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45–553 2009

PRESCRIPTION PSYCHOTROPIC DRUG USE 

AMONG CHILDREN IN FOSTER CARE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON 

INCOME SECURITY AND FAMILY SUPPORT 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

MAY 8, 2008 

Serial No. 110–83 

Printed for the use of the Committee on Ways and Means 

( 


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COMMITTEE ON WAYS AND MEANS 

CHARLES B. RANGEL, New York, Chairman 

FORTNEY PETE STARK, California 

SANDER M. LEVIN, Michigan 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

MICHAEL R. MCNULTY, New York 

JOHN S. TANNER, Tennessee 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

EARL POMEROY, North Dakota 

STEPHANIE TUBBS JONES, Ohio 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

RAHM EMANUEL, Illinois 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL JR., New Jersey 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

ALLYSON Y. SCHWARTZ, Pennsylvania 

ARTUR DAVIS, Alabama 

JIM MCCRERY, Louisiana 

WALLY HERGER, California 

DAVE CAMP, Michigan 

JIM RAMSTAD, Minnesota 

SAM JOHNSON, Texas 

PHIL ENGLISH, Pennsylvania 

JERRY WELLER, Illinois 

KENNY HULSHOF, Missouri 

RON LEWIS, Kentucky 

KEVIN BRADY, Texas 

THOMAS M. REYNOLDS, New York 

PAUL RYAN, Wisconsin 

ERIC CANTOR, Virginia 

JOHN LINDER, Georgia 

DEVIN NUNES, California 

PAT TIBERI, Ohio 

JON PORTER, Nevada 

JANICE MAYS, Chief Counsel and Staff Director 

BRETT LOPER, Minority Staff Director 

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT 

JIM MCDERMOTT, Washington, Chairman 

FORTNEY PETE STARK, California 

ARTUR DAVIS, Alabama 

JOHN LEWIS, Georgia 

MICHAEL R. MCNULTY, New York 

SHELLEY BERKLEY, Nevada 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

JERRY WELLER, Illinois 

WALLY HERGER, California 

DAVE CAMP, Michigan 

JON PORTER, Nevada 

PHIL ENGLISH, Pennsylvania 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Ways and Means are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

Page 

Advisory of May 1, 2008, announcing the hearing ............................................... 2 

WITNESSES 

Julie M. Zito, Ph.D., Professor of Pharmacy and Psychiatry, Pharmaceutical 

Health Services Research, University of Maryland, Baltimore ........................ 6 

Jeffery Thompson, M.D., Medical Director, Washington State Department 

of Social and Health Services, Olympia, Washington ....................................... 14 

Tricia Lea, Ph.D., Director of Medical and Behavioral Services, Department 

of Children’s Services, State of Tennessee, Nashville, Tennessee ................... 20 

Misty Stenslie, Deputy Director, Foster Care Alumni of America ...................... 27 

Laurel K. Leslie, Developmental-Behavioral Pediatrician, Center on Child 

and Family Outcomes, Tufts-New England Medical Center Institute for 

Clinical Research and Health Policy Studies, Boston, Massachusetts ............ 38 

Christopher Bellonci, M.D., Medical Director, The Walker School, Needham, 

Massachusetts ...................................................................................................... 46 

SUBMISSIONS FOR THE RECORD 

American Academy of Pediatrics, statement ......................................................... 74 

Vera Hassner Sharav, statement ........................................................................... 76 

Carl Smudde, statement ......................................................................................... 84 

Bruce Lesley, statement .......................................................................................... 84 

Jody Leibman Green, statement ............................................................................ 87 

Tara Thomson, statement ....................................................................................... 89 


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(1) 

PRESCRIPTION PSYCHOTROPIC DRUG USE 

AMONG CHILDREN IN FOSTER CARE 

THURSDAY, MAY 8, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON WAYS AND MEANS, 

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 11:00 a.m., in 

room B–318, Rayburn House Office Building, Hon. Jim McDermott 

(Chairman of the Subcommittee), presiding. 

[The advisory announcing the hearing follows:] 


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ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON 

INCOME SECURITY AND FAMILY SUPPORT 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1025 

May 01, 2008 

ISFS–16 

McDermott Announces Hearing on 

the Utilization of Psychotropic Medication 

for Children in Foster Care 

Congressman Jim McDermott (D–WA), Chairman of the Subcommittee on Income 

Security and Family Support, today announced a hearing to examine the use of 

psychotropic drugs for children in the foster care system. The hearing will take 

place on Thursday, May 8, 2008, at 11:00 a.m. in room B–318 Rayburn House 

Office Building. 

In view of the limited time available to hear witnesses, oral testimony at this 

hearing will be from invited witnesses only. However, any individual or organization 

not scheduled for an oral appearance may submit a written statement for consideration by the Subcommittee and for inclusion in the printed record of the hearing. 

BACKGROUND: 

Psychotropic medications have been increasingly prescribed for children in recent 

years, but the use of these drugs appears to be particularly elevated for children 

in foster care. One recent study found that psychotropic drug treatment was three 

or four times more common for youth in foster care than for other children receiving 

healthcare services through the Medicaid program. Additionally, children in foster 

care are often prescribed multiple psychotropic medications, and sometimes these 

drugs are used for off-label purposes (i.e., meaning their effects have not been demonstrated in children). These medicines are most commonly used to treat depression, 

anxiety and attention-deficit/hyperactivity disorder. 

While the trauma associated with coming into foster care may increase some children’s need for certain prescription drugs, the high rate of use of psychotropic medications in foster care has raised concerns regarding the monitoring of these drugs 

and whether a continuum of treatment services is being provided to these children 

beyond medication. It appears only a minority of States have established methods 

to formally regulate the use and administration of these medications among children 

in their care. 

In announcing the hearing, Chairman McDermott stated, ‘‘Some children in 

foster care may need and benefit from psychotropic medication. But these 

drugs should not be used as a shortcut to treat foster children when more 

effective treatments, including counseling, might provide long-term benefits. We need to carefully oversee the prescription of these medicines, especially when it comes to placing foster children on multiple drugs or prescribing medication for off-label use.’’ 

FOCUS OF THE HEARING: 

The hearing will examine the use of prescription psychotropic drugs among children in the foster care system. 


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DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee 

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘110th Congress’’ from the menu entitled, 

‘‘Hearing Archives’’ (http://waysandmeans.house.gov/Hearings.asp?congress=18). Select the hearing for which you would like to submit, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Follow the online instructions, 

completing all informational forms and clicking ‘‘submit.’’ Attach your submission as 

a Word or WordPerfect document, in compliance with the formatting requirements 

listed below, by close of business on May 22, 2008. Finally, please note that due 

to the change in House mail policy, the U.S. Capitol Police will refuse sealed-package deliveries to all House Office Buildings. For questions, or if you encounter technical problems, please call (202) 225–1721. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the Committee by a witness, any supplementary materials submitted for the printed record, and any written comments in response 

to a request for written comments must conform to the guidelines listed below. Any submission 

or supplementary item not in compliance with these guidelines will not be printed, but will be 

maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word or WordPerfect 

format and MUST NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official 

hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

3. All submissions must include a list of all clients, persons, and/or organizations on whose 

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone and fax numbers of each witness. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://waysandmeans.house.gov. 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TTD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

f 

Chairman MCDERMOTT. The meeting will come to order. 

I will not further apologize but to say thank you very much for 

staying. As a medical doctor and a child psychiatrist, today’s hearing is especially important to me because the issue before us is not 

some academic, text book study case. The issue is real and is defined by untold numbers of foster kids who are taking psychotropic 

drugs. 

When at-risk children are taken into custody for their own safety, they become foster children, and we become their parents. 

Along with that comes a special obligation, I believe, to protect and 

care for them. We are here today to fulfill part of our responsibility 

by evaluating the use and supervision of psychotropic or mind-altering drugs for children in foster care. 


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This review is particularly timely, since today is National Children’s Mental Health Awareness Day. While our discussion may 

touch on the fact that all children are prescribed psychotropic 

drugs, more now than in the past, that issue is now largely beyond 

the scope of the Subcommittee. Our focus today is on the use and 

regulation of these medications for foster children; and, recent research presents some troubling findings for us. 

