mental health services is limited because CMS does 

not collect information from states on whether children in Medicaid have received 

services for which they were referred. GAO recommended in 2011 that CMS 

identify options for collecting such data from state Medicaid programs. Findings 

in this report underscore the continued importance of CMS’s monitoring of 

children’s receipt of mental health services.

HHS’s Administration for Children and Families (ACF) reported that 18 percent of 

foster children were taking psychotropic medications at the time they were 

surveyed, although utilization varied widely by the child’s living arrangement. 

ACF also reported that 30 percent of foster children who may have needed 

mental health services did not receive them in the previous 12 months. HHS 

agencies are taking steps to promote appropriate mental health treatments for 

foster children, such as by sending information to states on psychotropic 

medication oversight practices.

HHS’s National Institutes of Health spent an estimated $1.2 billion on over 1,200 

children’s mental health research projects during fiscal years 2008 through 2011. 

Most of the funding—$956 million—was awarded by the National Institute of 

Mental Health, with more research projects studying psychosocial therapies than 

psychotropic medications. Other HHS agencies spent about $16 million 

combined on children’s mental health research during this period. 

HHS reviewed a draft of this report and provided technical comments, which 

GAO incorporated as appropriate. 

View GAO-13-15. For more information, 

contact Katherine Iritani at (202) 512-7114 or 

iritanik@gao.gov.
Page i GAO-13-15 Children’s Mental Health

Letter 1 

Background 9

Children in Medicaid Took Psychotropic Medications at a Higher 

Rate Than Those with Private Insurance, and Most Children in 

Medicaid with a Potential Mental Health Need Did Not Receive 

Services 16

Nearly One-Fifth of Foster Children Took Psychotropic 

Medications, and Nearly One-Third of Foster Children Who May 

Have Needed Mental Health Services Did Not Receive Them 25

NIH Spent an Estimated $1.2 Billion on Children’s Mental Health 

Research during Fiscal Years 2008 through 2011 31

Concluding Observations 37

Agency Comments 38

Appendix I Methodology Used to Analyze the Medical Expenditure 

Panel Survey 40

Appendix II Food and Drug Administration Reviews of Psychotropic 

Drug Label Changes for Children 46

Appendix III Results of the Medical Expenditure Panel Survey Analysis 49

Appendix IV GAO Contact and Staff Acknowledgments 53

Related GAO Products 54

Tables

Table 1: Most Common Types of Psychotropic Medications Taken 

by Children Covered by Medicaid or Private Insurance, 

Ages 0-20, 2007-2009 19

Contents 
Page ii GAO-13-15 Children’s Mental Health

Table 2: Percentages of Children with a Potential Mental Health 

Need Who Did Not Receive Certain Mental Health Services 

in a Calendar Year, by Medicaid or Private Insurance 

Coverage, 2007-2009 21

Table 3: Types of Providers Seen by Children Ages 0-20 Who Had 

One or More Mental Health Office Visits, by Medicaid and 

Private Insurance Coverage, 2007-2009 22

Table 4: National Institute of Mental Health Research Projects on 

Children’s Mental Health, by Topic, Fiscal Years 2008 

through 2011 34

Table 5: Psychotropic Medications Used in the MEPS Analysis 42

Table 6: Label Changes for Psychotropic Medications Resulting 

from the Best Pharmaceuticals for Children Act (BPCA) 

and the Pediatric Research Equity Act (PREA) during 

Fiscal Years 2008 through 2011 47

Table 7: Utilization of Psychotropic Medications and Other Mental 

Health Services by Children Covered by Medicaid and 

Private Insurance, 2007-2009 49

Table 8: Use of Psychotropic Medications and Other Mental Health 

Services by Children Covered by Medicaid and Private 

Insurance, by Age Group, 2007-2009 51

Figures

Figure 1: Receipt of Mental Health Services by Foster Children 

with a Potential Mental Health Need, Ages 1-19 28

Figure 2: HHS Expenditures for Children’s Mental Health Research, 

Fiscal Years 2008 through 2011 32
Page iii GAO-13-15 Children’s Mental Health

Abbreviations

AACAP American Academy of Child & Adolescent 

 Psychiatry

ACF Administration for Children and Families

ADHD attention deficit hyperactivity disorder

AHRQ Agency for Healthcare Research and 

 Quality

BPCA Best Pharmaceuticals for Children Act

CDC Centers for Disease Control and Prevention 

Child Improvement Act Child and Family Services Improvement and 

 Innovation Act

CHIP State Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services

EBT evidence-based therapy

EPSDT Early and Periodic Screening, Diagnostic, 

 and Treatment

FDA Food and Drug Administration

HHS Department of Health and Human Services

MEPS Medical Expenditure Panel Survey

NICHD Eunice Kennedy Shriver National Institute of 

 Child Health & Human Development

NIH National Institutes of Health

NIMH National Institute of Mental Health

NSCAW II National Survey of Child and Adolescent 

 Well-being II

PREA Pediatric Research Equity Act

SAMHSA Substance Abuse and Mental Health 

 Services Administration

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Page 1 GAO-13-15 Children’s Mental Health

United States Government Accountability Office

Washington, DC 20548

December 10, 2012

The Honorable Tom Harkin

Chairman

Committee on Health, Education, Labor, & Pensions

United States Senate

The Honorable Rosa DeLauro

The Honorable Lucille Roybal-Allard

House of Representatives

Children with mental health conditions are among the country’s most 

vulnerable populations, and there are concerns about whether they have 

access to the most appropriate kind of care for their conditions. Early 

detection and treatment of childhood mental health conditions can 

improve a child’s symptoms and reduce potentially detrimental effects on 

a child, such as difficulties with relationships, dropping out of school, and 

involvement with the juvenile justice system. Children with mental health 

conditions,1 such as attention deficit hyperactivity disorder (ADHD) or 

depression, can be treated with psychosocial therapies (sessions with a 

provider designed to reduce symptoms and improve functioning); 

psychotropic medication (medications that affect mood, thought, or 

behavior); or a combination of both. Many of these children, however, 

lack access to the treatments they need to help them manage or 

overcome their emotional or behavioral problems.2

 

1

In this report, the term “mental health condition” includes all mental, emotional, and 

behavioral disorders that are included in the Diagnostic and Statistical Manual of Mental 

Disorders, with the exception of pervasive developmental disabilities (such as autism) and 

substance use disorders, which we excluded from our study. Examples of disorders that 

are included are attention deficit hyperactivity disorder (ADHD); anxiety disorders, 

including post-traumatic stress disorder; mood disorders, including depression and bipolar 

disorder; schizophrenia; and eating disorders.

In addition, child 

mental health advocates, providers, and researchers have expressed 

concern about the increase in the prescribing of psychotropic medications 

for children, in part because there is limited evidence available regarding 

short- and long-term safety and efficacy for some types of medications, 

2

According to data from the Department of Health and Human Services’ (HHS) 2007 

National Survey of Children’s Health, about 40 percent of children ages 2 through 17 who 

needed treatment from a mental health professional did not receive it during the previous 

year.

 
 

Page 2 GAO-13-15 Children’s Mental Health

particularly for combinations of medications. Mental health experts are 

especially concerned about the recent increase in prescribing of 

antipsychotic medications—psychotropic medications developed to treat 

conditions such as schizophrenia and bipolar disorder—in part because 

these medications can cause very serious side effects, such as rapid 

weight gain and the development of diabetes.

Concerns about access to appropriate mental health services and the 

increased prescribing of psychotropic medications may be compounded 

for children in Medicaid, the State Children’s Health Insurance Program 

(CHIP),3 and foster care—children who may be at higher risk of mental 

health conditions than other children.4 Children in foster care, most of 

whom are eligible for Medicaid, are an especially vulnerable population 

because often they have been subjected to traumatic experiences 

involving abuse or neglect and they may suffer from multiple, serious 

mental health conditions.5 Although state Medicaid programs are 

generally required to cover services to screen children for mental health 

problems and to provide treatment for any identified conditions, we 

previously reported that it can be difficult for physicians to find mental 

health specialists to whom they can refer children in Medicaid.6

 

3

Medicaid is a federal-state program for certain categories of low-income children, 

families, and individuals. CHIP is also a federal-state program and provides health care 

coverage to children living in families whose incomes exceed the eligibility requirements 

for Medicaid. In 2010, there were an estimated 42 million children enrolled in Medicaid 

and CHIP.

 Concerns 

for children in Medicaid and CHIP are also related to studies that have 

shown that publicly insured children are prescribed psychotropic 

4

Data from the Centers for Disease Control and Prevention’s National Health Interview 

Survey showed that a higher proportion of children in Medicaid and CHIP had difficulties in 

emotion, concentration, or behavior than privately insured children—about 8 percent 

versus 4 percent, respectively, during 2001 through 2007. The Administration for Children 

and Families’ National Survey of Child and Adolescent Wellbeing II estimated that about 

32 percent of children in foster homes had a behavior problem during 2008 through 2009.

5

In 2010, about 408,000 children were in foster care. This estimate includes children who 

may live with relatives informally; such children are not included in the definition of foster 

care we used in this report. See U.S. Department of Health and Human Services, 

Children’s Bureau, Foster Care Statistics 2010 (Washington, D.C.: 2012).

6

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

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

Page 3 GAO-13-15 Children’s Mental Health

medications at higher rates than privately insured children.7 We reported 

in 2011 that children in foster care take these medications at higher rates 

than other children in Medicaid, and we recommended that HHS consider 

issuing guidance to state Medicaid and child welfare agencies on best 

practices for monitoring psychotropic medication prescriptions for foster 

children.8

Several agencies in the Department of Health and Human Services 

(HHS) have responsibilities related to children’s mental health. The 

Centers for Medicare & Medicaid Services (CMS) oversees, and jointly 

finances with the states, the Medicaid and CHIP programs, which provide 

health coverage for low-income children.9 State Medicaid programs are 

required by federal law to provide coverage for certain health services, 

which may include mental health services, for most children through the 

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 

benefit.10

 

7

See, for example, A. Martin et al., “Use of Multiple Psychotropic Drugs by MedicaidInsured and Privately Insured Children,” Psychiatric Services, vol. 53, no. 12 (2002).

The Administration for Children and Families (ACF) provides 

funding for and oversees states’ child welfare programs, which are 

responsible for monitoring and coordinating mental health services for

foster children, among other things. The Substance Abuse and Mental 

Health Services Administration (SAMHSA) works to increase the quality 

and availability of mental health treatments, such as by awarding grants 

that support the development of community-based services for children 

with mental health conditions, including children in foster care. Other HHS 

agencies, including the National Institutes of Health (NIH), Food and Drug 

Administration (FDA), Agency for Healthcare Research and Quality 

(AHRQ), and Centers for Disease Control and Prevention (CDC), 

8

We recommended that HHS 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. See GAO, Foster Children: HHS 

Guidance Could Help States Improve Oversight of Psychotropic Prescriptions, 

GAO-12-201 (Washington, D.C.: Dec. 14, 2011).

9

States may administer their CHIP programs as expansions of their Medicaid programs, 

as standalone CHIP programs, or as a combination.

10While states must also provide EPSDT services to CHIP children who are enrolled as 

part of an expansion of their state’s Medicaid program, CHIP children who are enrolled 

under a separate CHIP plan are not entitled to EPSDT services.
 

Page 4 GAO-13-15 Children’s Mental Health

conduct, fund, or review research that seeks to expand the knowledge of 

children’s mental health conditions and treatments.

Because of your interest in children’s access to appropriate mental health 

treatments, you asked us to provide information on mental health 

services, including medications, for children in Medicaid, CHIP, and foster 

care nationwide and on the federal investment in children’s mental health 

research. This report examines (1) the use of psychotropic medications 

and other mental health services by children nationwide in Medicaid and 

CHIP, and related CMS initiatives; (2) HHS information on the use of 

psychotropic medications and other mental health services by foster 

children nationwide, and related HHS initiatives; and (3) the amount HHS 

has invested in research to study children’s mental health conditions and 

treatments.

To examine the use of psychotropic medications and other mental health 

services by children in Medicaid and CHIP, we analyzed nationwide data 

from the Medical Expenditure Panel Survey (MEPS) from 2007 through 

2009.11 We included children ages 0 through 20 who were enrolled in 

Medicaid or CHIP for at least 10 months in a calendar year, excluding 

children in foster care.12 Because MEPS does not differentiate between 

children in Medicaid and children in CHIP, we could not report on these 

programs separately. For the purposes of this report, we used the term 

Medicaid to refer to both Medicaid and CHIP. We analyzed MEPS data 

for privately insured children as a point of comparison.13 Specifically, we 

examined annual rates of psychotropic medication use, numbers and 

types of medications taken,14

 

11MEPS is a nationally representative household survey conducted by AHRQ that collects 

information on individuals’ use of medical services by setting and provider type. 

Specifically, we examined children’s use of psychotropic medications, mental healthrelated office visits, and therapy visits. We pooled 3 years of data to obtain a sample size 

large enough to conduct our analyses.

and utilization of office-based mental health 

services, such as visits to a psychiatrist or psychologist. We also 

examined receipt of mental health services by children who had a 

12State Medicaid programs generally cover children under 21 years of age.

13We included children who were enrolled in private insurance for at least 10 months in a 

calendar year.

14MEPS reports on all medications taken in a calendar year but does not provide 

information on whether medications were taken concomitantly—that is, in combination 

with other medications.
 

