FOSTER CHILDREN

HHS Could Provide 

Additional Guidance to 

States Regarding 

Psychotropic Medications

Statement of Stephen Lord, Managing Director, 

Forensic Audits and Investigative Service Team

Testimony 

Before the Subcommittee on Human 

Resources, Committee on Ways and 

Means, House of Representatives

For Release on Delivery 

Expected at 2 p.m. ET

Thursday, May 29, 2014

GAO-14-651T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-651T, a testimony 

before the Subcommittee on Human 

Resources, Committee on Ways and Means, 

House of Representatives

May 29, 2014

FOSTER CHILDREN

HHS Could Provide Additional Guidance to States 

Regarding Psychotropic Medications

Why GAO Did This Study

Foster children have often been 

removed from abusive or neglectful 

homes and tend to have more mentalhealth conditions than other children. 

Treatment of these conditions may 

include psychotropic drugs, but the 

risks these drugs pose specifically to 

children are not well understood. This 

testimony discusses GAO’s recent 

work on (1) the extent to which children 

in foster care are prescribed 

psychotropic medications, (2) federal 

and state actions to oversee 

psychotropic prescribing to children in 

foster care, and (3) the extent to which 

the use of psychotropic medications 

was supported by foster and medical 

records for selected case studies of 

children in foster care who were 

prescribed these medications. This 

testimony is based on previous GAO 

reports issued from 2011 through 2014 

that used various methodologies, 

including reviewing federal studies, 

analyzing Medicaid prescription claims 

data from five states, and contracting 

with two experts to review 24 case files 

(selected, in part, based on potential 

health risk indicators). The findings 

related to the expert reviews of 24 

case files are not generalizable.

What GAO Recommends

GAO has made recommendations in 

prior work, including that the Secretary 

of Health and Human Services issue

guidance to state Medicaid, childwelfare, and mental-health officials 

regarding prescription-drug monitoring 

and oversight for children in foster care 

receiving psychotropic medications 

through MCOs. The Department of 

Health and Human Services (HHS) 

concurred with the recommendation 

and described planned actions.

What GAO Found

In December 2012, GAO reported on the results of the Administration for 

Children and Families (ACF) surveys of children in contact with the child-welfare 

system conducted during 2008-2011. 18 percent of foster-care children were 

taking a psychotropic medication at the time they were surveyed. Foster children 

who lived in group homes or residential treatment centers had much higher rates 

of psychotropic medication use than those living in nonrelative foster homes or 

formal kin care—48 percent versus 14 percent and 12 percent, respectively, 

according to the surveys. 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. Among foster children who 

took psychotropic medication, about 13 percent took three or more psychotropic 

medications concurrently. About 6.4 percent of foster children took an 

antipsychotic medication—psychotropic medications with potentially serious side 

effects that are intended to treat serious mental-health conditions such as 

schizophrenia—and the majority were ages 6 -11. In examining prescribing at the 

state level, GAO found similar results in its December 2011 review. Specifically, 

children in foster care in Florida, Massachusetts, Michigan, Oregon, and Texas 

were prescribed psychotropic medications at higher rates than nonfoster children 

in Medicaid during 2008, although prescribing rates varied by state. 

In April 2014, GAO found the federal government and states have taken a 

multitude of steps to better oversee psychotropic drug prescribing for children in 

foster care, although more can be done as states increasingly deliver their 

medication benefits through Medicaid managed care. In addition, GAO found 

that, to varying degrees, each of the five selected states it reviewed had policies 

and procedures designed to address the monitoring and oversight of 

psychotropic medications prescribed to children in foster care. For example, all 

five selected states’ foster-care programs use a screening tool that may prompt a 

referral of the foster child for a psychiatric evaluation. GAO also found that ACF 

had provided webinars and technical guidance to states. However, many states 

have, or are transitioning to, managed care organizations (MCO) to deliver 

Medicaid prescription-drug benefits, and GAO found variation in the extent that

the five selected states were taking steps to plan for the oversight of drug 

prescribing for foster children receiving these benefits through MCOs. 