Here, foster children are three to four times more likely to be 

prescribed psychotropic medication than other children receiving 

Medicaid services. Got a pill, here’s a problem. Got a pill is not the 

continuum of treatment options that these children deserve. Additionally, foster children are often prescribed and administered several of these drugs at the same time. 

We’ll hear about a case study in Texas where over 40 percent of 

foster children who have been dispensed psychotropic drugs in 

2004 were concurrently receiving three or more drugs at one time. 

Finally, it appears that a significant number of children in foster 

care are prescribed these medications that are for off-label use; 

which means that its effects have not been demonstrated in children. 

Now, children coming into foster care have suffered various degrees of psychological trauma. As a child psychiatrist I have no 

doubt that some of them may benefit from medication, but I also 

worry that foster children may sometimes be prescribed psychotropics, because such treatment is easy and quick as opposed to effective and really appropriate. I think we need better oversight and 

coordination for all healthcare needs of foster children and I include such a requirement in the legislation I recently introduced 

called the Invest in KIDS Act. In terms of specific reforms that address concerns about over-prescribing of psychotropic drugs, three 

issues come to mind. 

First, every State should establish a review process for use of 

these medications for foster kids. Are the drugs appropriate and 

safe for kids? Is the quantity used appropriate; and are other treatment options available? These are questions that need to be asked. 

Second, foster children need continuity in their healthcare. Their 

primary physician should not change every time their placement 

does; and their medical records should not be split between multiple doctor’s offices. This idea of a consistent, single healthcare 

provider is sometimes called a medical home; and, these kids need 

more than one home. 

Third, we need to ensure that foster children have access to a 

wide range of treatment options and a way to navigate through 

those options. Many believe the state’s ability to achieve this goal 

will be undermined by the administration’s regulation to limit Medicaid funding for so-called targeted case management services, 

which is a fancy term for helping people access services designed 

to promote their health and well-being. 

The House of Representatives recently passed legislation by a 

vote of 349 to 62 to suspend this and several other Medicaid regulations that threaten to restrict access to needed care. Foster kids 

are our kids. Jerry and I are the Godfathers of the foster kids of 

this country and we should treat them accordingly. 


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Today, we will focus on ensuring they receive the type of treatment that best meets their needs and best supports their long-term 

development. I now yield to Mr. Weller. 

Mr. WELLER. Thank you, Mr. Chairman. 

In Spanish you say ‘‘compadre,’’ as the Godfather. Thank you for 

conducting this hearing, Mr. Chairman, and to our witnesses, 

thank you for your patience this morning. We had votes today requested by both Republicans and Democrats, and we expect to 

spend a little more time on the floor than we anticipated. So, I’m 

sorry that you were tied up and I hope this doesn’t affect your 

schedules this afternoon. 

We appreciate the time you are committing to this important 

hearing today. We are here this morning to review concerns about 

the health of foster children and the healthcare provided them. 

Today, our specific topic is the use and possible overuse of psychotropic medications amongst these children. Children in foster care 

often have serious, mental and behavioral challenges. 

As we have heard in prior hearings, too many foster children 

have multiple home placements, jump from school to school, and 

are seen by multiple caseworkers and doctors with little consistent 

oversight. Foster children should have access to the same range of 

health treatments including medicines as other children so they 

can overcome their challenges and grow up to be healthy, productive adults. 

Through Medicaid and other programs, children in foster care 

are entitled to healthcare coverage; however, as we have learned 

from previous hearings, this does not mean that all foster children 

receive adequate care. At today’s hearing we’ll hear about the appropriateness of psychotropic medications provided to foster children and the systems in place to ensure that children are receiving 

proper care. 

Unfortunately, recent research points to serious questions about 

the use and possible overuse of such drugs amongst foster children. 

Given the challenges they face, it’s not surprising that many foster 

children may benefit from specialized medications to help them 

deal with anxiety, depression, and a host of other issues. 

However, it is bracing to learn that children in foster care use 

these drugs at three to four times the rate as other children with 

Medicaid coverage. It is our responsibility to ensure the foster care 

and medical systems carefully and responsibly establish that foster 

children are being properly cared for. So we have many questions 

today. 

For example, are we sure that all foster children receiving drugs 

need them? 

Are we sure and confident that the drugs they are taking are appropriate for and have been proven effective in children? 

Are we sure and confident that foster children are taking these 

drugs properly and that they benefit from the drugs they take? 

Are some foster children receiving dangerous combinations of 

multiple drugs? Do we know whether states have proper systems 

to monitor the safety and effectiveness of these drugs when prescribed to foster children? Those are the types of questions any parent would want to know before his or her child takes such medications. 


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As Misty Stenslie of the Foster Care Alumni Association, one 

who has personally experienced psychotropic drugs, notes in her 

testimony, we are standing in the place where the parents of children in foster care belong. So we need to ask these questions and 

we need to get answers. 

I look forward to testimony today and working with my colleagues in a bipartisan way to ensure we are doing right by these 

children. Again, thank you, Mr. Chairman, for conducting this important hearing and thank you to the panelists for joining us today. 

I yield back. 

Chairman MCDERMOTT. Thank you. Your testimony will be entered in full into the record; and, the purpose of this hearing really 

is to give us ideas about legislation that we can craft that will be 

useful across the country. 

One of the problems we’re going to hear about, I think, here is 

the sort of patchwork of what we have today and we’d like to have 

your ideas about how best to deal with that so that we can make 

it not a problem whether you’re raised in Kentucky, New Hampshire, Washington State, Illinois or wherever. 

You should get the same kind of treatment, more or less, with 

respect to these medications; so, we will begin by Dr. Zito from Baltimore, Maryland, University of Maryland. 

Dr. Zito? 

STATEMENT OF JULIE M. ZITO, PH.D., PROFESSOR OF PHARMACY AND PSYCHIATRY, PHARMACEUTICAL HEALTH SERVICES RESEARCH, UNIVERSITY OF MARYLAND 

Dr. ZITO. Thank you, Mr. Chairman. 

My name is Julie Magno Zito and I am really pleased to be invited to testify today, a professor of pharmacy and psychiatry at 

the University of Maryland in Baltimore, and my research focus 

has been on pharmico-epidemiology in the area of psychiatry with 

a particular focus on child mental health. 

We published over a hundred papers that deal with the various 

aspects of community-based medication used for emotional and behavioral conditions. Prior to coming to Maryland, I was at the New 

York State Office of Mental Health, where I developed guidelines 

for physician prescribing of psychotropic drugs for severe mental 

disorders. 

In the year 2000, Carol Strayhorne, Comptroller of the State of 

Texas, requested an independent analysis of psychotropic medication patterns for foster care children in the State of Texas, which 

we agreed to conduct with data that were supplied by the Texas 

Department of Health and Human Services and were then analyzed at the University of Maryland. So the focus of my comments 

to you will reflect the study on Texas foster care, primarily, but I 

would like to put it a bit in the context of the general overall use 

of psychotropic drugs in children in the United States. 

I would like to make four points in my 4 minutes, so these will 

be fairly brief. First, I think there is a real need for communitybased studies of outcomes of psychotropic treatment, not just in foster care, but in all children, because we have had this dramatic, 

expanded use of psychotropics for emotional, behavioral conditions, 

and, most of that evidence, is based on clinical trial studies in volVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00010 Fmt 6633 Sfmt 6602 E:\HR\OC\45553.XXX 45553

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unteer populations for short-term use. So we really don’t know the 

extent to which children (to answer Mr. Weller’s question ‘‘what do 

we know,’’) benefit based on community-based populations because 

they are not likely to be the same population as were in clinical trials. 

The second point I’d like to make is that we have to get beyond 

symptom control in knowing that drugs really work well in children, so beyond symptom controls, what does that mean? 

By beyond symptom control for short term use I think we want 

to know how well children benefit in terms of academic performance, in terms of their development, social needs and social relationships; and, also in terms of safety. Finally, in regard to this 

point I think we need cooperation that could take place right now 

within every State to link relevant foster care agencies: one that 

has responsibility for oversight (which in Maryland we call the Department of Human Resources) and, to link their databases with 

the databases that are in the Maryland Medicaid System so that 

we can better understand treatment services and outcomes of care. 