Page 5 GAO-13-15 Children’s Mental Health

potential mental health need. To identify children with a potential mental 

health need, MEPS employs a standardized psychometric scale designed 

to measure emotional and behavioral impairment.15 Using this scale, we 

identified the percentage of children whose emotions or behavior, as 

reported by their parents, indicated a potential need for mental health 

services.16 This measure does not indicate the level of treatment a child 

might require; rather, it identifies the percentage of children whose 

emotions or behavior indicated a need for, at a minimum, a mental health 

evaluation. Estimates using MEPS may be conservative because the 

survey excludes children in institutional settings, such as psychiatric 

hospitals, who are likely to be high utilizers of psychotropic medications 

and mental health services. In addition, MEPS relies on self-reporting by 

parents for utilization of medications and services, which may be 

understated because parents may be reluctant to report such information 

due to the stigma that can be associated with mental health conditions.17

We reviewed the MEPS survey instruments and methodology and 

determined that the data were sufficiently reliable for our purposes. (See 

app. I for more information about the methodology we used to analyze 

MEPS data.) We also reviewed relevant literature on children’s mental 

health and interviewed CMS officials and state mental health program 

directors to learn about their efforts to monitor prescribing of psychotropic 

medications and to increase access to mental health services among 

children.

 

15The psychometric scale is known as the Columbia Impairment Scale and consists of 13 

questions designed to assess emotional distress and behavioral impairment. The 

maximum score is 52, and children who score 16 or higher are considered to have a 

potential mental health need. Parents of children ages 5 through 17 are asked to rate on a 

scale of 0 to 4 (0 being no problem and 4 being a very big problem) how much of a 

problem their child has in several areas, including getting along with family members, 

being involved in activities, and behaving at school. The scale is considered to be valid 

and reliable for use in surveys. See H. R. Bird et al., “The Columbia Impairment Scale 

(CIS): Pilot Findings on a Measure of Global Impairment for Children and Adolescents,” 

International Journal of Methods in Psychiatric Research, vol. 3, no. 3 (1993).

16The preferred respondent for the interview is the person, 18 years or older, who is most 

knowledgeable about the family’s health care and who is keeping records about health 

care use and expenses. For the purposes of this report, we consider this person to be the 

child’s parent or guardian, although this may not always be the case.

17See, S. Zuvekas, “Prescription Drugs and the Changing Patterns of Treatment for 

Mental Disorders, 1996-2001,” Health Affairs, vol. 24, no. 1 (2005).
 

Page 6 GAO-13-15 Children’s Mental Health

To examine HHS information on the use of psychotropic medications and 

other mental health services by foster children nationwide, we reviewed

two reports published by ACF. Both reports presented the results of the 

National Survey of Child and Adolescent Well-being II (NSCAW II), a 

nationally representative longitudinal survey of children ages 0 through 

19 who were in contact with the child welfare system.18 The NSCAW II 

surveys occurred in multiple phases during 2008 through 2011. One 

report, published in November 2011, summarized NSCAW II data 

collected during phase 1, from March 2008 through September 2009.19

The second ACF report was a research brief on the use of psychotropic 

medication by children in contact with the child welfare system, which was 

published in 2012 and used NSCAW II data collected during phase 2, 

from October 2009 through January 2011.20 The survey collected 

information on children who either lived in out-of-home foster care 

placements or remained in the care of their parents or relatives.21 For this 

report, we considered children in foster care to be those who lived in outof-home foster care placements—that is, in nonrelative foster homes—

formal kin care,22 group homes, or residential treatment centers.23

 

18According to ACF, the child welfare system is a group of government services designed 

to promote the well-being of children, including foster children. Contact with the child 

welfare system can stem from reports of possible child abuse or neglect and from 

requests by families for help protecting their children.

We 

reported ACF’s estimates of foster children’s use of psychotropic 

19H. Ringeisen et al., NSCAW II Baseline Report: Children’s Services, OPRE Report 

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

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

2011).

20L.F. Stambaugh et al., Psychotropic Medication Use by Children in Child Welfare, OPRE 

Report #2012-33 (Washington, D.C.: Office of Planning, Research and Evaluation, 

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

2012).

21Child welfare systems can arrange for children to live with relatives, foster families, 

adoptive families, or other permanent placements when the child is not safe at home.

22Formal kin care is a living arrangement where the child is placed under legal custody of 

the state, but in physical custody of a relative.

23Group homes and residential treatment centers provide structured 24-hour care in a 

group setting to children with physical or behavioral needs. Residential treatment centers 

are inpatient facilities other than a hospital that provide specialized services to children, 

such as psychiatric services.
 

Page 7 GAO-13-15 Children’s Mental Health

medications and of receipt of mental health services by foster children.24

ACF’s reports identified children with a potential mental health need by 

selecting children whose scores were above a certain level on one of five 

standardized psychometric scales that were used in NSCAW II and were 

designed to measure emotional or behavioral problems. These scales 

were the Child Behavior Checklist, which is based on caregiver reports; 

the Youth Self-Report; the Teacher’s Report Form; the Children’s 

Depression Inventory; and the Trauma Symptom Checklist for Children.25

Questions in these scales were asked of the child, caregiver, or teacher, 

depending on the scale.26 We reviewed ACF’s report on psychotropic 

medication use to examine the extent to which the children ACF identified 

as having a potential mental health need received any mental health 

services within the past 12 months (or since the start of the child’s living 

arrangement, if less than 12 months).27 We also interviewed officials from 

ACF, AHRQ, and SAMHSA and representatives of provider organizations 

and mental health and child welfare advocacy groups to obtain 

information on the challenges foster children face in receiving appropriate 

mental health treatments.28

 

24The survey asked caregivers about the child’s receipt of mental health services in the 

previous 12 months or since the start of the living arrangement, if less than 12 months. 

Mental health services, which ACF refers to as specialty mental health services in OPRE 

Report #2012-33, include treatments received at an outpatient drug or alcohol clinic, 

mental health center, community health center, therapeutic nursery, hospital psychiatric 

unit, detox unit, inpatient unit, hospital emergency room, residential treatment center, 

group home, or school-based setting. Mental health services can also be received from a 

private mental health professional or family doctor, or during in-home counseling or crisis 

services.

Finally, to examine related HHS initiatives, we 

reviewed HHS documents and interviewed agency officials to obtain 

information about HHS’s activities to help states promote appropriate use 

of mental health treatments for foster children.

25According to ACF, these scales are reliable assessments of children’s behavioral and 

emotional problems.

26The Youth Self-Report, Children’s Depression Inventory, and Trauma Symptom 

Checklist for Children were all asked of the child.

27Stambaugh et al., OPRE Report #2012-33, 6.

28We spoke with, among other organizations, the American Academy of Child & 

Adolescent Psychiatry, the American Academy of Pediatrics, the American Psychological 

Association, the National Association of Social Workers, and the Child Welfare League of 

America. 
 

Page 8 GAO-13-15 Children’s Mental Health

To describe HHS’s investment in research to study children’s mental 

health conditions and treatments, we requested data on research 

activities and interviewed officials from selected HHS agencies that 

conduct or sponsor children’s mental health research: NIH, FDA, AHRQ, 

and CDC.29 We asked each agency for a list of research projects30 that 

were conducted internally by agency staff or conducted by external 

researchers and were funded by the agency for all or part of fiscal years 

2008 through 2011.31

• Include projects that tested children, as well as projects that tested 

both children and adults, such as family studies.

We used the following inclusion and exclusion 

criteria for our analysis:

32

• Exclude research involving animals, projects that primarily studied 

substance abuse or pervasive developmental disorders such as 

autism, and large-scale surveys examining the prevalence of mental 

health conditions or mental health service utilization.33

• Exclude grants that did not specifically fund research, such as grants 

supporting student training or scientific conferences.

 

29We also spoke with officials from CMS, ACF, and SAMHSA, who told us that these 

agencies do not conduct or sponsor children’s mental health research meeting our criteria.

30For the purposes of this report, we use the term “research projects” to encompass both 

internally conducted studies and external grants, contracts, and cooperative agreements.

31We included projects that began before fiscal year 2008 or extended past fiscal year 

2011. NIH, AHRQ, and CDC were able to provide grant funding information on an annual 

basis, but FDA did not provide information broken down by fiscal year for their research 

projects, so some of the funding attributed to FDA may have been spent before or after 

our fiscal year 2008 through 2011 time frame. 

32Agencies differed in their definition of a child. For example, NIH defines child as 0 to 20 

years of age, while FDA defines child as 0 to 16. 

33AHRQ and CDC sponsor large household surveys that have questions that address 

children’s mental health, but these surveys also cover topics other than mental health 

conditions in children. We excluded these surveys from our analysis due to the difficulty of 

determining how much of the overall survey funding was directed toward developing, 

testing, and fielding the specific questions on children’s mental health. Similarly, we did 

not include NIH’s National Children’s Study, a large prospective study of the effects of 

environment on children’s health. However, individual grants and contracts awarded by 

NIH may have used survey methodology, and we did not attempt to exclude these during 

analysis.
 

Page 9 GAO-13-15 Children’s Mental Health

NIH was unable to provide an agency-wide estimate of spending on 

children’s mental health research projects that met our criteria. Therefore 

we requested data individually from the two institutes at NIH that, 

according to agency officials, sponsor and conduct most of the children’s 

mental health research—the National Institute of Mental Health (NIMH) 

and the Eunice Kennedy Shriver National Institute of Child Health & 

Human Development (NICHD). We assessed the reliability of data from 

NIMH and NICHD by selecting a sample of research projects from each 

to determine whether they met our criteria. When some research projects 

in the NIMH sample appeared not to meet our criteria, we examined the 

primary research focus identified for each project. We then systematically 

excluded all projects with a primary research focus that did not appear to 

meet our criteria, such as schizophrenia in adults. On the basis of our 

review of the NIMH and NICHD samples, we determined that the data 

were sufficiently reliable for the purposes of our report. Because other 

institutes and centers at NIH may also have sponsored children’s mental 

health research, we have likely underestimated NIH’s total investment. 

We also determined that data from FDA, AHRQ, and CDC were 

sufficiently reliable for our purposes. We also spoke with officials from 

HHS agencies, representatives from provider and mental health advocacy 

groups, and researchers to better understand research needs in 

children’s mental health.

We conducted this performance audit from November 2011 to December

2012 in accordance with generally accepted government auditing 

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

obtain sufficient, appropriate evidence to provide a reasonable basis for 

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

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Children with mental health conditions can be treated with psychotropic 

medications, psychosocial therapies, or a combination of both.

Psychotropic medications can be very effective in treating children with 

mental health conditions, but they may also produce side effects, some of 

which can be serious. For example, according to the American Academy 

of Child & Adolescent Psychiatry (AACAP), medications used to treat 

ADHD can reduce symptoms such as hyperactivity in children, as well as 

improve their attention and increase their ability to get along with others. 

These medications have been widely tested in children and are generally 

Background 

Psychotropic Medications
 

Page 10 GAO-13-15 Children’s Mental Health

considered safe; however, ADHD medications have also been associated 

with side effects ranging from mild to serious, such as sleeplessness, loss 

of appetite, tics, agitation, hallucinations, liver problems, and suicidal 

thoughts.

Research has shown that foster children take psychotropic medications at 

much higher rates than other children covered by Medicaid. For example, 

we previously reported that while about 5 to 10 percent of nonfoster 

children in five states’ Medicaid programs took a psychotropic medication 

in 2008, rates among children in foster care were about 20 to 

39 percent.34 The use of five or more medications concomitantly (that is, 

at the same time), while rare, was also higher among children in foster 

care.35

Studies have shown that rates of psychotropic medication use among all 

children have increased. For example, one study found that the 

percentage of children’s doctor visits involving psychotropic medications 

increased by 75 percent from 1996 to 2007—from 6 percent to about 

11 percent.

We reported that several factors may have contributed to the 

higher utilization rates among foster children, such as the increased 

prevalence and greater severity of mental health conditions among these 

children.

36 Among these visits, those involving two or more 

medications rose from about 14 percent to about 20 percent.37 Experts 

have identified a number of potential factors that could account for the 

increased use of psychotropic medications. For example, AACAP’s 

guidelines on the use of psychotropic medications for children identified 

explanations such as the expanding evidence base demonstrating the 

efficacy of these medications for children38

 

34See, 

and the efforts of 

GAO-12-201. This analysis was based on fee-for-service Medicaid drug claims.

35Concomitant use of five or more medications ranged from 0.13 to 1.33 percent in foster 

children in the five states, compared with 0.01 to 0.07 in nonfoster children. See 

GAO-12-201. 

36J. S. Comer, M. Olfson, and R. Mojtabai, “National Trends in Child and Adolescent 

Psychotropic Polypharmacy in Office-Based Practice, 1996-2007,” Journal of the 

American Academy of Child & Adolescent Psychiatry, vol. 49, no. 10 (2010).

37The study also found that visits that were paid for by a public insurance program, such 

as Medicaid, were more likely to involve a prescription for multiple medications than were 

visits paid for by private insurance.

38However, AACAP noted that there is a lack of research on the efficacy of taking multiple 

psychotropic medications concomitantly.
 

Page 11 GAO-13-15 Children’s Mental Health

pharmaceutical companies to market drugs to prescribers and 

consumers.39

Children’s use of antipsychotic medications has also increased in recent 

years. For example, a recent analysis by a large pharmacy benefit 

manager40 found that use of antipsychotics among insured children ages 

10 through 19 increased from about 0.5 percent in 2001 to about 

1 percent in 2010.