For an April 2014 report, GAO contracted with two child psychiatrists to review

foster and medical records for 24 cases in five selected states and found varying 

quality in the documentation supporting the use of psychotropic medications for 

children in foster care. These experts found that for many of the cases the 

prescriptions were mostly supported by documentation. However, in some areas, 

such as evidence-based therapies—interventions shown to produce 

measureable improvements—the experts found documentation was lacking. For 

example, the experts found that 3 of 15 children who may have benefited from 

such therapies were mostly provided such services, while in 11 of the 15 cases, 

the experts found that evidence-based therapies were partially provided but also 

found that other evidence-based therapies that may have been more applicable 

or beneficial were not provided, based on the documents reviewed. In 1 of the 15 

cases there was no documentation that evidence-based therapies were provided.

View GAO-14-651T. For more information, 

contact Stephen Lord at (202) 512-6722 or 

lords@gao.gov or Katherine Iritani at (202) 

512-7114 or iritanik@gao.gov. 
Page 1 GAO-14-651T

Chairman Reichert, Ranking Member Doggett, and Members of the 

Subcommittee:

I am pleased to be here today to discuss our work examining the use of 

psychotropic drugs among children in foster care. Child mental-health 

advocates, providers, and researchers have expressed concerns about 

the increase in the prescribing of psychotropic medications (medications 

that affect mood, thought, or behavior) for children, in part because there 

is limited evidence available regarding short- and long-term safety and 

efficacy for some types of medications, particularly for combinations of 

these medications. Mental-health experts are especially concerned about 

the recent increase in the prescribing of antipsychotic medications—

psychotropic medications that are intended to treat serious mental-health 

conditions such as schizophrenia and bipolar disorder—in part because 

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

gain and the development of diabetes. Concerns about the increased 

prescribing of psychotropic medications may be compounded for children 

in foster care, who may be at higher risk of mental-health conditions than 

other children. Children in foster care 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.1

Early detection and treatment of mental-health conditions can improve a 

child’s symptoms and reduce potentially detrimental effects, such as 

difficulties with relationships, dropping out of school, and involvement with 

the juvenile justice system. Children with mental-health conditions, 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; or a 

combination of both.

Several agencies in the Department of Health and Human Services 

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

 1

According to the Administration for Children and Families (ACF), 46 percent of children 

investigated by child welfare services came to the state’s attention because of a report of 

neglect, and 27 percent had experienced physical abuse as the most serious form of 

maltreatment. See U.S. Department of Health and Human Services, Administration for 

Children and Families, National Survey of Child and Adolescent Well-Being (NSCAW), 

No. 7: Special Health Care Needs Among Children in Child Welfare (Washington, D.C.: 

Jan. 15, 2007).
Page 2 GAO-14-651T

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 children in foster 

care, among other things. The Centers for Medicare & Medicaid Services 

(CMS) oversees, and jointly finances with the states, the Medicaid 

program, which provides health coverage to most children in foster care.2

My testimony today relates to the use of psychotropic drugs among 

children in foster care. Specifically, my remarks will focus on three areas:

State Medicaid programs are required by federal law to provide coverage 

for certain health services, which may include mental-health services, for 

children through the Early and Periodic Screening, Diagnostic, and 

Treatment (EPSDT) benefit. The Substance Abuse and Mental Health 

Services Administration (SAMHSA) works to increase the quality and 

availability of mental-health services, such as by awarding grants that 

support the development of community-based services for children with 

mental-health conditions, including children in foster care.

• the extent to which children in foster care are prescribed psychotropic 

medications;

• federal and state actions to oversee psychotropic medication 

prescribing to children in foster care; and

• results from reviews of selected case studies of children in foster care 

who were prescribed these medications.