This linkage is relatively inexpensive and could be done immediately; and, what would that allow us to do? It would allow us to 

see the level of continuity of care and to see these outcomes in 

terms of the type of placement setting that the children are in. 

Also, in foster care from the data in our paper, rates of psychotropic utilization are three to four times higher than the children 

who are in Medicaid because of low income (TANF or S–CHIP). 

More interesting even than that fact is that if you look at preschoolers in Texas, foster care youth, 12 percent were receiving psychotropic meds and 67 percent of the kids in the 13 to 17 years of age. 

So, I suggest that parents and advocates would be willing to say 

that when two-thirds of foster care adolescence receive psychotropic 

medication for behavioral and emotional problems, which is far, far 

in excess of the non-foster care population, we should be able to 

have assurances that the youth are benefiting from the treatments. 

This is not just Texas by any means. We have data from Minnesota, California, Delaware, and Pennsylvania. All of them show 

the same thing—relatively high rates. 

So to conclude this point, I would ask why don’t we have national 

reporting of foster care treatment so that we can look at the variation by State and by region and come to a better understanding 

of what might be excessive or what might be appropriate? We don’t 

know from just looking at these numbers and we can’t really make 

very strong inferences about appropriateness, because there’s no 

question in anyone’s mind that the needs of these children for mental health services is very, very, great. 

Third point, concomitant medication use which you have alluded 

to, some people call it ‘‘polypharmacy,’’ but that’s a pejorative word 

in a lot of circles so we say concomitant, i.e., intended to be used 

together. Here, the Texas data were pretty compelling when 73 

percent of the kids on medicine were likely to receive two or more 

and forty percent three or more psychotropic drug classes. 

What do those concomitant classes tell you? That they are likely 

to be anti-depressants or anti-psychotics, although the population 

that’s actually being treated for psychosis is far smaller than the 

antipsychotic use suggests; and, the third group is stimulants. So 

that’s the story in terms of concomitant use. 


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Why do we worry about that? Well, first of all as you said it’s 

virtually all off-label, so there’s very little basic work that’s been 

done to support their efficacy or safety, even in ideal populations, 

let alone in community-based populations. 

The fourth point is that more therapeutic research is needed because pediatric populations are not the same as adults. Children 

are not little adults, as we all learned a long time ago, and even 

their adverse event profile looks remarkably different. So we’re 

really looking at experimental experience, which may be what the 

SSRI safety concerns pointed out to us 2 years ago. Related to concomitant use, the fact is that more drugs used together present 

more opportunities for expanded adverse events. So, what could we 

do about drug safety? 

We could get serious in the United States about drug safety, in 

order to look for low frequency (rare) events. You’ve got to look out 

there in the community, in the usual practice population, not only 

in the ideal subjects who come into clinical trials. 

We need money and funding for that naturally, and that sounds 

very self-serving. Beyond the money and funding for it, I think we 

need a change in the way we approach the answer to the question 

‘‘does this drug work and in whom?’’ Then, last point is on oversight. Here I would laud Illinois and Tennessee for their more creative approaches to the question of how to perform oversight. 

In general, oversight is pretty weak. There are no consequences 

if a physician gets a letter in the mail. Who knows why five or 

more concomitant psychotropic classes for a child is an adequate 

cut point to signal oversight review. There’s absolutely no empirical 

evidence—none—zero. It seems to be copied somewhere from adult 

standards which might be reasonable, but in children, it’s a really 

strange number. 

So we recommend that there be the kind of oversight that Illinois 

and Tennessee are suggesting after somebody’s on three concomitant classes at one time. I’ll stop there. 

[The prepared statement of Ms. Zito follows:] 

Prepared Statement of Julie M. Zito, Ph.D., 

Professor of Pharmacy and Psychiatry, Pharmaceutical Health 

Services Research, University of Maryland, Baltimore 

My name is Julie Magno Zito. Thank you for the invitation to testify today. I am 

a Professor of Pharmacy and Psychiatry at the University of Maryland, Baltimore. 

I have received more than 4 million dollars in NIH and foundation support. This 

support has allowed me to pursue pharmacoepidemiologic research as a specialty in 

the area of psychiatry, with a focus in the area of child mental health. Our team 

of specialists includes child psychiatrist and pediatrician researchers, pharmaceutical computing experts and epidemiologists and together we have published 

nearly 100 research papers on population-based medication use for the treatment 

of emotional and behavioral conditions. Prior to this position, I was a research scientist at the Nathan Kline Institute in New York where I developed guidelines for 

physician prescribing of psychotropic drugs for severe mental disorders (Zito, 1994). 

In 2006, Carole K. Strayhorn, Comptroller of the state of Texas requested an independent analysis of psychotropic medication patterns for foster care children in 

Texas which we agreed to conduct with data supplied by the Texas Department of 

Health and Human Services and analyzed at the University of Maryland. The results of that analysis are the focus of my report today. 

OBJECTIVES FOR THE PREPARED TESTIMONY 

My objective for the prepared testimony is to present and support four major 

points. 


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Need for Community-based Studies on Outcomes of Psychotropic Treatment. Since 

1990, the expanded use of psychotropic medication to treat emotional and behavioral 

problems in U.S. youth has caught the attention of the media without adequately 

informing the public of evidence of beneficial and appropriate use. To address this 

important gap in our knowledge base on the benefits and risks of such treatments 

requires sustained study in community-based youth populations—not just in clinical 

trial volunteers. Post-marketing studies are particularly important to identify and 

describe patient outcome in terms of academic performance, social development and 

avoidance of negative outcomes, e.g. crime, substance abuse and school failure—in 

other words, beyond symptom control. In the current U.S. research environment, 

most medication research focuses on symptom improvement in short-term clinical 

trials which is necessary but not sufficient information to establish the role of medication in community-based pediatric populations. Therefore, we recommend outcome 

studies of community-treated youth—for all youth, but particularly in foster care 

and disabled youth because they have the greatest likelihood of receiving complex, 

poorly evidenced, high cost medication regimens. Cooperation between the state 

agency responsible for oversight of child welfare and the Medicaid administration 

would permit databases to be linked so that the continuity of care and outcome in 

foster care can be assessed according to the type of placement setting. 

High Foster Care-specific Prevalence of Psychotropic Medication Use. Among community-based populations, foster care youth tend to receive psychotropic medication 

as much as or more than disabled youth and 3–4 times the rate among children 

with Medicaid coverage based on family income [temporary assistance for needy 

families (TANF) or state-Children’s Health Insurance Program, (s-CHIP)]. For example, in 2004, 38% of the 32,000+ Texas foster care youth less than 19 years of 

age received a psychotropic prescription (Zito et al., 2008). When 2005 data were 

disaggregated by age group the 2005 annual prevalence of psychotropic medication 

was: 12.4% in 0–5 year olds; 55% in 6–12 year olds; and 66.5% in 13–17 year olds. 

When two-thirds of foster care adolescents receive treatment for emotional and behavioral problems, far in excess of the proportion in non-foster care population, we 

should have assurances that the youth are benefiting from such treatment. Relatively high annual prevalence of psychotropic medications also has been reported 

for foster care youth in Minnesota (Hagen & Orbeck, 2006), Maryland (dosReis, Zito, 

Safer, & Soeken, 2001; Zito, Safer, Zuckerman, Gardner, & Soeken, 2005), Delaware 

(dosReis et al., 2005), California (Zima, Bussing, Crecelius, Kaufman, & Belin, 

1999), and Pennsylvania (Harman, Childs, & Kelleher, 2000). Collectively, these 

patterns raise questions but do not address appropriateness and the role of medication in this vulnerable and needy population. Whether medication addresses the social, environmental and developmental needs of youth where unstable family structures are the norm is unknown. 

Data for descriptive utilization studies are readily available through the Center 

for Medicaid and Medicare (CMS), and are relatively inexpensive to organize and 

analyze but as yet there is no national reporting of foster care treatment. Questions 

about why, typically foster care youth exceed the use of psychopharmacologic drugs 

observed in disabled youth deserve to be explored from a broader, societal perspective as well as from a clinical perspective. Poverty, social deprivation, and unsafe 

living environments do not necessarily justify complex, poorly evidenced 

psychopharmacologic drug regimens. 