41 Some studies have indicated that antipsychotic 

medications are increasingly being prescribed for off-label purposes—that 

is, prescribed for conditions and in populations that are not included in 

FDA-approved labels.42 For example, one study found that in 2004, 

almost 75 percent of children enrolled in Medicaid who were taking 

antipsychotic medications had mental health conditions other than those 

included in the drugs’ labels, most commonly ADHD. Although doctors 

may prescribe drugs off-label, the Congressional Research Service has 

noted that such prescribing may increase the risk of children receiving 

ineffective medications, receiving dosages that are too high or too low, or 

experiencing side effects that are unique to children.43

 

39J. Walkup et al., “Practice Parameter on the Use of Psychotropic Medication in Children 

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

vol. 48, no. 9 (2009).

While 

antipsychotics can be effective medications for some children, their side 

effects can be very serious and include increases in cholesterol, rapid 

weight gain, and the development of diabetes or irreversible movement 

disorders. Mental health researchers and others have stated that there is 

a need for further research on the safety and effectiveness of 

antipsychotics for children, particularly the long-term effects.

40Pharmacy benefit managers are firms that administer prescription drug benefits on 

behalf of health insurance plans.

41This estimate of antipsychotic use is specific to second-generation antipsychotics, also 

known as atypical antipsychotics. Second-generation antipsychotics have largely replaced 

first-generation antipsychotics in the past two decades. See America’s State of Mind 

Report (Medco Health Solutions, Inc. 2011).

42See S. Crystal et al., “Broadened Use of Atypical Antipsychotics: Safety, Effectiveness, 

and Policy Challenges,” Health Affairs, vol. 28, no. 5 (2009).

43Congressional Research Service, FDA’s Authority to Ensure That Drugs Prescribed to 

Children Are Safe and Effective (Washington, D.C.: June 25, 2012).
 

Page 12 GAO-13-15 Children’s Mental Health

Furthermore, some studies found that the prescribing of antipsychotics 

was higher among publicly insured children than among privately insured 

children, and even higher among foster children. One study found that 

children enrolled in Medicaid were prescribed antipsychotic medications 

at over four times the rate of children with private insurance in 2004.44 In 

addition, AHRQ funded a study of antipsychotic prescribing based on 

Medicaid claims from 13 states, which found that utilization of 

antipsychotics in 2007 was much higher among foster children than 

among nonfoster children in Medicaid—12.4 percent on average versus 

1.4 percent, respectively.45 Prescribing of antipsychotics is a concern for 

CMS and state Medicaid programs not only because of safety issues, but 

also because these medications are costly. They represented the single 

largest drug expenditure category for Medicaid in 2007—over 

$2.8 billion.46

One reason for particular concern about growing use of antipsychotics 

and other psychotropic medications in children is that manufacturers do 

not always test medications for use in children. Manufacturers are 

responsible for conducting clinical trials and demonstrating their products’ 

safety and efficacy to FDA, which is responsible for making decisions 

about whether and how medications can be marketed for children and for 

ensuring that manufacturers incorporate information from pediatric clinical 

trials into medication labels when required. However, because children 

are a small part of the overall population and physicians can prescribe 

medications off-label to children even if the medications have been tested 

only in adults, manufacturers may lack economic incentives to conduct 

 

44S. Crystal et al., “Broadened Use of Atypical Antipsychotics.” 

45Medicaid 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 (Rutgers, New Jersey: July 2010). 

Another recent AHRQ-funded analysis of prescribing rates for foster children using 

Medicaid claims from 48 states found that 11.8 percent of foster children used 

antipsychotics in 2007. See, D. Rubin et al., “Interstate Variation in Trends of Psychotropic 

Medication Use among Medicaid-Enrolled Children in Foster Care,” Children and Youth 

Services Review, vol. 34 (2012).

46This total applies only to Medicaid enrollees who were not dually eligible for Medicare. 

See J. Verdier, A. Bagchi, and D. Esposito, Prescription Drug Use and Cost among 

Medicaid Beneficiaries with Disabilities and Chronic Illnesses, a report prepared for the 

Centers for Medicare & Medicaid Services (September 2011).
 

Page 13 GAO-13-15 Children’s Mental Health

trials with children. According to a recent analysis by FDA scientists, 

fewer than half of all medications were adequately labeled for pediatric 

use in 2009.47 The Best Pharmaceuticals for Children Act (BPCA) and the 

Pediatric Research Equity Act (PREA)48 address testing of medications in 

children by authorizing FDA to provide incentives for or require 

manufacturers to conduct pediatric studies in certain circumstances.49

(For more information on BPCA and PREA and label changes for 

psychotropic medications resulting from these laws, see app. III.)

Psychosocial therapies are mental health treatments that generally 

involve sessions with a mental health professional that are designed to 

reduce patients’ emotional or behavioral symptoms. Such therapies may 

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

treat children with mental health conditions.50

 

47Labeling was considered adequate if it stated that the drug was approved for pediatric 

use or that the drug had been studied in children, or if the label included safety, efficacy, 

or dosing information for all pediatric age groups as appropriate. See A. Sachs et al., 

“Pediatric Information in Drug Product Labeling,” Journal of the American Medical 

Association, vol. 307, no. 18 (2012). 

Psychosocial therapies that 

have been shown to be effective in treating mental health conditions may 

be referred to as evidence-based therapies (EBT). While there is no 

standard definition of what constitutes “evidence-based,” some federal 

agencies and provider organizations evaluate and compile information on 

available therapies. For example, SAMHSA maintains the National 

Registry of Evidence-based Programs and Practices, a list of treatments 

that have been assessed by independent evaluators and rated on the 

48For BPCA, see 21 U.S.C. § 355a and 42 U.S.C. § 284m. For PREA, see 21 U.S.C. 

§§ 355c, 355d. 

49Under BPCA, manufacturers may opt to receive an additional 6 months of exclusive 

marketing for a medication from FDA in exchange for conducting pediatric studies. Under 

PREA, subject to certain exceptions, manufacturers must conduct pediatric studies before 

a medication can be marketed.

50Several large, federally funded studies have demonstrated that treatment with a 

combination of a psychosocial therapy and a psychotropic medication can be more 

effective than either treatment is alone for certain conditions. For example, NIMH funded a 

large multi-site study that found that treating children with anxiety with both an 

antidepressant medication and cognitive behavioral therapy was superior to either 

medication or therapy alone. See J. Walkup et al., “Cognitive behavioral therapy, 

sertraline, or a combination in childhood anxiety,” New England Journal of Medicine, 

vol. 359, no. 26 (2008). 

Psychosocial Therapies
 

Page 14 GAO-13-15 Children’s Mental Health

strength of the evidence showing their effectiveness. Provider 

organizations may also make recommendations to providers on which 

treatments to use. For example, AACAP publishes practice parameters 

that contain recommendations for treating specific disorders, with each 

recommendation labeled to indicate the strength of the evidence 

underlying it.

Although psychosocial therapies may be effective for many children, the 

Institute of Medicine and others have reported that a shortage of mental 

health providers in general is a major factor affecting access to services, 

especially for children.51 Furthermore, finding a mental health professional 

who has been trained to provide a specific EBT can be a challenge 

because training in EBTs is not uniformly required in medical and 

professional schools.52

Children enter foster care when they have been removed from their 

parents or guardians and placed under the responsibility of a state child 

welfare agency, often because of maltreatment at home. Removal from 

the home can occur for multiple reasons, including parental violence, 

substance abuse, severe depression, or incarceration. According to ACF, 

46 percent of children investigated by child welfare services came to a 

state’s attention primarily because of a report of neglect, and 27 percent 

had experienced physical abuse as the most serious form of recorded 

maltreatment.53

 

51Institute of Medicine of the National Academies, Committee on Crossing the Quality 

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

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

(Washington, D.C.: 2006).

Other children are referred when their own behaviors or 

conditions are beyond the control of their families or they pose a threat to 

themselves or the community. Children in foster care can experience 

traumatic stress due to maltreatment experienced at home as well as the 

52A 2006 survey of graduate programs in psychology, psychiatry, and social work found 

that although programs offered electives in EBTs, few programs required students to do 

both coursework and supervised clinical work in EBTs. See M. Weissman et al., “National 

Survey of Psychotherapy Training in Psychiatry, Psychology, and Social Work,” Archives 

of General Psychiatry, vol. 63 (2006).

53See National Survey of Child and Adolescent Well-being (NSCAW), No. 7: Special 

Health Care Needs among Children in Child Welfare (Washington, D.C.: Office of 

Planning, Research and Evaluation, Administration for Children and Families, U.S. 

Department of Health and Human Services).

Foster Care
 

Page 15 GAO-13-15 Children’s Mental Health

trauma of being removed from their homes. Trauma significantly 

increases the risk of mental health problems, difficulties with social 

relationships and behavior, physical illness, and poor school 

performance. Furthermore, child mental health experts have stated that 

the traumatic stress symptoms foster children may experience are often 

the same as symptoms that can indicate other mental health conditions, 

which may lead to misdiagnosis and inappropriate treatments.

When children are taken into foster care, the state’s child welfare agency 

becomes responsible for determining where the child should live and 

providing the child with needed supports. The agency may place the 

foster child in the home of a relative, with unrelated foster parents, or in a 

group home or residential treatment center, depending on the child’s 

needs. The agency is responsible for arranging needed services, 

including mental health services.54 Federal officials, providers, and child 

and mental health advocacy groups have identified several factors that 

create challenges for foster children in receiving appropriate mental 

health services. Foster children can experience frequent changes in their 

living placements, which can lead to a lack of continuity in mental health 

care, and new providers may not have the medical history of the patient.55

As a condition of receiving federal child welfare grant funding, state child 

welfare agencies must annually submit plans to ACF that, among other 

things, address the mental and other health needs of foster children. In 

2011, the Child and Family Services Improvement and Innovation Act 

(Child Improvement Act) required states, as part of these plans, to identify 

protocols for monitoring foster children’s use of psychotropic medications 

This lack of stability can lead to treatment disruptions and can increase 

the number of medications prescribed. Coordinating mental health care 

for foster children may be difficult for both the medical provider and the 

case worker because multiple people are making decisions on the child’s 

behalf. In addition, caseworkers in child welfare agencies may have large 

caseloads, making it difficult for them to ensure that foster children’s 

mental health needs are being met.

 

54Most foster children are eligible for Medicaid, which generally entitles them to needed 

health services under EPSDT, including mental health services.

55ACF reported that foster children moved an average of 1.6 times in an 18-month period 

and that some children changed placements as many as 12 times in that same period. 

See Stambaugh et al., OPRE Report #2012-33, 2.
 

Page 16 GAO-13-15 Children’s Mental Health

and to address how emotional trauma associated with children’s 

maltreatment and removal from their home will be monitored and 

treated.56 As part of their June 2012 Annual Progress and Service 

Reports to ACF, states provided information on their plans for monitoring 

psychotropic medication prescribing and treatment of emotional trauma 

for foster children. Prior to the Child Improvement Act, many states had 

already implemented policies and practices regarding prescribing 

psychotropic medications for foster children, such as issuing written 

guidelines for prescribers, collecting data to monitor prescribing, requiring 

informed consent from relevant parties before filling a prescription, and 

requiring consultation with a mental health specialist for prescriptions 

exceeding certain dosage thresholds.57

On average, 6.2 percent of noninstitutionalized children in Medicaid 

nationwide took psychotropic medications during a calendar year from 

2007 through 2009, and 21 percent of those children took an 

antipsychotic medication. The estimates for privately insured children 

were lower. About 14 percent of children in Medicaid had a potential need 

for mental health services, and over two-thirds of them did not receive 

any services. CMS and states have made efforts to ensure that children 

receive appropriate mental health services, but CMS’s ability to monitor 

their receipt of services for which they were referred is limited because 

CMS does not collect information from states on whether children in 

Medicaid have received services for which they were referred.

 

56Pub. L. No. 112-34, §§ 101(b)(1), (2), 125 Stat. 369 (2011) (codified at 42 U.S.C. 

§§ 622(b)(15)(A)(ii), (v)).

57According to a 2010 Tufts University study, 26 states had written guidelines on the use 

of psychotropic medications among foster children and 13 states were developing them at 

that time. See Multi-State Study on Psychotropic Medication Oversight in Foster Care

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

previously reviewed six states and reported that, although states are not required to follow 

best principle guidelines published by AACAP, none of them had monitoring programs that 

met all of these guidelines on monitoring psychotropic medication prescriptions for 

children. See GAO-12-201. 

Children in Medicaid 

Took Psychotropic 

Medications at a 

Higher Rate Than 

Those with Private 

Insurance, and Most 

Children in Medicaid 

with a Potential 

Mental Health Need 

Did Not Receive 

Services 
 

Page 17 GAO-13-15 Children’s Mental Health

Our analysis of MEPS data from 2007 through 2009 found that, on 

average, 6.2 percent of children in Medicaid nationwide—those who were 

not in institutions or in foster care and were ages 0 through 20—took at 

least one psychotropic medication during a calendar year.58 The 

comparable rate for privately insured children was lower—4.8 percent.59

The utilization rate was over twice as high for boys as for girls in 

Medicaid—8.4 percent versus 3.9 percent.60 There is a higher prevalence 

among boys of certain mental health disorders for which psychotropic 

medications are prescribed,61

 

58For purposes of this report, we refer to children in Medicaid and CHIP as children in 

Medicaid, because the MEPS data do not distinguish between children in Medicaid and 

CHIP. 

which is one possible explanation for this 

difference. Among children in Medicaid who took psychotropic 

medications, utilization was highest among youth ages 18 through 20—

12.7 percent—and lowest among children under age 5—less than 

1 percent. Utilization rates for privately insured children were highest 

among children ages 12 through 17—7.5 percent. (See app. III for moredetailed information on children who took psychotropic medications.)