My statement is based on our previously issued reports, issued from 

December 2011 to April 2014, related to psychotropic medication

prescribing among foster care children.3

 2

Medicaid is a joint federal-state program that finances health-care coverage for certain 

low-income individuals.

For this prior work, among other 

things, we described the results of ACF’s National Survey of Child and 

Adolescent Well-being II (NSCAW II), a nationally representative 

3

See GAO, Foster Children: HHS Guidance Could Help States Improve Oversight of 

Psychotropic Prescriptions, GAO-12-201 (Washington, D.C.: Dec. 14, 2011); Children’s 

Mental Health: Concerns Remain about Appropriate Services for Children in Medicaid and 

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

Additional Federal Guidance Could Help States Better Plan for Oversight of Psychotropic 

Medications Administered by Managed-Care Organizations, GAO-14-362 (Washington, 

D.C.: Apr. 28, 2014). Each of these products contains detailed information on the various 

methodologies used in our work.
Page 3 GAO-14-651T

longitudinal survey of children ages 0 through 19 who were in contact with 

the child welfare system.4 In addition, we analyzed 2008 Medicaid 

prescription drug claims and foster care data for five states (Florida, 

Massachusetts, Michigan, Oregon, and Texas), and contracted with two 

child psychiatrists to provide clinical evaluations of 24 cases.5

The work on which this statement is based was conducted 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 audit 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.

The case 

selections were based, in part, on potential health risk indicators identified 

by experts. The cases cannot be generalized to the foster-care 

population. The reports cited in this statement each provide detailed 

information on our scope and methodology.

Children enter state foster care when they have been removed from their 

parents or guardians and placed under the responsibility of a state childwelfare agency. At the end of fiscal year 2012, approximately 400,000 

children were living in foster care, mostly as a result of having 

experienced neglect or abuse by their parents.6

 4

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 support. The agency may place the foster child in the home of a 

relative, with unrelated foster parents, or in a group home or residential 

GAO-13-15; the NSCAW II surveys occurred in multiple phases during 2008 through 

2011. See Office of Planning, Research, and Evaluation, Administration for Children and 

Families, U.S. Department of Health and Human Services, NSCAW II Baseline Report: 

Children’s Services, OPRE Report #2011-27f (Washington, D.C.: 2011) and Office of 

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

Department of Health and Human Services, Psychotropic Medication Use by Children in 

Child Welfare, OPRE Report #2012-33 (Washington, D.C.: 2012).

5

GAO-12-201; GAO-14-362.

6

These are the most recent data available. See U.S. Department of Health and Human 

Services, The AFCARS Report, Preliminary FY 2012 Estimates as of July 2013, No. 20,

(Washington, D.C.: November 2013).

Background
Page 4 GAO-14-651T

treatment center, depending on the child’s needs.7

In 2011, the Child and Family Services Improvement and Innovation Act 

amended the Social Security Act to require states to identify protocols for 

monitoring foster children’s use of psychotropic medications and to 

address how emotional trauma associated with children’s maltreatment 

and removal from their homes will be monitored and treated.

The agency is also 

responsible for arranging needed services, including mental-health 

services. Coordinating mental-health care for children in foster care may 

be difficult for both the medical provider and the caseworker depending 

on the complexity of the child’s needs, and because multiple people are 

making decisions on a child’s behalf. In addition, caseworkers in childwelfare agencies may have large caseloads, making it difficult for them to 

ensure each child under their authority receives adequate mental-health 

services.

8 ACF 

requires states to address these issues in their required Annual Progress 

and Services Reports (APSR) and has provided guidance detailing how 

states are to address protocols for monitoring foster children’s use of 

psychotropic medications as part of the state’s APSR.9

• screening, assessment, and treatment planning to identify children’s 

mental-health and trauma-treatment needs, including a psychiatric 

evaluation, as necessary, to identify needs for psychotropic 

medications;

Among other 

things, state monitoring protocols are to address

• effective medication monitoring at both the client and agency level; 

and

• informed and shared decision making and methods for ongoing 

communication between the prescriber, the child, caregivers, other 

health-care providers, the child-welfare worker, and other key 

stakeholders.