Concomitant Psychotropic Medication Patterns in Foster Care with Little Evidence of Effectiveness or Safety. Combinations of medication are prescribed in order 

to address multiple symptoms. The sparse data on such practice patterns suggest 

that it is increasing (Safer, Zito, & dosReis, 2003). To assess concomitant psychotropic classes in the Texas foster care data, we selected a one month cohort of youth 

in July 2004 and found 29% (n=429) received one or more classes of these medications. Of these psychotropic-medicated youth, 72.5% received two or more psychotropic medication classes and 41.3% received 3 or more such classes. In such combinations, more than half the medicated youth had an antidepressant (56.8%); a 

similar proportion (55.6%) had an ADHD medication (a stimulant or atomoxetine) 

dispensed, and 53.2% had an antipsychotic dispensed. Most psychotropic combinations lack adequate evidence of effectiveness or safety in youth. Typically, they are 

adopted based on knowledge generalized from adult studies or assume that the combination is as safe and effective as each component of the regimen. Such assumptions, however, are not warranted because data reveal that children and adolescents 

differ from adults in adverse drug reactions to psychotropic medications (Safer, 

2004; Safer & Zito, 2006). In addition, pediatric research shows that increasing the 

number of concomitant medications increases the likelihood of adverse drug reactions (Turner, Nunn, Fielding, & Choonara, 1999; Martinez-Mir et al., 1999). Longterm safety and drug-drug interactions are also more problematic. Data show that 


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poorly evidenced regimens tend to increase in complexity over the age span suggesting that polypharmacy is not effective in managing the multiplicity of problems 

of foster care youth and others with serious social, behavioral and mental health 

problems who are often referred to as treatment-resistant or difficult to treat (Lader 

& Naber, 1999). This is particularly true when observing youth with repeated hospitalizations. In the Texas cohort, 13% had a psychiatric hospitalization in the study 

year and 42% of these had a psychiatric hospital diagnosis of bipolar disorder. As 

younger age youth receive psychotropic medications, the early introduction of medications to the developing youth (12% of preschoolers in these data from Texas), suggests the need for drug safety studies. Drug safety studies require access to large 

community-based data sets, formation of cohorts for longitudinal assessment over 

successive years and epidemiologic methods for conducting observational safety 

studies. Yet, funding and training of clinical scientists for this type of research is 

quite modest (Klein, 1993; Klein, 2006) while the FDA is largely focused on the premarketing assessment of new drugs (APHA Joint Policy Committee, 2006). 

Concomitant medication with antipsychotics and anticonvulsant-mood stabilizers 

is referred to as ‘‘off-label’ usage, i.e., lacking FDA approved labeling for either the 

age group or the indication for treatment, e.g. an antipsychotic for ADHD or disruptive disorders. In the Texas foster care data, most antidepressant use was also offlabel. Moreover, when the drug class use was compared among the leading diagnostic groups, there was little evidence of specificity. In youth with 3 or more medication classes, antipsychotic medications were used in 76.1% of those with an ADHD 

diagnosis; 75.8% of those with adjustment or anxiety diagnoses; and 84.1% of those 

with a depression diagnosis. If medication regimens increase the risk of adverse 

events without robust evidence of benefits (outcomes), prudence suggests that oversight programs monitor and review therapeutic interventions in professionally competent, individualized, and caring assessments. 

Foster Care Oversight, Quality Assessment and Public Health-oriented Prescriber 

Education. Quality assurance programs for psychopharmacologic treatments aim to 

review and assess the appropriateness of therapy. Such programs are understandably weak because: 1) record reviews are not always accurate; 2) multiple prescribing physicians may account for prescriptions that are not actually in use; 3) 

computerized systems that trigger automatic warning letters frequently have no impact (Soumerai, McLaughlin, & Avorn, 1990) in part because there are no consequences for prescribing outside the guidelines. In the Texas Medicaid system, the 

Texas Department of State Health Services panel produced practice guidelines for 

youth in Medicaid in 2005 (Texas Dept of State Health Services, 2005). They concluded that a department review should be required if antipsychotic agents and 

antidepressants were prescribed for youth under 4 years of age, stimulants under 

3 years of age, if 2 or more drugs from the same class were prescribed concomitantly, and if 5 or more different classes of psychotropic medication were prescribed 

concomitantly. Five months after promulgating these criteria, there was a 31% drop 

in use of 5 or more psychotropic classes among foster care youth (Texas Health and 

Human Services Commission, 2006). Illinois and Tennessee foster care programs 

have implemented oversight based on a central or regional academic reviewing process that is intended to keep prescribing physicians up to date on current practice 

and to discourage unnecessary or potentially unsafe regimens. This is a laudable 

step in the direction of more nuanced, comprehensive reviews and allows for a patient-specific, individualized review. If such programs are evaluated formally, they 

can provide valuable information on the feasibility and success of this approach to 

improve the quality of psychotropic medications for foster care. 

We recommend that the criterion for triggering an individualized patient record 

review is the dispensing of 3 or more concomitant psychotropic medication classes 

in youth given that such drug use lacks supportive evidence and systematic safety 

studies, and is off-label in almost all instances. Essentially, 3-drug class regimens 

have inadequate evidence for a therapeutic benefit and safety in youth. Additional 

appropriate triggers include young age (antipsychotic or antidepressant in <4 years 

olds) and 2 or more drugs used concomitantly within the same class. 

BACKGROUND 

Increased Psychotropic Medications for Youth: Good News or Bad News? 

Medicaid insurance covers vulnerable pediatric populations including youth with 

disabilities and those in foster care, as well as youth qualifying by low family income [temporary assistance to needy families (TANF) and state-Children’s Health 

Insurance Program (s-CHIP)]. The treatment experience of Medicaid youth is accessible for population-based research because the Center for Medicaid and Medicare 

Services (CMS) is a repository of detailed administrative data on outpatient visits 

and medication dispensings along with demographic data including race/ethnicity 


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and enrollment characteristics. These data enable researchers to create yearly 

trends in health service use including psychotropic drugs across states. 

Since 1990, psychotropic medication use in children and adolescents has increased 

dramatically across all insured youth (Zito et al., 2003). Among more than 900,000 

youth with either Medicaid or HMO insurance coverage, administrative claims data 

from the community showed the use of a psychotropic medication was 2–3 times 

greater in 1996 than 10 years earlier. In general, Medicaid youth receive more mental health services including psychotropic medications than commercially-insured 

youth because they have more impairments (Shatin, Levin, Ireys, & Haller, 1998). 

Data on Medicaid-insured youth in a northeastern state showed 8.9% of youth less 

than 19 years old received a psychotropic medication in 2007 (Pandiani & Carroll, 

2008). Remarkably, antipsychotic use increased approximately 6-fold between 1997 

and 2007. While the rising use affects all age groups, the rise is particularly notable 

in preschoolers. Medicaid-insured preschoolers from 7 states were 5-times more likely to received an antipsychotic and twice as likely to receive an antidepressant in 

2001 compared with 1995 data from 2 other states (Zito et al., 2007). The trend toward increased prevalence of psychotropic medication is similar in commercially-insured youth although the annual rate is lower. This trend is illustrated by national 

parent survey data [Medical Expenditure Panel Survey, MEPS] for the 1987–1996 

decade and showed similar growth (Olfson, Marcus, Weissman, & Jensen, 2002). In 

summary, population-based analyses of psychotropic usage patterns for youth show 

variations in use according to region, race/ethnicity, type of insurance, as well as 

clinically relevant differences in age group, gender and type of condition (Zito, Safer, 

& Craig, 2008). When the 30% of U.S. youth with Medicaid insurance are analyzed 

according to eligibility, foster care is likely to be the group receiving the highest 

rates of psychotropic medication relative to the disabled (eligible by Supplemental 

Security Income) and those with income eligibility. 