These estimates of medication use may be lower than other estimates because MEPS 

excludes children living in institutional settings and because the survey relies on selfreporting by parents, whose information on the utilization of medications and services may 

be understated due to the stigma that can be associated with mental health conditions. In 

addition, these estimates may be lower because we excluded from our analysis children 

with developmental disorders such as autism, and such children may be taking 

psychotropic medications. However, some children with autism take medications for other 

mental health conditions. These children would likely have been included in our analysis.

Finally, these estimates do not include foster children, whom we excluded from this

analysis. We previously reported that rates of psychotropic medication usage by children 

in Medicaid ranged from 5 percent to 10 percent across five states, on the basis of an 

analysis of fee-for-service claims. See GAO-12-201. 

59The difference between children in Medicaid and privately insured children was 

statistically significant.

60For privately insured children, utilization was also higher among boys than girls— 

6.3 percent versus 3.2 percent, respectively. 

61For example, the prevalence of ADHD may be as much as six times higher among 

prepubescent boys than among girls, and the prevalence of schizophrenia in adolescents 

is estimated to be twice as high among boys. See J. Seida et al., First- and SecondGeneration Antipsychotics for Children and Young Adults. Comparative Effectiveness 

Review No. 39. AHRQ Publication No. 11(12)-EHC077-EF (Rockville, Md.: Agency for 

Healthcare Research and Quality, 2012).

About 6 Percent of 

Children in Medicaid Took 

Psychotropic Medications, 

and They Were over Twice 

as Likely as Privately 

Insured Children to Take 

an Antipsychotic
 

Page 18 GAO-13-15 Children’s Mental Health

Nationwide, almost half of children in Medicaid who took psychotropic 

medications took multiple psychotropic medications in a 1-year period. 

Specifically, our analysis found that 28 percent of the children in Medicaid 

who took psychotropic medications took two medications within a year, 

and 16 percent took three or more. Among privately insured children who 

took psychotropic medications, 22 percent took two medications within a 

year, and 11 percent took three or more.62

The most common types of psychotropic medications taken by children 

were ADHD medications, antidepressants, and antipsychotics. We found 

that, of children who took psychotropic medications, about three-fourths 

took ADHD medications. According to a recent analysis by FDA officials, 

utilization of ADHD medications increased 46 percent from 2002 to 2010, 

and methylphenidate, a stimulant used to treat ADHD, was the most 

commonly prescribed medication for adolescents ages 12 through 17.

This finding may reflect 

concomitant use of multiple medications—that is, medications taken in 

combination—or providers prescribing different drugs over time to find 

one that works best for the child.

63

Antidepressants were the second most common type of medication 

taken—about one-fourth of the children in Medicaid and one-third of 

privately insured children who were taking psychotropic medication took 

an antidepressant. (See table 1.)

 

62Estimates were not significantly different between Medicaid and private insurance. 

Because MEPS does not allow for analysis of concomitant medication use, we do not 

know whether medications taken in the same year were taken concurrently or 

sequentially. Sequential use is not uncommon because different medications or dosages 

might be tried before one is found that works for a particular child. 

63G. Chai et al., “Trends of Outpatient Prescription Drug Utilization in US Children, 2002-

2010,” Pediatrics, vol. 130, no. 1 (2012).
 

Page 19 GAO-13-15 Children’s Mental Health

Table 1: Most Common Types of Psychotropic Medications Taken by Children 

Covered by Medicaid or Private Insurance, Ages 0-20, 2007-2009

Percentage of children who took the type of medication among children who took 

any psychotropic medication

Type of medication Medicaid Private insurance

ADHD medication 78% 74%

Antidepressant 24 33

Antipsychotic 21 a 10

Source: GAO analysis of HHS data.

Notes: Data are from the Medical Expenditure Panel Survey. The percentages do not sum to 100 

because children can take multiple medications. Differences between children covered by Medicaid 

and those covered by private insurance were not statistically significant, unless otherwise noted. 

Percentages represent estimated average annual rates.

a

The difference between children in Medicaid and privately insured children was statistically 

significant.

Our analysis also found that children in Medicaid were over twice as likely 

as privately insured children to take an antipsychotic medication. Overall, 

about 1.3 percent of children in Medicaid and 0.5 percent of privately 

insured children took antipsychotics.64

Our analysis also found that many children who took psychotropic 

medication did not receive other mental health services during the same 

year. Most children who took psychotropic medication did not receive 

psychosocial therapy or counseling in the same year—61 percent of 

Medicaid children and 66 percent of privately insured children.

Regardless of whether children 

were covered by Medicaid or private insurance, the majority of children 

who took an antipsychotic were males ages 6 through 17.

65 While not 

all children would necessarily benefit from both medication and therapy, 

AACAP has stated that medication alone is rarely adequate treatment for 

children with complex mental health needs.66

 

64This difference was statistically significant.

Furthermore, 26 percent of 

Medicaid children and 30 percent of privately insured children who took 

psychotropic medication did not have any mental health-related office 

65Differences between children in Medicaid and those with private insurance were not 

statistically significant.

66See The Mental Health Needs of Children in Foster Care, accessed September 7, 2012, 

http://www.aacap.org/cs/2011_press_releases/the_mental_health_needs_of_children_in_f

oster_care. 
 

Page 20 GAO-13-15 Children’s Mental Health

visits in the same year.67 This finding suggests that they did not have a 

medication-management follow-up visit, which pediatric provider 

organizations recommend. For example, guidelines from the American 

Academy of Pediatrics state that physicians consider follow-up visits 

every 3 to 6 months for children taking ADHD medications to monitor the 

child’s behavior and medication side effects.

Our analysis of national survey data from 2007 through 2009 indicated 

that 14 percent of noninstitutionalized children in Medicaid and 9 percent 

of noninstitutionalized privately insured children had a potential mental 

health need.68 As described earlier, these estimates of potential mental 

health need are based on a broad measure of a child’s emotional or 

behavioral impairment, as reported by parents.69 One possible 

explanation for the higher level of potential mental health need among 

Medicaid children could be the lower average family incomes of children 

enrolled in Medicaid compared to those of children with private insurance. 

Some studies have found that low income is associated with an increased 

prevalence of mental health conditions.70

Our analysis also indicated that most children with a potential mental 

health need did not receive mental health services, regardless of their 

insurance type. For example, over 80 percent of children with a potential 

need, whether covered by Medicaid or private insurance, did not receive 

any psychosocial therapy, and over 70 percent did not have any mental 

health office visits. (See table 2.) While it is not possible to assess which 

services a child may need on the basis of survey data, our analysis 

indicates that most children whose parents indicated a significant level of 

 

67Differences between children in Medicaid and those with private insurance were not 

statistically significant.

68This difference was statistically significant. Estimates of potential mental health need 

apply only to children ages 5 through 17 because MEPS asks questions from the 

Columbia Impairment Scale only of parents of children in this age range.

69Parents were asked to rate how much of a problem their child has in several areas, 

including getting along with family members, being involved in activities, and behaving at 

school. Most children—80 percent—who were considered to have emotional or behavioral 

impairment had scores ranging from 16 to 26. The highest possible score is 52.

70See, for example, J. Sareen et al., “Relationship between Household Income and Mental 

Disorders: Findings from a Population-Based Longitudinal Study,” Archives of General 

Psychiatry, vol. 68, no. 4 (2011). 

About 14 Percent of 

Children in Medicaid Had a 

Potential Mental Health 

Need, but Most Did Not 

Receive Mental Health 

Services
 

Page 21 GAO-13-15 Children’s Mental Health

behavioral impairment did not even receive a mental health evaluation. 

Even when a child received at least one mental health service, it is not 

possible to know whether his or her mental health needs were fully met.

Table 2: Percentages of Children with a Potential Mental Health Need Who Did Not 

Receive Certain Mental Health Services in a Calendar Year, by Medicaid or Private 

Insurance Coverage, 2007-2009

Service Medicaid Private insurance

No mental health office visits 72% 75%

No psychosocial therapy 82 83

No psychotropic medications 69 75

No mental health office visits or medications 65 69

Source: GAO analysis of HHS data.

Notes: Data are from the Medical Expenditure Panel Survey. Children were ages 5-17. Differences 

between children covered by Medicaid and those covered by private insurance were not statistically 

significant. Percentages represent estimated average annual rates.

Children were considered to have a potential mental health need if they scored 16 or above on the 

Columbia Impairment Scale, a psychometric scale used by MEPS that is designed to measure 

emotional and behavioral impairment.

About one-fourth of all children with a potential mental health need had a 

mental health office visit. Among Medicaid children who had mental 

health office visits, about 40 percent saw a psychiatrist and 30 percent 

saw a pediatrician at least once in a calendar year. (See table 3.) Just 

over half of children with any mental health office visits received 

psychosocial therapy, which suggests that nearly half of all mental health 

office visits involved another type of service, such as diagnostic 

assessment or medication management. Among children in Medicaid with 

at least one mental health office visit, the average number of visits in a 

year was about seven.71

 

71The average number of visits per year for privately insured children was about six. This 

difference was not statistically significant. Overall, 5.6 percent of all children in Medicaid 

and 4.5 percent of privately insured children had a mental health office visit in a calendar 

year. The difference between the two groups was not statistically significant.
 

Page 22 GAO-13-15 Children’s Mental Health

Table 3: Types of Providers Seen by Children Ages 0-20 Who Had One or More 

Mental Health Office Visits, by Medicaid and Private Insurance Coverage, 2007-2009

Percentage

Type of provider seen Medicaid Private insurance

Mental health specialist

Psychiatrist 40% 38% 

Psychologist 20 24

Social worker 6 8 

Nonspecialist

Pediatrician 30 25

Family physician 11 12

Source: GAO analysis of HHS data.

Notes: Data are from the Medical Expenditure Panel Survey. Differences between children covered 

by Medicaid and those covered by private insurance were not statistically significant.

Percentages add to more than 100 because children could have multiple office visits with different 

types of providers.

Numbers presented are estimates. Percentages represent the proportion of children with at least one 

visit to the provider type in a calendar year and do not reflect whether a child had multiple visits with a 

particular provider type.

CMS has initiated activities to help ensure that children in Medicaid

receive appropriate mental health services. For example, CMS has begun 

working with states to improve their monitoring of the prescribing of 

psychotropic medications, and in August 2012 the agency issued an 

Informational Bulletin to states titled, “Collaborative Efforts and Technical 

Assistance Resources to Strengthen the Management of Psychotropic 

Medications for Vulnerable Populations.” The bulletin provided a link to 

additional information on the CMS website that discusses practices some 

states have employed to enhance the ability of their Drug Utilization 

Review programs to monitor psychotropic medication prescribing, such as 

using Drug Utilization Reviews to identify and contact providers whose 

prescribing patterns vary significantly from recommended standards of 

care for children.72

 

72See 

In addition, through its voluntary Pediatric Quality 

Measures Program, CMS is working with states to collect data on three 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Benefits/Prescription-Drugs/Drug-Utilization-Review.html (accessed Sept. 10, 

2012).

CMS and States Have 

Made Efforts to Ensure 

That Children Receive 

Appropriate Mental Health 

Services, but CMS’s Ability 

to Monitor Children’s 

Receipt of Services Is 

Limited
 

Page 23 GAO-13-15 Children’s Mental Health

quality measures related to mental health, including receipt of follow-up 

care for children prescribed ADHD medication.

CMS has also begun working with states to improve access to mental 

health services through the EPSDT benefit. Most children in Medicaid are 

entitled to services under EPSDT, which covers regular checkups and 

screenings as well as treatment services. Children found to have mental 

health needs at a screening are generally entitled to treatment services to 

address those needs, whether or not the services are typically covered 

under the Medicaid program in the child’s state. According to CMS, its 

National EPSDT Improvement Workgroup has a Behavioral Health 

Subgroup that is developing an action plan to determine steps CMS can 

take to work with states to promote access to effective mental health care 

for children through EPSDT. The agency also told us it plans to issue an 

Informational Bulletin on children’s behavioral health screening, referral, 

and treatment, which it will disseminate to state Medicaid agencies and 

others in early 2013.

As required under federal law, states annually submit data to CMS on the 

provision of services under EPSDT, such as the number of children 

referred for additional services as a result of checkups and screenings.73

These data may include referrals for mental health services for children 

found to have mental health needs during screenings. We previously 

reported that CMS does not impose requirements beyond this federal law 

and, accordingly, does not collect information from states on whether 

children received the services for which they were referred, which limits 

CMS’s ability to monitor whether children in Medicaid are receiving the 

services they need.74

 

7342 U.S.C. § 1396a(a)(43).

We recommended that CMS work with states to 

identify options for collecting such information. CMS officials told us that 

the agency had contracted for a study examining options for collecting 

data from state Medicaid programs on EPSDT referrals; the study 

concluded that states were unlikely to be able to produce accurate 

information on referred services using existing data sources. The officials 

also said that, as of September 2012, CMS was in the process of 

identifying alternative approaches for collecting data on children’s receipt 

of treatment services, such as analyzing national survey data. However, 

74GAO, Medicaid and CHIP: Reports for Monitoring Children’s Health Care Services Need 

Improvement, GAO-11-293R (Washington, D.C.: Apr. 5, 2011).
 