 7

Group homes and residential treatment centers provide 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.

8

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

101(b)(1) and (2), 125 Stat. 369 (amending 42 U.S.C. § 622(b)(15)(A)).

9

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

Families, Program Instruction ACYF-CB-PI-12-05 (Washington, D.C.: Apr. 11, 2012).
Page 5 GAO-14-651T

According to ACF, child-welfare systems that choose to pursue 

comprehensive and integrated approaches to screening, assessing, and 

addressing children’s behavioral and mental-health needs—including the 

effects of childhood traumatic experiences—are more likely to increase 

children’s sense of safety and provide them with effective care.

Children in foster care who are enrolled in Medicaid may receive services 

generally through one of two distinct service-delivery and financing 

systems—managed care or fee-for-service. Under a managed-care 

model, states may contract with a managed-care organization (MCO) and 

prospectively pay the MCO a fixed monthly fee per patient to provide or 

arrange for most health services, which may include prescription-drug 

benefits. The MCOs, in turn, pay providers. In the traditional fee-forservice delivery system, the Medicaid program reimburses providers 

directly and on a retrospective basis for each service delivered.

In December 2012, we reported information on national levels of 

psychotropic drug use among foster care children based on the results of 

the NSCAW II.10 According to the results from NSCAW II, 18 percent of 

foster-care children were taking a psychotropic medication at the time 

they were surveyed.11 Additionally, foster children who lived in group 

homes or residential treatment centers had much higher rates of 

psychotropic medication use than foster children living in nonrelative 

foster homes or formal kin care—48 percent versus 14 percent and 12 

percent, respectively.12

 10

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 

GAO-13-15.

11In 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. 

12Based 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. U.S. Department of Health and Human 

Services, Psychotropic Medication Use by Children in Child Welfare, 2. Formal kin care is 

a living arrangement where the child is placed under legal custody of the state, but in 

physical custody of a relative. Differences 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). U.S. Department of Health and Human Services, 

NSCAW II Baseline Report: Children’s Services, 45–46. 

Children in Foster 

Care Receive 

Psychotropic 

Medications at Higher 

Rates than Other 

Children in Medicaid
Page 6 GAO-14-651T

percent had a potential mental-health need compared to about 44 percent 

of children living in nonrelative foster homes.13 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.14

NSCAW II data showed that 30 percent of foster children with a potential 

mental-health need had not received any mental-health services, such as 

treatment at an outpatient mental-health center or with a mental-health 

professional or family doctor, within the previous 12 months or since the 

start of the child’s living arrangement, if less than 12 months.15

In December 2012 we also found that in addition to reporting on overall 

use of psychotropic medications, the NSCAW II included information on 

concurrent use of psychotropic medications and on the use of 

antipsychotics by foster children. Among foster children who took 

psychotropic medication, 13 percent took three or more psychotropic 

medications concurrently.16 The American Academy of Child & 

Adolescent Psychiatry (AACAP) has noted that there is a lack of research 

on the efficacy of taking multiple psychotropic medications concurrently. 

NSCAW II survey findings also showed that 6.4 percent of foster children 

took an antipsychotic medication and that the majority were ages 6 

through 11.17

 13ACF’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. According to ACF, these scales are reliable 

assessments of children’s behavioral and emotional problems. 

Mental-health researchers and others have stated that there 

14M. 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).

15Estimates of children with potential mental-health need who had not received mentalhealth services are based on NSCAW II phase 2 data (collected during October 2009 

through January 2011). U.S. Department of Health and Human Services, Psychotropic 

Medication Use by Children in Child Welfare, 6.