Foster Care Psychotropic Medication Use 

Demographic Profile of Foster Care Youth in the United States. In 2005, 514,000 

youth were in publicly supported foster care—less than 1% (0.7%) of the 74 million 

youth less than 18 years of age (Administration for Children Youth and Families, 

2008). Data from 2000 showed gender is equally split. A majority is 6–15 years old: 

11–15 year olds (29%); 6–10 year olds (25%); 1–5 (24%); 16–18 year olds (16%); and 

the remainder are less than 1 and over 18. In FY 2000, African-American youth represented the largest share of children in foster care (41%) followed by White (40%), 

Hispanic (15%) and Native American (2%). These race/ethnicity characteristics are 

disproportionately high relative to the U.S. population of African-Americans (15%) 

and Native Americans (1%). Length of stay data indicate that 55% of youth are in 

foster care for less than 2 years. As children age, their chances of reaching optimal 

residency (permanency goal) diminishes. A large majority of youth in foster care live 

in a non-relative foster home (47%) or in a relative foster home (25%). Most youth 

return to parental care (57%) while adoption or living with relatives occurs in 27% 

of cases. Against this statistical demographic profile, we will explore the medical 

treatments for behavioral and psychiatric conditions with a focus on psychotropic 

medications. 

Psychotropic Prevalence in Foster Care. Among the 32,135 Texas foster care Medicaid enrollees less than 20 years old in the study year September 2003 to August 

2004, 37.9% of youths had a psychotropic medication dispensing (Zito et al., 2008). 

This figure contrasts with 25.8% (CI 25.0–26.6) annual prevalence from a Mid-Atlantic foster care population in 2000 (Zito et al., 2005). In 1998, 34% of youth ages 

3–16 in St. Louis County, Minnesota Family Foster Care had at least 1 psychotropic 

medication dispensing. This compared with 15% of youth receiving a psychotropic 

medication in the general population (Hagen et al., 2006). 

Among Medicaid enrollees less than 20 years old in a populous suburban county 

of a mid-Atlantic state in 1996, psychotropic treatment prevalence rates for foster 

care youths were 1.7 (95% CI=1.4,2.2) times higher than those for SSI youths and 

18 (95% CI=14.9,22.7) times higher than those for youths in the other aid group 

(dosReis et al., 2001). Other aid refers primarily to eligibility based on income or 

medical need. 

In FY 1995, Medicaid claims from foster care youth 5–17 continuously enrolled 

youth in Southwestern Pennsylvania showed these children were 3 to 10 times more 

likely to receive a mental health diagnosis. They were 7.5 times more likely to be 

hospitalized for a mental health condition than children covered by AFDC. Prevalence of psychiatric conditions was comparable between foster care and disabled 

youth (Harman et al., 2000). 

Foster care youth with a diagnosis of autism spectrum disorder (ASD) were twice 

as likely to receive concomitant drug therapy (defined as 3 or more medication classVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00015 Fmt 6633 Sfmt 6621 E:\HR\OC\45553.XXX 45553

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es overlapping for more than 30 days in the year 2001) compared with their counterparts eligible by low family income. Findings from this large national sample suggest that factors unrelated to clinical presentation may account for these prescribing 

practices and warrant further research ((Mandell et al., 2008). 

Concomitant Psychotropic Medications: More Than One in the Same Class or Between Classes 

A recent review of the sparse literature on concomitant psychotropic medication 

use in youth revealed that this treatment regimen was rarely used in children in 

the late 1980s (Safer et al., 2003). Bhatara et al. showed concomitant use for the 

treatment of attention deficit hyperactivity disorder (ADHD) based on national ambulatory medical care survey (NAMCS) data increased 5-fold from 1993 through 

1998 (Bhatara, Feil, Hoagwood, Vitiello, & Zima, 2002). Across all conditions, there 

was an increase of 2.5-fold from 4.7% to 11.6% using MEPS data that was observed 

by Olfson et al. for the period from 1987 through 1996 (Olfson et al., 2002). In general, this review suggests that concomitant use of psychotropic medications in youth 

is a recent phenomenon. Common combinations include stimulants and clonidine 

(Zarin, Tanielian, Suarez, & Marcus, 1998) and stimulants and antidepressants 

(Zito et al., 2002). 

Concomitant use is likely to be greater in populations treated by psychiatrists 

than those treated by pediatricians. (Bussing, Zima, & Belin, 1998) showed that in 

a Florida school district-wide sample of elementary school age special education 

youth, concomitant psychotropic use occurred in 48% of psychiatrist-treated youth 

compared with 6% of pediatrician-treated youth. 

In the Texas study, in a one month cohort (July 2004), 72.5% of the medicated 

youth received concomitant medications (Zito et al., 2008). Among the medicated 

youth, 41.3% received ≥3 psychotropic medication classes concomitantly, 15.9% received ≥4, and 2.1% received ≥5 classes. The rank order of the most common concomitant psychotropic class combinations was as follows: antipsychotics with ADHD 

medications, antipsychotics with antidepressants, antidepressants with ADHD medications, and anticonvulsant-mood stabilizers with antidepressants (Zito et al., 2008). 

Generally, psychotropic treatment by medication class was not specific relative to 

the leading diagnostic groups (Depression; ADHD; Adjustment/Anxiety). To illustrate, 76 to 84% of youth with 3 or more concomitant classes had antipsychotic 

dispensings regardless of the diagnostic group and the vast majority reflected behavioral and emotional symptoms, i.e. non-psychotic use. At the time of the study, all 

antipsychotic and anticonvulsant-mood stabilizer use was off-label use, i.e. without 

FDA-approved labeling for an indication, dose or age group (Roberts, Rodriguez, 

Murphy, & Crescenzi, 2003). 

Foster Care Oversight for Medication Quality of Care 

Clinical guidelines on foster care services have been produced by professional organizations, e.g. The American Academy of Child and Adolescent Psychiatry (American Academy of Child and Adolescent Psychiatry, 2008). Their standards focus on 

minimal and ideal recommendations. The recommendation on requests by the prescribing physician for consultation with child and adolescent psychiatry experts is 

only initiated by the requesting physician. The American Academy of Pediatrics 

statement on healthcare of young children in foster care recommends more frequent 

monitoring of the health status of children in placement than for children living in 

stable homes with competent parents (American Academy of Pediatrics, 2002). 

Clinical education teams working the public sector are known as academic detailers and have been shown to be effective (Soumerai & Avorn, 1990). Ideally, a team 

of clinical pharmacists led by a psychopharmacologist in child psychiatric drug therapy could work to balance drug information originating from proprietary-funded 

thought leaders. Such an approach could lead to a balance between a marketing perspective and a long-term public mental health perspective. 

Another concern of Medicaid treatment is cost. In the Texas data we analyzed, 

very expensive psychotropic medications were prescribed, including antipsychotic 

agents (averaging $22/month) and anticonvulsant-mood stabilizers (averaging $110/ 

month). In fact, over 50% of the Medicaid expenditures for the foster care youth in 

FY 2004 were for antipsychotic medications (Strayhorn, 2006). In light of the vast 

public expenditures and services related to medication use, public-interest academic 

detailing should be encouraged. 

Reference List 

Administration for Children Youth and Families (2008). Trends in Foster Care 

and Adoption—FY2000–FY2005 http://www.acf.hhs.gov/programs/cb/stats_research/ 

afcars/trends.htm. 

American Academy of Child and Adolescent Psychiatry (2008). AACAP Position 

Statement on Oversight of Psychotropic Medication Use for Children in State 


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Custody: A Best Principles Guideline http://www.aacap.org/galleries/ 

PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf. 

American Academy of Pediatrics (2002). Healthcare of young children in foster 

care. Pediatrics, 109, 536–541. 

APHA Joint Policy Committee (2006). Regulating Drugs for Effectiveness and 

Safety: A Public Health Perspective: Position Paper http://www.lwwmedicalcare.com/pt/re/medcare/aplus.html. 

Bhatara, V.S., Feil, M., Hoagwood, K., Vitiello, B., & Zima, B.T. (2002). Trends 

in combined pharmacotherapy with stimulants for children. Psychiatric Services, 53, 

244. 

Bussing, R., Zima, B.T., & Belin, T. (1998). Variations in ADHD treatment among 

special education students. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 968–976. 

dosReis, S., Zito, J.M., Safer, D.J., Gardner, J.F., Puccia, K.B., & Owens, P. L. 

(2005). Multiple psychotropic medication use for youths: a two-state comparison. 

Journal of Child and Adolescent Psychopharmacology, 15, 68–77. 

dosReis, S., Zito, J.M., Safer, D.J., & Soeken, K. (2001). Mental health services 

for youths in foster care and disabled youths. American Journal of Public Health, 

91, 1094–1099. 