Page 24 GAO-13-15 Children’s Mental Health

the alternatives currently under consideration would not produce the data 

from all states that would enable CMS to monitor at the state level 

children’s receipt of treatment services for which they were referred 

through Medicaid.

States have also made efforts to increase children’s access to mental 

health services. Because many children receive mental health services 

from nonspecialists, 28 states have programs to facilitate consultation 

between primary care providers and child psychiatrists. For example, 

under Washington state’s Second Opinions program, psychiatrists review 

Medicaid psychotropic prescriptions that exceed certain safety 

thresholds—such as dose or use of combinations of medications—and 

provide a second opinion to the prescribing physician. An evaluation of 

Washington’s Second Opinions program and its Partnership Access 

Line—the state’s voluntary program for physicians seeking child 

psychiatry consultations—found that such consultations are cost-effective 

and that they have resulted in an increase in referrals for psychosocial 

therapy and a decrease in prescribing of antipsychotic medications.75

Similarly, Massachusetts’s program, the Massachusetts Child Psychiatry 

Access Program, has been found to increase the ability of primary care 

providers to treat or refer their patients with mental health needs.76

Some states have also begun to integrate mental health services into 

primary care settings in an effort to increase access to mental health 

services. For example, through the “State Option to Provide Health 

Homes for Enrollees with Chronic Conditions,” authorized under the 

Patient Protection and Affordable Care Act, states have the option to 

implement person-centered health care delivery systems, known as 

In a 

survey of primary care providers participating in the Massachusetts 

program, 63 percent reported that they were usually able to meet the 

needs of their psychiatric patients, an increase from only 8 percent of 

providers before they enrolled in the program.

 

75According to a program official, Washington’s psychotropic monitoring programs have 

been associated with an 8.6 percent decrease in the number of children in Medicaid who 

took an antipsychotic from 2007 to 2010, and a cost savings to the state of about 

$300,000 per month.

76According to an evaluation of the Massachusetts program, primary care providers 

contacted the program with diagnostic questions, with requests for assistance in 

identifying local referrals and resources, and for consultation regarding medication.
 

Page 25 GAO-13-15 Children’s Mental Health

health homes.77 Health homes, which are designated providers that 

render comprehensive services for individuals with chronic conditions, 

must address mental health and substance abuse treatment needs. 

According to CMS, a number of states are developing proposals to 

establish health homes as part of their Medicaid programs, and CMS is 

providing technical assistance to these states.

ACF reported that 18 percent of foster children ages 1 through 19 took 

psychotropic medications. In addition, ACF found that 30 percent of foster 

children with a potential mental health need did not receive mental health 

services in a 12-month period. HHS is taking several steps to promote 

appropriate mental health treatment for foster children.

ACF reported that 18 percent of foster children were taking one or more 

psychotropic medications at the time they were surveyed, although 

utilization varied widely by living arrangement.78

 

7742 U.S.C. 1396w-4.

ACF reported that foster 

children who lived in group homes or residential treatment centers had 

much higher rates of psychotropic medication use than foster children 

78In the survey, caregivers were asked whether the child was currently taking a 

psychotropic medication. Estimates for foster children refer to those who lived in 

nonrelative foster homes, formal kin care, group homes, or residential treatment centers, 

unless otherwise noted. Estimates of medication utilization are based on NSCAW II phase 

2 data (collected during October 2009 through January 2011). Stambaugh et al., OPRE 

Report #2012-33, 3.

Nearly One-Fifth of 

Foster Children Took 

Psychotropic 

Medications, and 

Nearly One-Third of 

Foster Children Who 

May Have Needed 

Mental Health 

Services Did Not 

Receive Them

ACF Reported That 

18 Percent of Foster 

Children Took 

Psychotropic Medications
 

Page 26 GAO-13-15 Children’s Mental Health

living in nonrelative foster homes or formal kin care79—48 percent versus 

14 percent and 12 percent, respectively.80 The higher utilization rate 

among children living in group homes or residential treatment centers 

may be related to these children having higher rates of potential mental 

health need—about 69 percent had a potential mental health need 

compared to about 44 percent of children living in nonrelative foster 

homes.81 Another study found that child welfare workers were more likely 

to place children with behavior problems in a group living arrangement 

than with a foster family.82

In addition to reporting on overall use of psychotropic medications, ACF 

reported on concomitant use of psychotropic medications and on the use 

of antipsychotics by foster children. Among foster children who took 

psychotropic medication, ACF reported that 13 percent took three or more 

psychotropic medications concomitantly.83 In addition, ACF reported that 

6.4 percent of foster children took an antipsychotic medication and that 

the majority were ages 6 through 11.84

 

79Based on data that ACF reported, about 50 percent of foster children lived in nonrelative 

foster homes, 41 percent lived in formal kin care arrangements, and 9 percent lived in 

group homes or residential treatment centers. Stambaugh et al., OPRE Report #2012-33, 

2.

80Differences in medication utilization by living arrangement are statistically significant and 

are based on NSCAW II phase 1 data (collected during March 2008 through September 

2009). Ringeisen et al., OPRE Report #2011-27f, 45-46. 

81ACF reported that differences in potential mental health need by living arrangement 

among children ages 11 through 17 are statistically significant and are based on 

NSCAW II phase 1 data (collected during March 2008 through September 2009). 

Ringeisen et al., OPRE Report #2011-27f, 34-35.

82M. E. Courtney, “Correlates of Social Worker Decisions to Seek Treatment-Oriented 

Out-of-Home Care,” Children and Youth Services Review, vol. 20, no. 4, (1998).

83Estimates of concomitant use are based on NSCAW II phase 2 data (collected during 

October 2009 through January 2011). This estimate does not include children in formal kin 

care. Less than 1 percent of children in formal kin care were taking three or more 

medications at the time of the survey. Stambaugh et al., OPRE Report #2012-33, 4. 

84Estimates of antipsychotic use are based on NSCAW II phase 2 data (collected during 

October 2009 through January 2011). This estimate does not include children in formal kin 

care. About 5 percent of children in formal kin care were taking an antipsychotic 

medication at the time of the survey. Stambaugh et al., OPRE Report #2012-33, 4.
 

Page 27 GAO-13-15 Children’s Mental Health

ACF reported that 30 percent of foster children with a potential mental 

health need had not received any mental health services within the 

previous 12 months or since the start of the child’s living arrangement, if 

less than 12 months.85 (See fig. 1.) Although 70 percent of foster children 

with a potential mental health need received at least one mental health 

service, it is not possible to know the extent to which the child’s mental 

health needs were met.

 

85In the survey, caregivers were asked to report about the child’s mental health service 

use within 12 months or since the start of the child’s living arrangement, if less than 

12 months. Estimates of children with a potential mental health need who had not 

received mental health services are based on NSCAW II phase 2 data (collected during 

October 2009 through January 2011). Stambaugh et al., OPRE Report #2012-33, 6.

ACF Reported That 

30 Percent of Foster 

Children with a Potential 

Mental Health Need Did 

Not Receive Mental Health 

Services
 

Page 28 GAO-13-15 Children’s Mental Health

Figure 1: Receipt of Mental Health Services by Foster Children with a Potential 

Mental Health Need, Ages 1-19

Notes: ACF analysis is based on NSCAW II phase 2 data (collected during October 2009 through 

January 2011). See L.F. Stambaugh et al., Psychotropic Medication Use by Children in Child Welfare, 

OPRE Report #2012-33, (Washington, D.C.: Office of Planning, Research and Evaluation, 

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

Children with a potential mental health need were considered to be those who scored above a certain 

level on one of five standardized psychometric scales used in NSCAW II to measure a child’s 

emotional or behavioral problems.

For the survey, caregivers reported the child’s receipt of mental health services in the previous 

12 months or since the start of the living arrangement, if less than 12 months. Mental health services, 

which ACF refers to as specialty mental health services in OPRE Report #2012-33, include 

treatments received at an outpatient drug or alcohol clinic, mental health center, community health 

center, therapeutic nursery, hospital psychiatric unit, detox unit, inpatient unit, hospital emergency 

room, residential treatment center, group home, or school-based setting. Mental health services can 

also be received from a private mental health professional or family doctor, or during in-home 

counseling or crisis services.
 

Page 29 GAO-13-15 Children’s Mental Health

In response to concerns related to the prescribing of psychotropic 

medications for foster children, HHS convened an interagency workgroup 

on the use of psychotropic medications for foster children in summer 

2011. Led by ACF, the workgroup also has representatives from CMS, 

SAMHSA, NIH, AHRQ, and FDA. The workgroup developed a plan to 

expand the use of evidence-based screening, diagnosis, and 

interventions; strengthen the oversight and monitoring of psychotropic 

medications; and expand the overall knowledge and evidence base 

regarding medications and psychosocial treatments for foster children 

with mental health or trauma-related needs. The primary activity of the 

workgroup is to meet regularly to share information about individual and 

joint agency activities related to foster children’s mental health. For 

example, the workgroup convened a meeting in September 2011 with 

researchers to increase federal staff’s knowledge about psychotropic 

medication use among foster children, their mental health needs, the 

extent to which best practices on state oversight and monitoring of 

psychotropic medications exist, and future data needs. On the basis of 

the efforts of the workgroup, HHS has identified several areas where 

more research is needed, including clinical trials related to foster 

children’s use of psychotropic medications, studies on differences 

between trauma and mental health diagnoses, and studies on EBTs for 

foster children.

Three member agencies of the workgroup—ACF, CMS, and SAMHSA—

have collaborated on certain activities regarding use of psychotropic 

medications among foster children. In November 2011, the three 

agencies sent a joint letter to state Medicaid directors, mental health 

authorities, and child welfare directors. This letter contained information 

on the three agencies’ activities and resources that aim to improve the 

mental health and well-being of foster children, such as ACF’s Child 

Welfare Information Gateway website and SAMHSA’s National Traumatic 

Stress Initiative grants. These agencies also jointly held several webinars 

to disseminate this information. In addition, they hosted a summit in 

August 2012 for state child welfare, Medicaid, and mental health agencies 

to help states develop psychotropic drug oversight practices and to 

facilitate interagency coordination for foster children. ACF is also working 

with CMS to develop quality measures specific to foster children as part 

of CMS’s Pediatric Quality Measures Program.

In addition to participating in the workgroup, ACF is working with states to 

build the capacity of child welfare agencies to effectively respond to the 

complex needs of foster children. For example, in addition to overseeing 

the NSCAW surveys, ACF took the following actions:

HHS Has Provided 

Information to States on 

Use of Psychotropic 

Medications and Other 

Mental Health Services for 

Foster Children
 

Page 30 GAO-13-15 Children’s Mental Health

• ACF issued a Program Instruction to help states implement the new 

requirements in the Child Improvement Act. In the Program 

Instruction, ACF described five components that state child welfare 

agencies should include in their plans to monitor psychotropic 

medications.86 In addition, the instructions provided guidelines to 

states on treating and monitoring children experiencing emotional 

trauma, another requirement of the law. As of August 2012, ACF 

officials told us that all states had submitted their plans as required by 

the Child Improvement Act and the agency was reviewing them.

• ACF published two Information Memoranda for state child welfare 

agencies—one on promoting social and emotional well-being for 

children in child welfare and one on best practices in state 

psychotropic drug oversight.

• ACF has provided information about psychotropic medication 

prescribing and monitoring on its Child Welfare Information 

Gateway—a website that provides resources for child welfare 

agencies.87

SAMHSA has provided funding, guidance, and information to states and 

others to increase appropriate mental health services among foster 

children. For example:

• For its fiscal year 2012 National Child Traumatic Stress Initiative 

grants, SAMHSA placed a specific emphasis on child welfare. The 

initiative supports services for children experiencing trauma-related 

behavioral health problems and places a strong focus on using 

evidence-based psychosocial therapies.

 

86ACF identified the following five areas that the psychotropic medication protocols must 

address: (1) screening, assessment, and treatment planning mechanisms; (2) shared 

decision making and communication among the prescriber, the child, caregivers, other 

health care providers, and the child welfare worker; (3) effective medication monitoring at 

both the patient and the agency-wide level; (4) availability of child and adolescent 

psychiatrists for consultation; and (5) mechanisms for sharing accurate and up-to-date 

information related to psychotropic medications with clinicians, child welfare staff, and 

consumers. See Administration for Children and Families, U.S. Department of Health and 

Human Services, Program Instruction, ACYF-CB-PI-12-05 (Washington, D.C.: Apr. 11, 

2012), 13. 

87See http://www.childwelfare.gov.
 

Page 31 GAO-13-15 Children’s Mental Health

• SAMHSA worked with AACAP to develop guidance for service 

providers and agency leaders on the use of psychotropic medications 

among children, including foster children. Through its Systems of 

Care grants, SAMHSA has also provided funding for foster children’s 

mental health services; the agency reported in 2011 that 22 of its 

grantees had a child welfare focus or a partnership with a child 

welfare organization.