16Estimates of concurrent 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. U.S. Department of Health and Human Services, Psychotropic Medication Use by 

Children in Child Welfare, 4.

17Estimates 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. U.S. Department of Health and Human Services, Psychotropic Medication Use by

Children in Child Welfare, 4. 
Page 7 GAO-14-651T

is a need for further research on the safety and effectiveness of 

antipsychotics for children, particularly the long-term effects.

In December 2011, we reported findings from our analysis of five states’

Medicaid prescription drug data that found children in foster care in 

Florida, Massachusetts, Michigan, Oregon, and Texas were prescribed 

psychotropic medications at higher rates than nonfoster children in 

Medicaid during 2008.18

In our December 2011 report, we also found that prescriptions for foster 

children in these five states were more likely to have indicators of 

potential health risks. According to experts consulted, no evidence 

supports the concurrent use of five or more psychotropic drugs in adults 

or children, yet an analysis of Medicaid claims data suggested that 

hundreds of both foster and nonfoster children in these five states had 

such a drug regimen. Increasing the number of drugs used concurrently 

increases the likelihood of adverse reactions and long-term side effects, 

such as high cholesterol or diabetes, and limits the ability to assess which 

of multiple drugs are related to a particular treatment goal.

Specifically, we found that among these states 

foster children were prescribed psychotropic drugs at rates 2.7 to 4.5 

times higher than were nonfoster children in Medicaid in 2008. The rates 

were higher among foster children for each of the age ranges—0 to 5 

years old, 6 to 12 years old, and 13 to 17 years old—that we reviewed. 

According to research, experts we consulted, and certain federal and 

state officials we interviewed as part of our December 2011 report, this 

could be due in part to foster children’s greater exposure to traumatic 

experiences, frequent changes in foster placements, and varying state 

oversight policies.

19

 18

Similarly, in 

December 2011 we found that thousands of foster and nonfoster children 

in Medicaid were prescribed doses higher than the maximum levels cited 

in guidelines developed by Texas based on FDA-approved product labels 

GAO-12-201. 

19See Julie M. Zito et al., Psychotropic Medication Patterns Among Youth in Foster Care, 

Pediatrics. vol.121, no. 1 (2008), 157–163.
Page 8 GAO-14-651T

or medical literature maximum dosages for children and adolescents.20

Our experts said that this increases the risk of adverse side effects and 

does not typically increase the efficacy of the drugs to any significant 

extent.21 Further, foster and nonfoster children under 1 year old were 

prescribed psychotropic drugs, which experts consulted said have no 

established use for mental-health conditions in infants and providing them 

these drugs could result in serious adverse effects. These experts also 

said that the prescriptions could have been prescribed for non-mentalhealth reasons, such as for seizures, and to treat allergies, itching, or 

other skin conditions.22

 20Analysis included in our December 2011 report used dosage guidelines developed by 

the state of Texas based on FDA-approved or medical literature maximum dosages for 

children and adolescents. ACF lists these guidelines as an example for other states. For 

additional information, see GAO-12-201 and Texas Department of Family and Protective 

Services, and the University of Texas at Austin College of Pharmacy, Psychotropic 

Medication Utilization Parameters for Foster Children (Austin, Tex.: December 2010).

21The Food and Drug Administration (FDA), within HHS, approves drugs for use for 

specified indications, and these indications are set forth on the drugs’ FDA-approved drug 

labels. 

22Experts also noted that some of these prescriptions may have been written with the 

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

the data whether this was the case.
Page 9 GAO-14-651T

In December 2011, we found that six selected states’ monitoring 

programs for psychotropic drugs provided to foster children fell short of 

best principles guidelines published by the AACAP.23 The guidelines, 

which states were not required to follow at the time of this report, covered 

four categories.24

• Consent: Each state had some practices consistent with AACAP 

consent guidelines such as identifying caregivers empowered to give 

consent.