Hagen, S. & Orbeck, L. A. (2006). The prescription of psychotropic medications in 

foster care children: a descriptive study in St. Louis County. www.d.umn.edu/sw/executive/hstacy.html. 

Harman, J.S., Childs, G.E., & Kelleher, K.J. (2000). Mental healthcare utilization 

and expenditures by children in foster care. Archives of Pediatrics & Adolescent 

Medicine, 154, 1114–1117. 

Klein, D.F. (1993). Clinical psychopharmacologic practice. The need for developing 

a research base. Archives of General Psychiatry, 50, 491–494. 

Klein, D.F. (2006). The flawed basis for FDA post-marketing safety decisions: the 

example of antidepressants and children. Neuropsychopharmacology, 31, 689–699. 

Lader, M. & Naber, D. (1999). Difficult Clinical Problems in Psychiatry. London: 

Martin Dunitz Ltd. 

Mandell, D.S., Morales, K.H., Marcus, S.C., Stahmer, A.C., Doshi, J., & Polsky, 

D.E. (2008). Psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders. Pediatrics, 121, e441–e448. 

Martinez-Mir, I., Garcia-Lopez, M., Palop, V., Ferrer, J.M., Rubio, E., & MoralesOlivas, F.J. (1999). A prospective study of adverse drug reactions in hospitalized 

children. British Journal of Clinical Pharmacology, 47, 681–8. 

Olfson, M., Marcus, S.C., Weissman, M.M., & Jensen, P.S. (2002). National trends 

in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 514–521. 

Pandiani, J. & Carroll, B. (2008). Vermont Mental Health Performance Indicator 

Project http://healthvermont.gov/mh/docs/pips/2008/documents/Pip022908.pdf. 

Roberts, R., Rodriguez, W., Murphy, D., & Crescenzi, T. (2003). Pediatric drug labeling. The Journal of the American Medical Association, 290, 905–911. 

Safer, D.J. (2004). A comparison of risperidone-induced weight gain across the age 

span. Journal of Clinical Psychopharmacology, 24, 429–436. 

Safer, D.J. & Zito, J.M. (2006). Treatment-emergent adverse events from selective 

serotonin reuptake inhibitors by age group:children versus adolescents. Journal of 

Child and Adolescent Psychopharmacology, 16, 203–213. 

Safer, D.J., Zito, J.M., & dosReis, S.M. (2003). Concomitant psychotropic medication for youths. American Journal of Psychiatry, 160, 438–449. 

Shatin, D., Levin, R., Ireys, H.T., & Haller, V. (1998). Healthcare utilization by 

children with chronic illnesses: a comparison of Medicaid and employer-insured 

managed care. Pediatrics, 102, e44. 

Soumerai, S.B. & Avorn, J. (1990). Principles of educational outreach (‘academic 

detailing’) to improve clinical decision making. The Journal of the American Medical 

Association, 263, 549–556. 

Soumerai, S.B., McLaughlin, T.J., & Avorn, J. (1990). Quality assurance for drug 

prescribing. Quality Assurance in Healthcare, 2, 37–58. 

Strayhorn, C.K. (2006). Foster Children Texas Healthcare Claims Study-Special 

Report Texas Comptroller. 

Texas Dept of State Health Services (2005). Psychotropic medication utilization 

parameters for foster children www.dshs.state.tx.us/mhprograms/ 

psychotropicmedicationutilizationparametersfosterchildren.pdf. 

Texas Health and Human Services Commission (2006). New guidelines reduce use 

of psychotropic drugs http://www.hhsc.state.tx.us/stakeholder/Sep_Oct06/psychotropic_drugs.html. 


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Turner, S., Nunn, A.J., Fielding, K., & Choonara, I. (1999). Adverse drug reactions 

to unlicensed and off-label drugs on paediatric wards: a prospective study. Acta 

Paediatr, 88, 965–968. 

Zarin, D.A., Tanielian, T.L., Suarez, A.P., & Marcus, S.C. (1998). Treatment of attention-deficit hyperactivity disorder by different physician specialties. Psychiatric 

Services, 49, 171. 

Zima, B.T., Bussing, R., Crecelius, G.M., Kaufman, A., & Belin, T.R. (1999). Psychotropic medication treatment patterns among school-aged children in foster care. 

Journal of Child and Adolescent Psychopharmacology, 9, 135–147. 

Zito, J.M. (1994). Psychotherapeutic Drug Manual. New York: Wiley and Sons. 

Zito, J.M., Safer, D.J., & Craig, T.J. (2008). Pharmacoepidemiology of psychiatric 

disorders. In A.G.Hartzema, H.H. Tilson, & K.A. Chan (Eds.), Pharmacoepidemiology and Therapeutic Risk Management (pp. 817–854). Cincinnati: Harvey Whitney 

Books. 

Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Magder, L., Soeken, K. et al. 

(2003). Psychotropic practice patterns for youth: a 10-year perspective. Archives of 

Pediatrics & Adolescent Medicine, 157, 17–25. 

Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Soeken, K., Boles, M. et al. 

(2002). Rising prevalence of antidepressant treatments for U.S. youths. Pediatrics, 

109, 721–727. 

Zito, J.M., Safer, D.J., Sai, D., Gardner, J.F., Thomas, D., Coombes, P. et al. 

(2008). Psychotropic medication patterns among youth in foster care. Pediatrics, 

121, e157–e163. 

Zito, J.M., Safer, D.J., Valluri, S., Gardner, J.F., Korelitz, J.J., & Mattison, D.R. 

(2007). Psychotherapeutic medication prevalence in Medicaid-insured preschoolers. 

Journal of Child and Adolescent Psychopharmacology, 17, 195–203. 

Zito, J.M., Safer, D.J., Zuckerman, I.H., Gardner, J.F., & Soeken, K. (2005). Effect 

of Medicaid eligibility category on racial disparities in the use of psychotropic medications among youths. Psychiatric Services, 56, 157–163. 

f 

Chairman MCDERMOTT. Thank you for your testimony. 

Dr. Jeffrey Thompson is a physician in Washington State. Dr. 

Thompson? 

Dr. THOMPSON. Thank you Representative McDermott. 

Chairman MCDERMOTT. Thank you for coming all this way. 

Dr. THOMPSON. Yes, well, I was actually at CMS all week so 

this was an easy drive, somewhat easy from Baltimore. 

STATEMENT OF JEFFERY THOMPSON, M.D., MEDICAL DIRECTOR, WASHINGTON STATE DEPARTMENT OF SOCIAL AND 

HEALTH SERVICES 

Dr. THOMPSON. My name is Jeff Thompson. I am the Chief 

Medical Officer for Washington State Medicaid. 

I want to thank you for the opportunity to testify on this very 

important topic. I want to also talk about what Washington State 

is doing. Our leaders in Washington State are doing some great 

stuff; and, so, I want to cover what’s happening there and how the 

leadership is emphasizing integration of services as well as outcomes in safety. Safety is something, I think, we can all stand on. 

Second, I want to talk about our findings using pharmacy claims 

data, which show some serious variations in pharmacy practice and 

children in foster care. 

Third, the importance of forming good working relationships with 

the family and children’s communities as well as the providers, because we can’t do it without them. You can’t just put administrative controls, but what we have been able to do is show data that 

bring everybody to the table including the drug companies. 

Finally, I want to talk about how we’re attempting to find national best practices by working with the National Association of 

Medicaid Directors and Carol Clancy at the Agency for Healthcare 


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Quality and Research, AHRQ. I want to recognize the leadership 

of our Governor, Christine Gregoire, as one of the key leaders, as 

well as key Washington State House and Senate leaders, in particular, Mary Lou Dickerson and James Hargrove as well as my 

Secretary, Ms. Robin Arnold-Williams. 

With their guidance, our Medicaid program is integrating mental 

health services under legislation house bill 1088. Simply, this State 

statute puts children at the center of care and ensures that the 

medical care, the mental healthcare, and the family services are all 

integrated. We are trying. It’s difficult to do. We accomplish this 

by trying to integrate treatment protocols by increasing the amount 

of community-based, mental health services available to children in 

foster care by educating our primary care physicians and our mental health professionals, and using an evidence-based practice center at the University of Washington with Dr. Trupin to set safety 

standards for review of medication and prescription histories setting thresholds. 