• The 2012 SAMHSA-sponsored National Children’s Mental Health 

Awareness Day event had a special focus on foster children, and 

SAMHSA is planning a meeting in January 2013 titled “Improving 

Outcomes for African American Males in Foster Care.” 

NIH spent about $1.2 billion on research projects related to children’s 

mental health; NIMH was responsible for most of this funding, with the 

rest being spent by NICHD. Other HHS agencies—FDA, AHRQ, and 

CDC—spent an estimated $16 million on external research projects 

related to children’s mental health.

During fiscal years 2008 through 2011, NIH spent about $1.2 billion to 

support over 1,200 children’s mental health research projects, most of 

which were supported by NIMH.88

 

88We use the term “spent” to refer to funds actually expended or provided to the recipient 

of a grant or cooperative agreement, to a contractor, or to agency scientists conducting 

research internally. Recipients of grants and cooperative agreements draw down funds 

either as an advance or as a reimbursement for costs incurred in accordance with the 

terms of the grant or cooperative agreement. Contractors receive funds as payment for 

goods and services provided under a contract. Intramural research expenditures include 

funding for salaries and research resources for agency scientists. Totals reported here 

represent the amount expended for projects during fiscal years 2008 through 2011 and do 

not reflect total amounts for all of the projects over their lifetimes. For example, for a 

project funded for 5 years starting in 2008, we included only the amount expended for the 

first 4 years (i.e., through 2011).

NIMH accounted for 81 percent—about 

$956 million—of NIH’s funding for children’s mental health research. (See 

fig. 2.) NIMH’s $956 million (which represented about 18 percent of 

NIMH’s total research budget in fiscal years 2008 through 2011) 

NIH Spent an 

Estimated $1.2 Billion 

on Children’s Mental 

Health Research 

during Fiscal Years 

2008 through 2011

Most NIH Funding for 

Children’s Mental Health 

Research Was Spent by 

NIMH
 

Page 32 GAO-13-15 Children’s Mental Health

supported slightly over 900 research projects related to mental health in 

children ages 18 or younger.89 The most-commonly studied mental health 

conditions were ADHD, major depression, and bipolar disorder. Nearly all 

of the projects (97 percent) were conducted externally under grants and 

contracts, with expenditures of about $861 million.90

Figure 2: HHS Expenditures for Children’s Mental Health Research, Fiscal Years 

2008 through 2011

The remaining 

research projects, for which NIMH spent about $95 million, were 

conducted internally by NIMH scientists. For example, NIMH scientists 

used brain imaging techniques to examine how brain development in 

children with ADHD differed from typical brain development in children.

Note: According to NIH officials, NIMH and NICHD conduct and fund most of the NIH research on 

children’s mental health. Additional NIH institutes and centers may have also sponsored children’s 

mental health research, but NIH was unable to provide data from these other institutes and centers 

that met our criteria.

 

89Although NIH defines a child as 0 to 20 years of age, NIMH was able to identify studies 

that specifically included children 0 to 18, so we have reported numbers for this age 

range.

90Of the $861 million expended for extramural grants and contracts during this period, 

about $59 million (7 percent) was from appropriations made by the American Recovery 

and Reinvestment Act.
 

Page 33 GAO-13-15 Children’s Mental Health

About half of NIMH-sponsored research projects (482) examined mental 

health treatments for children, with more projects studying psychosocial 

therapies than psychotropic medications. (See table 4.) Of the 482 

treatment research projects, 325 involved testing psychosocial therapies. 

For example, one project tested the effect of therapies such as parent 

training and skill building on preventing negative outcomes such as 

substance use and school truancy in middle-school-aged girls in foster 

care. Psychotropic medication studies accounted for 137 of the 482 

research projects.91 For example, one project tested the effect of an 

antidepressant medication on brain activity in children with anxiety 

disorders, with the goal of better understanding how the medication 

works. NIMH also funded 66 research projects that tested the effects of 

combinations of treatments, such as two medications or a medication and 

a psychosocial therapy. For example, one project tested the effect of 

parent training—a psychosocial treatment—with and without the addition 

of a stimulant (or of a stimulant and an antipsychotic medication) on 

children with a disruptive behavior disorder in combination with ADHD 

and severe aggression. NIMH officials told us that the agency does not 

have quotas for the kinds of treatment studies it funds and encourages 

grant applications from researchers for both psychosocial and 

psychotropic treatment studies. However, officials noted that NIMH 

expects to fund more projects examining psychosocial therapies than 

projects that test medications because researchers may perceive 

psychosocial therapies to be less risky for children and not all 

psychotropic medications are approved for pediatric use.

 

91Treatment types do not add to 482 because a project could test both psychosocial 

therapies and psychotropic medications, or neither of these.
 

Page 34 GAO-13-15 Children’s Mental Health

Table 4: National Institute of Mental Health Research Projects on Children’s Mental 

Health, by Topic, Fiscal Years 2008 through 2011

Topic

Number of 

research projects

Expenditures 

(dollars in millions)

Mental health treatment

a

482 b $458

Psychosocial therapies 325 268

Psychotropic medications 137 155

Combination 66 c 62

Other than treatment 425 d 498

Total 907 $956

Source: GAO analysis of NIMH data.

a

These expenditure amounts refer to funds actually provided to the recipient of a grant or cooperative 

agreement, to a contractor, or to agency scientists conducting research internally. These amounts are 

the sum of NIMH spending on an annual basis during fiscal years 2008 through 2011.

b

Numbers and expenditure amounts for treatment research project types do not add to mental health 

treatment total because projects can include more than one type of treatment.

c

These research projects tested the effects of combinations of treatments, such as of two medications 

or a medication and a psychosocial therapy.

d

NICHD spent about $218 million to sponsor 324 research projects related 

to mental health in children in fiscal years 2008 through 2011.

These research projects did not examine the effects of a treatment such as a psychotropic 

medication or psychosocial therapy.

92 Almost all 

projects (98 percent) were conducted externally under grants and 

contracts, with expenditures of about $195 million. NICHD’s own 

scientists conducted the remaining research projects, for which NICHD 

spent about $23 million. Of the 324 research projects, 72 focused on 

mental health conditions, such as depression and ADHD.93

 

92NICHD-sponsored research projects include children ages 0 to 20. 

For example, 

NICHD sponsored one study that examined the effectiveness of a mood 

stabilizing psychotropic medication—lithium—in children ages 7 to 17 with 

bipolar disorder.

93Research projects that did not study mental health conditions may have studied children 

who were developing typically. For example, one project looked at the development of 

socially appropriate behavior in children ages 0 to 4 and how it related to factors such as 

the child’s temperament and relationships with caregivers. Other research project types 

included studies of children with genetic conditions such as spina bifida.
 

Page 35 GAO-13-15 Children’s Mental Health

NIMH and NICHD collectively spent about $309 million during this period 

to support almost 350 research projects that examined children’s mental 

health in minority and health disparity populations.94

NIMH and NICHD also funded translational research,

NIMH sponsored 297 

such projects, with expenditures of about $283 million, and NICHD spent 

about $26 million to sponsor 50 projects. For example, NIMH sponsored a 

study of Latino adolescents with depression that tested the effectiveness 

of a psychosocial therapy—cognitive behavioral therapy—with and 

without an additional educational component for parents.

95 which tests 

treatments in real world settings and identifies effective strategies for 

implementing them in communities.96 For example, NICHD sponsored a 

research project that evaluated the effectiveness of a psychosocial 

therapy for girls with post-traumatic stress disorder and concurrent 

substance abuse disorders who were involved with the juvenile justice 

system. The study examined ways to adapt the treatment for this 

population, and the researchers planned to use the study as a model to 

adapt other EBTs for children involved in the juvenile justice and child 

welfare systems.

 

94NIH defines a health disparity population as one that experiences a greater burden of 

illness when compared to the general population. Racial and ethnic minorities, persons 

with low socioeconomic status, and persons who live in rural areas are considered health 

disparity populations.

95The data NIMH and NICHD provided did not identify which projects were translational, 

so it was not possible to determine the total number of projects or how much was spent on 

this research.

96Providers we spoke with said that translational studies are important because 

treatments are often developed and tested under highly controlled conditions, and 

therefore it is unclear whether the treatments will work with different conditions or 

populations.
 

Page 36 GAO-13-15 Children’s Mental Health

Together, FDA, AHRQ, and CDC spent about $16 million on research 

projects on children’s mental health in fiscal years 2008 through 2011. 

FDA spent about $4.5 million on four external research projects on the 

safety and effectiveness of psychotropic medications for children.97 For 

example, FDA cosponsored a study with AHRQ that examined serious 

cardiovascular events such as heart attack and stroke among children 

taking ADHD medications. In addition, at the end of fiscal year 2011, FDA 

awarded a contract for about $6 million for a study on antipsychotic 

medications and the risk of type 2 diabetes in children; this study is 

currently under way.98

AHRQ spent about $8.6 million to fund five external research projects 

related to children’s mental health in fiscal years 2008 through 2011.99

Consistent with the agency’s focus on improving outcomes by 

encouraging the use of evidence to make health care decisions, two of 

the five research projects AHRQ supported compared outcomes of using 

different mental health treatments. For example, one AHRQ-sponsored 

project compared outcomes of using various antipsychotic medications to 

treat children with ADHD who were enrolled in Medicaid, including 

children in foster care.100

 

97FDA provided expenditure data on contracts for which the performance period 

overlapped fiscal years 2008 through 2011. FDA did not provide a breakdown of 

expenditures by fiscal year, so some of the $4.5 million reported here may have been 

spent before or after fiscal years 2008 through 2011.

Child mental health experts we spoke with 

highlighted the need for more research that compares different 

psychotropic medications. For example, one federal official noted that all 

antidepressant medications bear the same “black box” warning describing 

98We did not include this contract in our total for FDA because it overlapped our time 

frame by only 1 month (September 2011).

99Of the $8.6 million in expenditures, about $1.2 million (14 percent) was from 

appropriations made by the American Recovery and Reinvestment Act. AHRQ also spent 

about $2 million on the project it cosponsored with FDA on cardiovascular effects of 

ADHD medications. However, because AHRQ spent these funds prior to the time frame 

examined in this report, we have not included that amount in AHRQ’s total.

100In addition to sponsoring new studies that compare treatments for mental health 

conditions, AHRQ also funds systematic reviews of existing studies on available 

treatments. For example, AHRQ recently sponsored a review of the use of antipsychotic 

medications for children; the review stated that for most conditions there was limited 

evidence to determine which were safer or more efficacious. See J. Seida et al., First- and 

Second-Generation Antipsychotics for Children and Young Adults. 

Other HHS Agencies Spent 

an Estimated $16 Million 

on Children’s Mental 

Health Research Projects
 

Page 37 GAO-13-15 Children’s Mental Health

the potential for increases in suicidal thinking in children101

CDC spent about $2.7 million on two external research projects during 

fiscal years 2008 through 2011, one on ADHD and the other on Tourette 

Syndrome and other tic disorders. The ADHD project examined topics 

including the prevalence of ADHD, the prevalence of ADHD in 

combination with other mental health conditions, and children’s utilization 

of psychosocial and medication treatments. The project on tic disorders 

also looked at children’s utilization of different kinds of treatments, as well 

as their school performance, social relationships, and factors associated 

with poorer functioning. Both projects were designed to include a diverse 

sample of children with the aim of detecting differences due to sex or 

race/ethnicity. For example, the ADHD study oversampled girls and 

included large samples of Black, Latino, and American Indian children.

but that there 

is limited information about whether any antidepressants are safer or 

more effective for children than other antidepressants.

Mental health conditions such as ADHD, depression, and bipolar disorder 

can have debilitating effects on a child’s life, and early detection and 

treatment of childhood mental health conditions can improve children’s 

outcomes into the future. While some children receive highly effective 

mental health treatments, our findings suggest that many children, 

including some in Medicaid and in foster care, may not be receiving 

appropriate treatment. Our analysis of national survey data indicates that 

concerns raised by providers, children’s advocates, and others about 

potentially inappropriate prescribing of psychotropic drugs for some 

children and a lack of needed mental health services for some children 

may be warranted. Antipsychotic medications are of particular concern in 

light of the very serious side effects they can have for children, the limited

understanding of their long-term effects, and their high cost. Children in 

Medicaid and in foster care are prescribed these medications at higher 

rates than other children. Furthermore, most children in Medicaid and 

many children in foster care with potential mental health needs do not 

receive mental health services that could help them. Differing rates of 

medication among the groups of children do not necessarily represent a 

problem, because potential factors beyond the scope of this review could 

 

101A black box warning is the strongest warning an FDA-approved product can carry and 

may describe, for example, an adverse reaction that is so severe that it is essential that it 

be considered when evaluating the risks and benefits of a medication.

Concluding 

Observations 
 

Page 38 GAO-13-15 Children’s Mental Health

help explain the differences. Nonetheless, these findings do suggest that 

the recent federal and state initiatives to improve monitoring and 

oversight are appropriate, and that continued assessment of the 

prescribing of psychotropic medications to vulnerable populations and of 

the receipt of mental health services is important. Initiatives such as 

CMS’s National EPSDT Improvement Workgroup and plans to help states 

improve their monitoring efforts, as well as the ACF-led interagency 

workgroup on the use of psychotropic medications for foster children, 

have the potential to help ensure that vulnerable children in Medicaid and 

foster care have access to effective mental health treatments that are 

appropriate for their mental health conditions. We recommended in 2011 

that CMS identify options to collect information from states on whether 

children in Medicaid receive the services for which they are referred 

through their EPSDT-mandated screenings and check-ups, which would 

include referrals for specialty care such as mental health services. CMS 

has begun to explore options to address this recommendation, but it has 

not yet identified ways to systematically collect such data from state 

Medicaid programs. We continue to believe this recommendation is valid, 

and our findings in this report underscore the importance of HHS’s 

monitoring the receipt of needed referral and treatment services, including 

those for mental health, by children in Medicaid.