The following describes the extent to which the selected 

states’ monitoring programs in our review covered these areas.

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

oversight guidelines, which include monitoring rates of prescriptions.

• Consultation: Five states had implemented some but not all 

guidelines, which include providing consultations by child psychiatrists 

by request.

• Information: Four states had created web-sites about psychotropic 

drugs for clinicians, foster parents, and other caregivers.

We found that this variation was expected because states set their own 

guidelines, and, at the time of our 2011 report, HHS had not yet endorsed 

specific measures for state oversight of psychotropic prescriptions for 

children in foster care. We recommended that HHS consider endorsing 

guidance for states on best practices for overseeing psychotropic 

prescriptions for children in foster care. HHS concurred with the 

recommendation and, in April 2012, issued guidance regarding the 

oversight of psychotropic medications among children in foster care. HHS 

has also undertaken collaborative efforts to provide guidance and 

promote information sharing among states.

In April 2014, we issued a follow-up report to, among other things, assess 

HHS actions taken since our 2011 report and describe selected states’

policies related to psychotropic medication.25

 23

In addition to issuing the 

guidance we recommended, HHS efforts have focused on using mentalGAO-12-201. The six selected states included Florida, Maryland, Massachusetts, 

Michigan, Oregon, and Texas. 

24AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in 

State Custody: A Best Principles Guideline.

25GAO-14-362.

HHS and States Have 

Made Progress in 

Improving Oversight 

of Psychotropic 

Prescriptions, but 

Additional Guidance 

Could Help Officials 

Manage Psychotropic 

Medications
Page 10 GAO-14-651T

health screening tools and providing therapies that address trauma, which 

seek to ensure that the mental-health needs of children in foster care are 

appropriately met. See figure 1 below for a list of initiatives undertaken 

since our December 2011 report by ACF, CMS, and SAMHSA.
Page 11 GAO-14-651T

Figure 1: Department of Health and Human Services (HHS) Efforts to Support States’ Oversight of Psychotropic Medications 

among Children in Foster Care and Encourage the Use of Mental-Health Assessments and Screening Tools since December 

2011
Page 12 GAO-14-651T

In our April 2014 follow-up report, we also found that, to varying degrees, 

each of the five selected states we reviewed has policies and procedures 

designed to address the monitoring and oversight of psychotropic 

medications prescribed to children in foster care. For example:

• All five selected states’ foster-care programs use some type of 

functional assessment or screening tool, such as the Child and 

Adolescent Needs and Strengths (CANS), for screening and 

treatment planning, which may prompt a referral for a psychiatric 

evaluation as deemed appropriate.

• All five of the selected states have designed a mechanism to 

coordinate and share some or all Medicaid prescription claims data 

with the state’s foster-care agency to help monitor and review cases 

based on varying criteria, such as prescriptions for children under a 

particular age, high dosages, or concurrent use of multiple 

medications.

Three of five states—Florida, Massachusetts and Texas—included in our 

April 2014 review use, or are transitioning from fee-for-service to, MCOs 

to administer prescription-drug benefits for mental-health medications.

Medicaid officials from two of those three states reported that their states 

had conducted limited planning to ensure appropriate oversight of MCOs 

administering psychotropic medications.

ACF, CMS, and SAMHSA have developed guidance for state Medicaid, 

child-welfare, and mental-health officials related to the oversight of 

psychotropic medications that underscored the need for collaboration 

between state officials to improve prescription monitoring. However, we

found in April 2014 that this guidance does not address oversight within 

the context of a managed-care environment, in which states rely on a 

third party to administer benefits such as psychotropic medications. Many 

states have, or are transitioning to, MCOs to administer prescription-drug 

benefits, and, as our work demonstrates, selected states have taken 

limited steps to plan for the oversight of drug prescribing for foster 

children receiving health care through MCOs—which creates a risk that 

controls instituted in recent years under fee-for-service may not remain 

once states move to managed care. In our April 2014 report, we 

concluded that additional guidance from HHS that helps states prepare 

and implement monitoring efforts within the context of a managed-care 

environment could help ensure appropriate oversight of psychotropic 

medications to children in foster care. We recommended that the 

Secretary of Health and Human Services issue guidance to state 
Page 13 GAO-14-651T