We are also piloting wrap-around programs for family services. 

We are equally concerned as the Committee with the trend of increased medication use in children as well as adults and the elderly. Using our pharmacy claim system, we note an increasing use 

of off-label drugs and medications, multiple medications, poly pharmacy, whatever the correct term is. We also note that there are 

many providers or prescriptions that are happening for a single client, so we are concerned about whether there is good continuity of 

care; and, we have questions about medication adherence. When 

prescribed, are they actually taking it? 

These issues, in short, may or may not be in the best interest of 

our clients, both the children and vulnerable adults in foster care. 

We note that parents are seeking services from across the State, 

across the Cascade Mountains. They go up and down the I–5 corridor, sometimes great distances, to find care. This is not the best 

medical home or coordination of care. 

In foster care, we note a high use of mental health medications, 

combinations sometimes exceeding the FDA adult doses in children 

of very low ages; and, finally, we have shared with the community 

these regional variations in poly pharmacy or concurrent use and 

are working with the University of Washington as well as advocacy 

communities, the primary care communities, the mental health 

communities, the target pilot programs where we see high variations in care. In short, we cannot do this without working across 

our agencies; so we are actually working with our children’s administration our DD populations, our aging and disability agency as 

well as anybody we can find to bring the provider types of drug 

companies, our contracted services, to basically lay out the full 

story of what’s happening. 

Washington State Medicaid believes that improving care and reducing the variation can only happen by working with community 

providers and advocacy groups. We do this by a continuous collaboration on database snapshots from our claims data and our pharmacy data for the care of the population. The examples, I might 

add, are showing them that the number of children who are under 

the age of 5 that are getting anti-psychotics, sometimes as low as 

age 1 or less. 


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Looking at the number of foster kids that are on five or more 

mental health drugs concurrently, looking at adherence histories to 

find out whether they actually picking up the medications that are 

being prescribed and what are the presence of county variations 

and dosing variations that exceeds agreed-upon safety thresholds. 

We find this data actually allows us to be collaborative and bring 

everybody to the table; and then we have successfully set community standards across the State. We accomplish this positive change 

with mood stabilizers, anti-depressants, stimulant use and ADHD, 

and we will shortly sell safety thresholds for anti-psychotics and 

children’s healthcare. 

We note that the data is presented in a non-judgmental manner. 

This brings the Committee together, and I might add, the drug 

companies are actually at the table when we discuss this. What we 

want to do is stop and take a short, deep breath and review the 

treatment plans to ensure that there’s an integrated plan for the 

treatment. 

Recently, our safety standards for stimulants have steered as 

many as 56 percent of prescriptions for stimulants to lower dose, 

fewer medications, and sometimes to rethink prescriptions in the 

very young. Note that 44 percent of prescriptions that are at high 

dose are in the very young, when our community and us agree that 

this is actually the appropriate use. So, it’s very complex. It’s an 

all or nothing. There’s a lot of gray here. 

Finally, Washington State can’t do this alone. When you look 

across the country you see antipsychotic use varies among states. 

When we look at the entire population it’s as varied between 4 and 

13 percent of the entire Medicaid population in some states, maybe 

on antipsychotics. Since there’s so much variation, the Medicaid 

medical directors across the country have asked the National Association of Medicaid Directors and Carol Clancy at AHRQ to sponsor 

an up-to-date pharmacy claims review and then do a program to 

benchmark best practices. 

If we can highlight these best practices, like the Texas algorithms, the Massachusetts provider consultations, the New York 

and Rutgers integration project, Arizona’s mental healthcare contracts, or the San Diego project to improve medication adherence 

and other programs, this will help us to find the best evidencebased care with the appropriate mix of State services. 

Thank you for the opportunity to testify on this important topic. 

[The prepared statement of Dr. Jeffery Thompson follows:] 

Prepared Statement of Jeffery Thompson, M.D., Medical Director, 

Washington State Department of Social and Health Services, 

Olympia, Washington 

I want to thank you for this opportunity to testify on the important topic of medication use in children—and more specifically, children in foster care. I will be brief 

in my testimony, which will cover four items: 

1. First, I will cover what is happening in Washington State’s Medicaid program, 

where we are leaders in emphasizing the integration of services, outcomes and 

safety. 

2. Second, our findings using Medicaid-paid pharmacy claims indicate serious 

variations of prescription practice for children and foster care. 

3. Third, the importance of forming a good working relationship with the child 

and family’s community, while using data to reduce variation and improve care. 


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4. Finally, how we are attempting to find ‘‘best practices’’ among Medicaid programs nationally by working with the National Association of Medicaid Directors (NASMD) and the Agency for Health Research and Quality (AHRQ). 

I want to recognize the leadership of our Governor, Christine Gregoire, as well 

as key members of the Washington House and Senate (in particular, Representative 

Mary Lou Dickerson and Senator James Hargrove), and the Secretary of the Department of Social and Health Services (Robin Arnold-Williams). With their guidance, 

our Medicaid program is integrating mental health services under legislation known 

as HB 1088. Simply, this state statute puts the child at the center of care and ensures that medical, mental health and family services are integrating all care, communicating care plans, and tailoring individualized services with families for care 

of the child. We accomplish this through integrated treatment planning, increasing 

mental health community-based services, educating Primary Care Providers (PCPs) 

and mental health providers in evidence-based practices, setting safety standards to 

review prescriptions that exceed safety thresholds, and piloting ‘‘wraparound’’ services for the family. 

We are concerned over the trend of increasing medication use in children as well 

as adults, and the elderly. Using our pharmacy claims system we note an increasing 

use of ‘‘off label’’ medications, use of multiple medications, use of multiple providers 

to direct care, and questions about medication adherence—issues that in short may 

or may not be in the best interest of our children and vulnerable adults. 

We note that parents seek services across the state—sometimes very distant from 

their residence. In foster care we note a higher use of mental health medications 

and combinations—sometimes exceeding FDA dosing for adults. Finally we have 

shared with the community the regional variations in poly-pharmacy and are working with the University of Washington and the advocacy community as well as primary care and mental health providers to target our pilot projects to areas of variation in foster care services. These pilots will allow providers to call or seek Webbased consultations during business hours based on evidence-based standards. But, 

we cannot do this alone and must work across agencies, provider types, contracted 

services and the community to understand the full story. 

Washington Medicaid believes that improving care and reducing variation can 

only happen by working with community providers and advocacy groups. We do this 

by continuous collaboration on data-based snapshots of care in the population. Examples include the number of children under 5 years old on anti-psychotics, the 

number of foster children on five or more mental health drugs concurrently, the lack 

of adherence to the medications, the presence of county variations, and dosing variations that exceed safety thresholds. This is data we share with partners including 

the state’s Pharmacy and Therapeutics Committee, the mental health work group 

(which includes drug companies, advocacy groups, primary care and mental providers) and, importantly, our sister agencies. We find data and collaboration can 

successfully set community standards of care. 

We have accomplished this positive practice change for mood stabilizers, 

antidepressants, stimulants to treat ADHD, and will shortly set safety thresholds 

for anti-psychotics. We note that when data is presented in a non-judgmental manner the community can work with the state to ‘‘stop and take a deep breath’’ and 

review care plans in an integrated framework. Recently, our safety standards for 

stimulants have steered 56% of prescriptions to lower doses, fewer scripts or encouraged prescribers to rethink stimulant use in the young. Please note that 44% of 

pharmacy care is continued. This emphasizes that the clinical picture is complex— 

and some kids do need these medications. 

Finally, this is not an issue for Washington State alone. When we look across the 

country we see antipsychotic use that varies between states—as much as 4% to 13% 

in the Medicaid populations. Because there is so much variation, the Medicaid medical directors asked NASMD and AHRQ to sponsor an up-to-date pharmacy claims 

and program benchmarking project. We hope this benchmarking will highlight ‘‘best 

practices’’ like the Texas algorithms, the Massachusetts provider consultations, the 

New York and Rutgers integration project, the Arizona mental health contracts, the 

San Diego projects to improve medication adherence, and other programs that will 

help to define the best evidence-based care and the appropriate program mix for 

state services. 