HHS did not comment on our findings but provided technical comments, 

which we incorporated as appropriate. 

As arranged with your office, unless you publicly announce the contents 

of this report earlier, we plan no further distribution until 30 days after its 

issuance date. At that time, we will send copies of this report to the 

Secretary of Health and Human Services and other interested parties. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov. 

Agency Comments
 

Page 39 GAO-13-15 Children’s Mental Health

If you or your staff members have any questions, please contact me at 

(202) 512-7114 or iritanik@gao.gov. Contact points for our Offices of 

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

of this report. Major contributors to this report are listed in appendix IV.

Katherine Iritani

Director, Health Care
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 40 GAO-13-15 Children’s Mental Health

To provide information on the use of psychotropic medications and other 

mental health services by children covered by Medicaid, the Children’s 

Health Insurance Program (CHIP), and private insurance, we analyzed 

nationwide data from the Medical Expenditure Panel Survey (MEPS) from 

2007 through 2009. MEPS is a nationally representative survey of 

families, medical providers, and employers across the United States 

administered by the Agency for Healthcare Research and Quality 

(AHRQ). MEPS collects self-reported information on individuals’ 

demographics, health and insurance status, and use of medical services 

by setting and provider type, among other things.1 Specifically, we 

examined the use of psychotropic medications2 and mental health-related 

office visits, therapy visits, and behavioral impairment. We pooled 3 years 

of data to obtain a sample size large enough to conduct our analyses, 

and reported average annual estimates.3 To conduct our analysis, we 

constructed two cohorts of children who were insured for at least 10 

months in 2007, 2008, or 2009—those who were enrolled in Medicaid or 

CHIP4 and those covered by private insurance. We included children 

ages 0 through 20 and excluded children in foster care from our analysis.5

To develop the list of psychotropic medications used in the analysis, we 

compiled a list based on a list published by the National Institute of 

Mental Health as well as prescription drug lists from six state Medicaid 

programs. We then refined the list on the basis of input from two 

contracted child psychiatrists with clinical and research experience in the 

In total, the sample Medicaid/CHIP cohort had 11,224 children, and the 

sample private insurance cohort had 11,639 children.

 

1

The preferred respondent for the interview is the person, 18 years or older, who is most 

knowledgeable about the family’s health care and who is keeping records about health 

care use and expenses. For the purposes of this report, we consider this person to be the 

child’s parent or guardian, although this may not always be the case.

2

MEPS reports on all medications taken in a calendar year, but does not provide 

information on whether medications were taken concomitantly—that is, in combination 

with other medications.

3

We did not report on utilization of mental health-related inpatient, outpatient, and 

emergency room visits because the numbers of cases were too low to conduct further 

analyses.

4

Because MEPS does not differentiate between children in Medicaid and children in CHIP 

in the survey, we could not report on these programs separately. For the purposes of this 

report, we used the term Medicaid to refer to both Medicaid and CHIP.

5

State Medicaid programs generally cover children under 21 years of age.

Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 41 GAO-13-15 Children’s Mental Health

prescription of psychotropic medications to children.6 (See table 5.) In our 

estimates of psychotropic medication utilization, we included only those 

instances when a medication was associated with a mental health 

condition (diagnosis codes 293-298, 300-302, 306-314 from the 

International Classification of Diseases, Ninth Revision, Clinical 

Modification) as the reason for the prescription, because some 

psychotropic medications can be used for non-mental-health purposes.

Similarly, we identified office visits that included a mental health diagnosis 

code as the reason for the visit. Among the mental health-related visits, 

we also identified those visits during which the child was reported by the 

parent or guardian to have received psychotherapy or counseling.

 

6

This list of psychotropic drugs was initially developed for use in a recent GAO report. For 

more information about the methodology used to develop the list of psychotropic 

medications, see GAO, Foster Children: HHS Guidance Could Help States Improve 

Oversight of Psychotropic Prescriptions, GAO-12-201 (Washington, D.C.: Dec. 14, 2011). 
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 42 GAO-13-15 Children’s Mental Health

Table 5: Psychotropic Medications Used in the MEPS Analysis 

Type of psychotropic medication Medication ingredient

Attention deficit hyperactivity disorder (ADHD) medication Amphetamine aspartate, amphetamine sulfate, dextroamphetamine 

saccharate, dextroamphetamine sulfate

ADHD medication 

a

Atomoxetine hydrochloride

ADHD medication Clonidine

ADHD medication Dexmethylphenidate hydrochloride

ADHD medication Dextroamphetamine sulfate

ADHD medication Guanfacine hydrochloride

ADHD medication Lisdexamfetamine dimesylate

ADHD medication Methamphetamine

ADHD medication Methylphenidate hydrochloride

ADHD medication Pemoline

Antianxiety Alprazolam

Antianxiety Buspirone hydrochloride

Antianxiety Chlordiazepoxide hydrochloride

Antianxiety Clonazepam

Antianxiety Clorazepate dipotassium

Antianxiety Diazepam

Antianxiety Diphenhydramine hydrochloride

Antianxiety Hydroxyzine

Antianxiety Lorazepam

Antianxiety Meprobamate

Antianxiety Oxazepam

Antianxiety Prazosin hydrochloride

Antianxiety Propranolol hydrochloride

Antianxiety Quazepam

Anticonvulsant Carbamazepine

Anticonvulsant Divalproex sodium

Anticonvulsant Gabapentin

Anticonvulsant Lamotrigine

Anticonvulsant Oxcarbazepine

Anticonvulsant Topiramate

Anticonvulsant Valproate sodium

Anticonvulsant Valproic acid

Antidepressant Amitriptyline hydrochloride

Antidepressant Amoxapine

Antidepressant Bupropion hydrochloride
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 43 GAO-13-15 Children’s Mental Health

Type of psychotropic medication Medication ingredient

Antidepressant Citalopram hydrobromide

Antidepressant Clomipramine hydrochloride

Antidepressant Desipramine hydrochloride

Antidepressant Desvenlafaxine succinate

Antidepressant Doxepin hydrochloride

Antidepressant Duloxetine hydrochloride

Antidepressant Escitalopram oxalate

Antidepressant Fluoxetine hydrochloride

Antidepressant Fluvoxamine maleate

Antidepressant Imipramine

Antidepressant Isocarboxazid

Antidepressant Maprotiline hydrochloride

Antidepressant Mirtazapine

Antidepressant Nefazodone hydrochloride

Antidepressant Nortriptyline hydrochloride

Antidepressant Paroxetine

Antidepressant Phenelzine sulfate

Antidepressant Protriptyline hydrochloride

Antidepressant Selegiline

Antidepressant Sertraline hydrochloride

Antidepressant Tranylcypromine sulfate

Antidepressant Trazodone hydrochloride

Antidepressant Trimipramine maleate

Antidepressant Venlafaxine

Antienuretic Desmopressin acetate

Antiparkinson Amantadine hydrochloride

Antiparkinson Benztropine mesylate

Antiparkinson Trihexyphenidyl hydrochloride

Antipsychotic Aripiprazole

Antipsychotic Chlorpromazine

Antipsychotic Clozapine

Antipsychotic Droperidol

Antipsychotic Fluphenazine

Antipsychotic Haloperidol

Antipsychotic Loxapine

Antipsychotic Mesoridazine besylate

Antipsychotic Molindone hydrochloride
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 44 GAO-13-15 Children’s Mental Health

Type of psychotropic medication Medication ingredient

Antipsychotic Olanzapine

Antipsychotic Paliperidone

Antipsychotic Perphenazine

Antipsychotic Pimozide

Antipsychotic Quetiapine fumarate

Antipsychotic Risperidone

Antipsychotic Thioridazine

Antipsychotic Thiothixene

Antipsychotic Trifluoperazine hydrochloride

Antipsychotic Ziprasidone

Combination antianxiety 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

We also used MEPS to examine the receipt of mental health services by 

those children who were considered to have a potential mental health 

need. To estimate potential mental health need, we measured the 

percentage of children in each cohort whose score on a standardized 

psychometric scale designed to measure mental health impairment 

indicated a potential need for a mental health service. The psychometric 

scale, known as the Columbia Impairment Scale, consists of 13 questions 

and was developed such that children who scored a 16 or higher (out of a 

possible maximum score of 52) were considered to have emotional or 

behavioral impairment. As part of the MEPS survey, parents of children 

ages 5 through 17 were asked to rate on a scale of 0 to 4 (0 being no 

Amphetamine aspartate, amphetamine sulfate, dextroamphetamine saccharate, and 

dextroamphetamine sulfate are medications indicated for treatment of ADHD and were considered a 

single ingredient for the purposes of our review.
Appendix I: Methodology Used to Analyze the 

Medical Expenditure Panel Survey

Page 45 GAO-13-15 Children’s Mental Health

problem and 4 being a very big problem) how much of a problem their 

child has in several areas, including getting along with family members, 

being involved in activities, and behaving well at school. This measure of 

emotional or behavioral impairment does not indicate the level of 

treatment a child might require; rather it identifies the percentage of 

children whose emotions or behavior indicated a need for, at a minimum, 

a mental health evaluation.7

Estimates of utilization rates for medication and other mental health 

services from MEPS may be conservative, because the survey excludes 

children who live in institutional settings, who are likely to be high utilizers 

of psychotropic medications and mental health services. In addition, 

MEPS relies on self-reporting by parents on their child’s utilization of 

medications and services, which may be understated because parents 

may be reluctant to report such information due to the stigma that can be 

associated with mental health conditions.8

 

7

The scale is considered to be valid and reliable for use in surveys. See H. R. Bird et al., 

“The Columbia Impairment Scale (CIS): Pilot Findings on a Measure of Global Impairment 

for Children and Adolescents,” International Journal of Methods in Psychiatric Research, 

vol. 3, no. 3 (1993).

 These estimates may also be 

lower because we excluded from our analysis children with 

developmental disorders such as autism, and such children may be 

taking psychotropic medications. However, some children with autism 

take medications for other mental health conditions and these children 

would likely have been included in our analysis. Finally, these estimates 

do not include foster children, whom we excluded from this analysis. We 

reviewed the MEPS survey instruments and methodology and determined 

that the data were sufficiently reliable for our purposes.

8

See S. Zuvekas., “Prescription Drugs and the Changing Patterns of Treatment for Mental 

Disorders, 1996-2001,” Health Affairs, vol. 24, no. 1 (2005). 
Appendix II: Food and Drug Administration 

Reviews of Psychotropic Drug Label Changes 

for Children

Page 46 GAO-13-15 Children’s Mental Health

The Food and Drug Administration (FDA) is responsible for reviewing the 

results of pediatric studies conducted under two related laws—the Best 

Pharmaceuticals for Children Act (BPCA) and the Pediatric Research 

Equity Act (PREA). BPCA is a program under which manufacturers may 

receive an additional 6 months of market exclusivity in exchange for 

conducting pediatric studies.1 Under PREA, subject to certain exceptions, 

drug manufacturers must conduct pediatric studies before a drug can be 

marketed.2 FDA is responsible for reviewing the results of pediatric 

studies submitted under BPCA and PREA and ensuring manufacturers 

incorporate new information on pediatric use into medication labels when 

required. During fiscal years 2008 through 2011, 168 label changes 

resulted from studies conducted under these laws, 16 of which were for 

psychotropic medications. For example, the label for Invega, an atypical 

antipsychotic medication, was changed to indicate that it is safe and 

effective for the treatment of schizophrenia in children as young as 

age 12. (See table 6 for information on all 16 label changes.) In addition 

to reviewing label changes related to BPCA and PREA, in 2009 FDA 

began working with manufacturers to change the labels of all atypical 

antipsychotics to more clearly present data on their metabolic risks for 

children, which an FDA official said will help prescribers in selecting 

medications for their patients.3

 

1

21 U.S.C. 355a, 42 U.S.C. 284m. Before marketing a new drug and before making 

certain changes to a previously approved drug, manufacturers must apply to FDA for 

approval. Once approval is granted, manufacturers may have protection from certain 

types of competition for a specified time frame based on patents listed for and exclusivity 

obtained for the drug. FDA may request pediatric studies from manufacturers that have 

applications approved or pending. If the manufacturer conducts the studies that FDA has 

requested and does so in accordance with generally accepted scientific principles and 

protocols, FDA will award 6 months of pediatric exclusivity, which attaches to existing 

patent and exclusivity protection for the drug.

2

21 U.S.C. §§ 355c, 355d. When submitting a new drug application, drug manufacturers 

must conduct assessments of safety and efficacy for all relevant pediatric populations and 

to support dosing instructions. FDA may also require manufacturers that have already 

received approval to market a drug to conduct these assessments in certain 

circumstances, including if the FDA has determined that the product is used for a 

substantial number of pediatric patients for the labeled indications and the absence of 

adequate labeling could pose significant risks to pediatric patients.

3

As of August 2012, 7 of 13 atypical antipsychotics had undergone label changes and the 

remaining 6 were pending review by FDA. FDA officials said they anticipate that all label 

changes will be finalized by early 2013. 