Medicaid, child-welfare, and mental-health officials regarding prescriptiondrug monitoring and oversight for children in foster care receiving 

psychotropic medications through MCOs. HHS concurred with the 

recommendation and described planned actions to address it, such as 

having CMS work with other involved agencies to coordinate guidance 

between CMS and other HHS agencies.

As part of our April 2014 report, we also contracted with two child 

psychiatrists to provide clinical evaluations of 24 cases that we selected 

from the population of foster children prescribed psychotropic drugs in

2008.26

Screening, Assessment, and Treatment Planning. Our experts’

evaluation of this category included whether medical pediatric exams and 

evidence-based therapies—which are interventions shown to produce 

measureable improvements—were provided as needed, according to 

The case selections were based, in part, on potential health risk 

indicators, such as concurrent use of five or more psychotropic 

medications, doses higher than the maximum levels cited in guidelines 

developed by Texas based on FDA-approved labels or medical literature 

maximum dosages for children and adolescents, and children less than 1 

year old prescribed psychotropic drugs. Our experts’ reviews of 24 foster 

children’s foster and medical files in five selected states found that the 

quality of documentation supporting the prescription of psychotropic 

medication usage varied with respect to (1) screening, assessment, and 

treatment planning; (2) medication monitoring; and (3) informed and 

shared decision making.

 26GAO-14-362.

Case Studies

Varied in Quality

of Documentation 

Supporting the

Use of Psychotropic 

Medications

Expert Reviews of Select 

Foster Children’s Foster 

and Medical Files Found 

Variation in the Quality of 

Documentation
Page 14 GAO-14-651T

records.27

Medication Monitoring. Our experts’ evaluation of this category included 

the appropriateness of medication dosage and the rationale for 

concurrent use of multiple medications, according to records. Our experts 

found appropriateness of medication dosages was mostly supported by 

documentation in 13 of 24 cases and partially supported in the other 11 

cases. The rationale for concurrent use of multiple medications was 

mostly supported in 5 of the 20 cases where multiple medications were 

used, but 14 of 20 cases included documentation that partially supported 

concurrent use, and 1 case did not include documentation to support 

concurrent use. For example, in one case with partially supporting 

documentation, our experts found that a child was prescribed four 

psychotropic drugs concurrently, when nonmedication interventions could 

have been considered.

Our experts found in 22 of 24 cases that medical pediatric 

exams were mostly supported by documentation. For example, in one 

case with mostly supporting documentation, experts found that a child 

with a history of behavioral and emotional problems had records 

documenting a medical pediatric exam and thorough psychological 

assessments, with comprehensive discussions of diagnostic issues and 

medication rationale. With regard to evidence-based therapies, experts 

found that 3 of 15 children who may have benefitted from such therapies

were mostly provided such services. In 11 of 15 applicable cases, the 

experts found that evidence-based therapies were partially provided, such 

as for instances when some psychosocial or evidence-based therapies 

were documented, but other evidence-based therapies that may have 

been more applicable or beneficial were not provided. In 1 of 15 cases 

there was no documentation that evidence-based therapies were 

provided.