Appendix II: Food and Drug Administration 

Reviews of Psychotropic Drug Label Changes 

for Children
Appendix II: Food and Drug Administration 

Reviews of Psychotropic Drug Label Changes 

for Children

Page 47 GAO-13-15 Children’s Mental Health

Table 6: Label Changes for Psychotropic Medications Resulting from the Best Pharmaceuticals for Children Act (BPCA) and 

the Pediatric Research Equity Act (PREA) during Fiscal Years 2008 through 2011

Medication Medication type Date of changes Label change(s)

BPCA or 

PREA a

Abilify

b

Antipsychotic Oct. 29, 2007 Extended use for the treatment of 

schizophrenia from adults to children as 

young as age 13; added information on 

dosing and safety 

BPCA 

Feb. 27, 2008 Extended use for the treatment of bipolar 

disorder from adults to children as young 

as age 10; added information on dosing 

and safety

Both 

Nov. 19, 2009 Approved marketing for the treatment of 

irritability associated with autism in 

children as young as age 6; added 

information on dosing and safety

PREA 

Daytrana Stimulant (attention 

deficit hyperactivity 

disorder (ADHD)) 

Dec. 14, 2009 Added safety information regarding skin 

reactions

PREA 

Jun. 29, 2010 Extended use for the treatment of ADHD 

from children 6 to 12 to children ages 13 to 

17; added information on safety

PREA 

Depakote ER Depakote 

Sprinkles 

Anticonvulsant mood 

stabilizer

Mar. 24, 2008 Added statements that efficacy was not 

established for the treatment of bipolar 

disorder in children ages 10 to 17 or for 

the prevention of migraine in children ages 

12 to 17 and additional safety information

Both 

Focalin XR Stimulant (ADHD) Oct. 23, 2009 Added information on dosing PREA 

Intuniv Nonstimulant (ADHD) Sept. 2, 2009 Approved marketing for the treatment of 

ADHD in children as young as age 6; 

added information on dosing and safety

PREA 

Feb. 25, 2011 Approved marketing for the treatment of 

ADHD in combination with stimulant 

ADHD medication for children as young as 

age 6; added information on safety

PREA 

Invega Antipsychotic Apr. 6, 2011 Extended use for the treatment of 

schizophrenia from adults to children as 

young as age 12; added information on 

dosing and safety

Both 

Kapvay Extended Release 

Tablets

Nonstimulant (ADHD) Sept. 28, 2010 Approved marketing for the treatment of 

ADHD alone and in combination with 

stimulant ADHD medication for children as 

young as age 6; added information on 

safety

PREA 

Lexapro Antidepressant Mar. 19, 2009 Approved marketing for the treatment of 

major depression in children as young as 

age 12; added information on dosing and 

safety

BPCA 
Appendix II: Food and Drug Administration 

Reviews of Psychotropic Drug Label Changes 

for Children

Page 48 GAO-13-15 Children’s Mental Health

Medication Medication type Date of changes Label change(s)

BPCA or 

PREA a

Seroquel

b

Antipsychotic Dec. 2, 2009 Extended use for the treatment of 

schizophrenia from adults to children as 

young as age 13 and treatment of bipolar 

disorder to children as young as age 10; 

added information on dosing and safety

Both 

Vyvanse Capsules Stimulant (ADHD) Nov. 10, 2010 Extended use for the treatment of ADHD 

from adults and children 6 to 12 to children 

ages 13 to 17; added information on safety

PREA 

Zyprexa Antipsychotic Aug. 14, 2008 Added statement that safety and 

effectiveness were not established for 

children and additional safety information

BPCA 

Dec. 4, 2009 Extended use for the treatment of 

schizophrenia and bipolar disorder from 

adults to children as young as age 13; 

added information on dosing and safety

BPCA 

Source: GAO analysis of Food and Drug Administration (FDA) information.

Notes: For BPCA, see 21 U.S.C. § 355a and 42 U.S.C. § 284m. For PREA, see 21 U.S.C. §§ 355c, 

355d.

a

This column contains a summary of key changes to the label and does not include all changes that 

were made.

b

This column indicates whether drug manufacturers voluntarily submitted pediatric studies under 

BPCA or were required by FDA to submit studies under PREA. Drug manufacturers can submit 

studies to satisfy both laws; for example, if FDA requires a company to conduct studies under PREA, 

the manufacturer can request that the studies fulfill BPCA requirements to be awarded an additional 

6 months of market exclusivity.
Appendix III: Results of the Medical 

Expenditure Panel Survey Analysis

Page 49 GAO-13-15 Children’s Mental Health

Tables 7 and 8 provide estimates of children’s utilization of psychotropic 

medications and other mental health services, based on our analysis of 

MEPS data.

Table 7: Utilization of Psychotropic Medications and Other Mental Health Services by Children Covered by Medicaid and 

Private Insurance, 2007-2009

Percentage of children (standard error) 

Characteristic Medicaid Private insurance

Use of psychotropic medications

Percentage of all children 6.2% (0.4) 4.8%* (0.3)

Sex 

Males 8.4 (0.7) 6.3* (0.5)

Females 3.9 (0.4) 3.2 (0.4)

Age 

0-5 years 0.6 (0.2) 0.1(0.1) a

6-11 years

a

8.6 (0.9) 4.8* (0.6)

12-17 years 8.4 (0.8) 7.5 (0.7)

18-20 years 12.7 (1.8) 6.6* (0.8)

Information on children taking psychotropic medicationsb

Number of medications taken

One medication 56.3 (2.9) 67.0 (3.0)

Two medications 28.0 (2.6) 22.2 (2.3)

Three or more medications 15.7 (2.1) 10.7 (1.9)

Types of medications taken

Attention deficit hyperactivity disorder (ADHD) medication 78.4 (2.4) 73.5 (2.4)

Antidepressant 23.5 (2.7) 32.7 (2.8)

Antipsychotic 21.1 (2.6) 9.9* (2.1)

Receipt of other mental health services

Mental health office visit 73.5 (2.6) 70.3 (2.5)

Psychotherapy 39.1 (2.8) 33.9 (3.1)

Information on children who had a mental health office visitc

Took a psychotropic medication 81.0 (2.3) 73.8 (2.8)

Office visit included psychotherapy 54.5 (2.9) 52.1 (3.5)

Type of provider seen 

Psychiatrist 40.0 (3.4) 37.9 (3.4)

Psychologist 19.6 (2.2) 24 (3.0)

Social worker 6.4 (1.6) 8.3 (1.7)

Pediatrician 30.1 (3.1) 24.6 (2.4)

Appendix III: Results of the Medical 

Expenditure Panel Survey Analysis
Appendix III: Results of the Medical 

Expenditure Panel Survey Analysis

Page 50 GAO-13-15 Children’s Mental Health

Percentage of children (standard error) 

Characteristic Medicaid Private insurance

Family practice physician 11.2 (1.9) 11.6 (2.2)

Receipt of mental health services by children with a potential mental health need

Percentage of children with a potential mental health need 13.5 (0.7) 8.7* (0.5)

Utilization of mental health services among children with a mental health need

No mental health office visits 71.7 (2.1) 75.4 (2.2)

No psychosocial therapy 82.4 (1.9) 83.2 (2.0)

No psychotropic medications 69.4 (2.0) 75.2 (2.4)

No office visits or medications 65.4 (2.2) 69.3 (2.5)

Legend: Asterisk indicates a statistically significant difference from children in Medicaid at the 99

percent confidence level.

Source: GAO analysis of Department of Health and Human Services data.

Notes: Data are from the Medical Expenditure Panel Survey. Numbers in parentheses are the 

standard errors—a measure of variation around the estimate. Children were ages 0 through 20 and 

had at least 10 months of coverage by either Medicaid or private insurance in a calendar year.

a

The relative standard error is greater than or equal to 30 percent. Relative standard error is the 

proportion of the standard error divided by the estimate itself.

b

Information below pertains only to children who took psychotropic medications.

c

Information below pertains only to children who had a mental health office visit.
Appendix III: Results of the Medical 

Expenditure Panel Survey Analysis

Page 51 GAO-13-15 Children’s Mental Health

Table 8: Use of Psychotropic Medications and Other Mental Health Services by Children Covered by Medicaid and Private 

Insurance, by Age Group, 2007-2009

Percentage of children (standard error) 

Age group

Characteristic 0-5 years 6-11 years 12-17 years 18-20 years

Use of psychotropic medications

Use of one medication

Medicaid 0.5 (0.2) 4.6 (0.6) a 4.8 (0.6) 7.1 (1.3)

Private insurance 0.1 (0.1) 2.6 (0.4) a 5.5 (0.5) 4.7 (0.6)

Use of two medications

Medicaid 0.1 (0.1) 2.7 (0.4) a 2.0 (0.4) 3.6 (1.0)

Private insurance — 1.5 (0.3) 1.4 (0.3) 1.2 (0.3)

Use of three or more medications

Medicaid — 1.3 (0.3) 1.5 (0.3) 2.0 (0.7)

Private insurance

a

— 0.7 (0.2) 0.6 (0.2) a 0.8 (0.3)

Types of medications taken

a

ADHD medications

Medicaid 0.2 (0.1) 2.6 (0.3) a 1.7 (0.2) 0.3 (0.1)

Private insurance — 1.4* (0.2) 1.7 (0.2) 0.4 (0.1)

Antidepressants

Medicaid — 0.3 (0.1) 0.6 (0.1) 0.6 (0.1)

Private insurance — 0.3 (0.1) 0.7 (0.1) a 0.6 (0.1)

Antipsychotics

Medicaid — 0.6 (0.1) 0.5 (0.1) 0.2 (0.1)

Private insurance — 0.1* (0.1) 0.2 (0.1) a — 

Children with a potential mental health needb

Medicaid 6.4 (1.2) 12.3 (0.9) 16.2 (1.1) N/A

Private insurance 4.2 (1.1) 7.8* (0.6) 9.8* (0.6) N/A

Receipt of Mental Health Services by Children with a Potential Mental Health Need

No mental health office visits

b

Medicaid 88.2 (6.0) 65.7 (3.2) 76.3 (2.8) N/A

Private insurance — 75.4 (3.6) 75.2 (2.6) N/A

No psychosocial therapy

Medicaid 90.4 (5.5) 80.4 (3.0) 83.5 (2.6) N/A

Private insurance — 82.6 (3.4) 82.9 (2.3) N/A

No psychotropic medications

Medicaid 91.2 (5.3) 61.7 (3.4) 74.7 (2.6) N/A

Private insurance — 78.5* (3.8) 72.0 (3.2) N/A
Appendix III: Results of the Medical 

Expenditure Panel Survey Analysis

Page 52 GAO-13-15 Children’s Mental Health

Percentage of children (standard error) 

Age group

Characteristic 0-5 years 6-11 years 12-17 years 18-20 years

No office visits or medications

Medicaid 88.2 (6.0) 58.8 (3.5) 69.9 (2.9) N/A

Private insurance — 70.7 (4.1) 67.3 (3.2) N/A

Legend: Asterisk indicates a statistically significant difference from privately insured children at the 

99 percent confidence level. Dashes indicate the sample size was too small to produce a reliable 

estimate. N/A = not applicable.

Source: GAO analysis of Department of Health and Human Services data.

Notes: Data are from the Medical Expenditure Panel Survey. Numbers in parentheses are the 

standard errors—a measure of variation around the estimate. Children were ages 0 through 20 and 

had at least 10 months of coverage by either Medicaid or private insurance in a calendar year.

a

The relative standard error is greater than or equal to 30 percent. Relative standard error is the 

proportion of the standard error divided by the estimate itself.

b

Children were considered to have a potential mental health need if they scored 16 or above on the 

Columbia Impairment Scale, a psychometric scale used by MEPS that is designed to measure 

emotional and behavioral impairment. The scale was only administered for children ages 5 through 

17; thus the estimates for children ages 18 through 20 were not applicable (N/A).
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 53 GAO-13-15 Children’s Mental Health

Katherine Iritani, (202) 512-7114 or iritanik@gao.gov

In addition to the contact named above, Helene F. Toiv, Assistant 

Director; Laura Brogan; Britt Carlson; Sandra George; Giselle Hicks; 

Hannah Locke; Roseanne Price; and Hemi Tewarson made key 

contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 
Related GAO Products

Page 54 GAO-13-15 Children’s Mental Health

Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions. GAO-12-201. Washington, D.C.: 

December 14, 2011.

Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions. GAO-12-270T. Washington, D.C.: 

December 1, 2011.

Medicaid and CHIP: Most Physicians Serve Covered Children but Have 

Difficulty Referring Them for Specialty Care. GAO-11-624. Washington, 

D.C.: June 30, 2011.

Pediatric Research: Products Studied under Two Related Laws, but 

Improved Tracking Needed by FDA. GAO-11-457. Washington, D.C.: 

May 31, 2011.

Medicaid and CHIP: Reports for Monitoring Children’s Health Care 

Services Need Improvement. GAO-11-293R. Washington, D.C.: 

April 5, 2011.

Foster Care: State Practices for Assessing Health Needs, Facilitating 

Service Delivery, and Monitoring Children’s Care. GAO-09-26. 

Washington, D.C.: February 6, 2009.

Prescription Drugs: FDA’s Oversight of the Promotion of Drugs for OffLabel Uses. GAO-08-835. Washington, D.C.: July 28, 2008.

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