Informed and Shared Decision Making. Our experts’ evaluation of this 

category included whether informed consent and communication between 

treatment providers occurred, according to records. Our experts found 

that informed-consent decisions were mostly documented in 5 of 23 

applicable cases. In 11 of 23 cases, our experts found partial 

documentation of informed consent—such as when some, but not all, 

medications prescribed to the child included documentation of informed 

 27Psychosocial therapies that have been shown to be effective in treating mental-health 

conditions may be referred to as evidence-based therapies. Trauma-focused cognitive 

behavioral therapy is an example of an evidence-based therapy.
Page 15 GAO-14-651T

consent—and 7 other cases did not include any documentation of 

informed consent. For example, in one case, our experts reported there 

was no documentation of informed consent, psychiatric evaluation, 

psychiatric diagnosis, or monitoring of antipsychotic medication. In this 

case, the child was prescribed an antianxiety medication (buspirone), an 

antipsychotic medication (risperidone), and an ADHD medication 

(clonidine) at 4 years of age, presumably to treat psychiatric symptoms 

that interfered with his functioning, including short attention span, 

wandering off, self-injury, and aggression. However, our experts noted 

the documentation was too sparse to determine why the psychotropic 

medications were prescribed, and the indications, monitoring, and side 

effects could not be evaluated. In addition, our experts found that 

communication between treatment providers was mostly documented in 

15 of 23 applicable cases. However, communication between treatment 

providers was partially documented in 5 of 23 cases, and there was no 

evidence that such communication occurred in 3 of 23 cases. 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. 28 This lack of 

stability can lead to treatment disruptions and can increase the number of 

medications prescribed.

Of the 24 cases reviewed, 9 were infant cases that our experts evaluated 

to determine whether the prescriptions were for psychiatric or non-mentalhealth reasons. Our experts agreed that prescriptions of psychotropic 

medications to infants carries significant risk as there are no established 

mental-health indications for the use of psychotropic medications in 

infants and the medications have the potential to result in serious adverse 

effects for this age group. Our experts found in 4 of 9 infant cases 

reviewed that the prescription of psychotropic medication was for nonmental-health purposes, such as to treat skin conditions, based on 

documentation reviewed. However, our experts found that in 2 of 9 cases 

the infants were prescribed psychotropic medications for psychiatric 

 28ACF 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 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).

Some Prescriptions in 

Infant Cases Were for 

Non-Mental-Health 

Reasons, but Others

Were for Psychiatric or 

Unclear Reasons
Page 16 GAO-14-651T

reasons, and the rationale and oversight for such medications were 

partially supported by documentation. In 3 of 9 infant cases, our experts 

were unable to discern whether the psychotropic medications were 

prescribed to infants for mental-health purposes or for some other 

medical reason, based on documentation reviewed.

In conclusion, early detection and treatment of mental-health conditions 

can improve a child’s symptoms and reduce potentially detrimental 

effects, such as difficulties with relationships, dropping out of school, and 

involvement with the juvenile justice system. Despite the need for 

treatment, child mental-health advocates, providers, and researchers 

have expressed concern about the increase in prescribing of psychotropic 

medications for children because of limited information on the safety and 

efficacy of the medications being prescribed in the child population. 

Children in foster care are especially vulnerable because they more 

frequently have been subjected to traumatic experiences involving abuse 

or neglect and they may suffer from multiple, serious mental-health 

conditions. Our analysis of national survey data, state Medicaid data, and 

a sample of case files indicates that concerns raised by providers, 

advocates, and others about potentially inappropriate prescribing of 

psychotropic medications for children in foster care may be warranted. 

The federal government and state governments in our review recently 

have taken action to improve the oversight of psychotropic medication 

prescribing to foster care children, however, continued assessment and 

guidance is needed to protect this vulnerable population.

Chairman Reichert, Ranking Member Doggett, and Members of the 

Committee, this completes my prepared statement. I would be pleased to 

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

For further information on this testimony, please contact Stephen Lord at 

(202) 512-6722 or lords@gao.gov or Katherine Iritani at (202) 512-7114 

or iritanik@gao.gov. Individuals making key contributions to this testimony 

include Lori Achman, Assistant Director; Matthew Valenta, Assistant 

Director; Scott Clayton; and Linda Miller.

Contacts and 

Acknowledgments

(192446)
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