Thank you for the opportunity to testify on this important topic. 


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Chairman MCDERMOTT. Thank you for your testimony. 

I would like to say I realize I kept you a long time waiting. We 

would like you try and hold your time to 5 minutes. 

Dr. Lea from Tennessee. 

STATEMENT OF TRICIA LEA, PH.D., DIRECTOR OF MEDICAL 

AND BEHAVIORAL SERVICES, DEPARTMENT OF CHILDREN’S 

SERVICES 

Dr. LEA. Mr. Chairman and Members of the Committee, thank 

you for the opportunity to talk with you today. 

My name is Tricia Lea and I am here to testify on behalf of the 

American Public Human Services Association, it’s affiliate, the National Association of Public Child Welfare Directors, and the State 

of Tennessee where I serve as the Director of Medical and Behavioral Services for the Department of Children’s Services. 

The Tennessee child welfare system has been under intense scrutiny since May of 2000 when the lawsuit was filed on behalf of children who had experienced difficulties while in State custody. One 

concern in the lawsuit focused specifically on the inappropriate use 

of psychotropic medications, and the subsequent settlement agreement required the department to hire a full-time medical director 

specifically to oversee the implementation of policies and procedures concerning the use of psychotropic medication for children in 

State custody. 

I serve in this medical director position and would like to share 

with you our child welfare agency’s progress in this area. Tennessee began a reform by conducting an in-depth evaluation of policies and practices with the assistance of Dr. Christopher Bellonci, 

who is also here to testify today. 

He and I co-facilitated a multi-disciplinary work group that developed five policies related to the use of medication. Dr. Bellonci 

also drafted the initial DCS medication monitoring guidelines as a 

tool for our case managers to use in monitoring the psychotropic 

medications prescribed for children in their care. 

An initial review of a sample of children’s case files audited by 

the lawsuit’s Federal monitor found that approximately 25 percent 

of children in custody were prescribed psychotropic medications in 

2003. Despite some fluctuation, the numbers of custody-children 

prescribed medication have declined and currently average around 

20 percent with the majority of these children being the adolescents and being prescribed one or two psychotropic medications. 

Tennessee has also hired a part-time consulting child and adolescent psychiatrist, Dr. Deborah Gatlin, who has established a pharmacy and therapeutics Committee to review medication practice 

across the State. This Committee has also assisted in updating the 

DCS medication-monitoring guidelines using the standards that 

were developed by the State of Texas. 

Cases that fall outside of the utilization parameters are reviewed 

at several levels in our State. DCS has a statewide network of 

nurses and psychologists that monitor healthcare for our children, 

including the use of psychotropic medication, along with the consulting child psychiatrist, a pediatric nurse practitioner, and myself. 


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Outside of our agency we have five centers of excellence that are 

partnerships with the State of Tennessee and academic medical 

centers and community providers. These centers were created to 

serve children in and at risk of custody and they provide a second 

opinion capacity for children regarding prescriptions of psychotropic medications. 

The review of medications falling outside our parameters have 

also become automated via our database system, and this happened in the fall of ’07. Anytime a medication regimen falls outside 

of the parameters, the system automatically sends an e-mail alert 

to our psychiatrist triggering further review. The majority of cases 

that she has reviewed have been found to be clinically appropriate 

care for our kids. 

The updated child welfare database also allows for more accurate 

tracking of all health information and all health services for the 

children in custody. The system provides an ongoing summary 

which acts as a health passport for the child and this summary is 

shared with all care givers and providers serving the child and is 

similar to what Texas has developed. 

Tennessee is able to see cases in which children and youth in our 

custody have benefited from the oversight and monitoring processes we have put in place regarding medication. One example that 

I want to share is about a child who is 14 years old. He is in full 

guardianship. Parental rights have been terminated and he has 

had multiple diagnoses, including mild mental retardation, bipolar 

disorder, impulse control disorder, and psychotic disorder. He was 

placed at a residential treatment facility, but was continuing to require frequent, acute, psychiatric hospitalizations. He was prescribed six psychotropic medications at the same time. When our 

DCS regional nurse reviewed these medications to give consent, 

she contacted our psychiatrist, because the combination fell outside 

several of our utilization parameters. 

The psychiatrist was concerned enough about this combination 

and this child’s care and the frequent medication changes that she 

wanted his psychiatric care to transfer to our regional centers of 

excellence. The youth has now been taken off several of these 

psychotropic medications, is in a family foster home, and is doing 

fairly well. 

The State of Tennessee Department of Children’s Services has 

made significant progress regarding psychotropic medication practices for children in custody. We continue to work to ensure that 

children in custody have all of their health needs adequately addressed and that those who are prescribed psychotropic medication 

are only done so when clinically indicated. 

In those cases we want to assure that if medication is appropriate, informed consent is given and ongoing monitoring occurs. 

Additionally, Tennessee is working diligently to assure that psychotropic medication is not used inappropriately or as a means of control, punishment, or discipline for a child or for the convenience of 

staff or care givers. 

Thank you very much for the opportunity to testify on this important topic. 

[The prepared statement of Tricia Lea, Ph.D., follows:] 


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Prepared Statement of Tricia Lea, Ph.D., 

Director of Medical and Behavioral Services, 

Department of Children’s Services, State of Tennessee 

Introduction 

Thank you for the opportunity to submit testimony regarding the use of psychotropic medication among children in the child welfare system. My name is Tricia 

Lea, Ph.D., and I am submitting testimony on behalf of the State of Tennessee, 

where I serve as the Director of Medical and Behavioral Services for the Department of Children’s Services (DCS), and the National Association of Public Child 

Welfare Administrators (NAPCWA), an affiliate of the American Public Human 

Services Association (APHSA). APHSA is a nonprofit, bipartisan organization representing state and local human service professionals for over 77 years. NAPCWA, 

created as an affiliate in 1983, works to enhance and improve public policy and administration of services for children, youth, and families. As the only organization 

devoted solely to representing administrators of state and local public child welfare 

agencies, NAPCWA brings an informed view of the problems facing families today 

to the forefront of child welfare policy. DCS is the agency responsible for our state’s 

child welfare programs. The Department’s mission is to empower families and support community safety and partnerships to help ensure safety, permanency and 

wellbeing for children in our care. The State of Tennessee is committed to protecting 

the children served in our child welfare system by ensuring that medical, mental 

and behavioral health services are provided in the least intrusive manner and in 

the least restrictive setting that meets each child’s needs. 

Background 

The child welfare system in Tennessee serves over 20,000 children and youth at 

risk of custody each year and has approximately 8100 children and youth currently 

in custody. The Department of Children’s Services has been under intense scrutiny 

since May 2000, when a civil rights class action lawsuit was filed by Children’s 

Rights, Inc., on behalf of children who had experienced difficulties within the child 

welfare system. According to the complaint, Tennessee was not fulfilling its obligations to children in foster care, as children were staying in custody for long lengths 

of time, being placed in emergency shelters or congregate care settings rather than 

family-like settings, experiencing multiple placement moves, and not getting all of 

their healthcare and educational needs met. Additional concerns in the lawsuit focused on the inappropriate use of psychotropic medications for children in care, inadequate monitoring of psychotropic medications, and the possible use of these 

medications as a means of control, punishment or discipline of children or for the 

convenience of staff providing care to foster children. 

A settlement agreement was finalized in the lawsuit in July 2001. This agreement 

became known as the Brian A. Settlement Agreement, as it was named after one 

of the eight foster youth for whom the original lawsuit was filed. This settlement 

established the outcomes to be achieved by the State of Tennessee on behalf of children in custody and their families. It also mandated the creation of the Technical 

Assistance Committee (TAC) consisting of experts in the child welfare field to serve 

as a resource and monitoring function for the Department in the development and 

implementation of its reform effort. The Settlement Agreement also required that 

Tennessee DCS review all policies and procedures surrounding the use of psychotropic medication, that DCS implement all recommendations made by TAC, and 

that the Department hire a full-time Medical Director specifically to oversee the implementation of policies and procedures concerning the use of psychotropic medication for children in DCS custody. I serve in this Medical Director position and would 

like to share with you one child welfare agency’s progress in the area of psychotropic 

medication. 

First Area of Reform: Evaluation of Current Policies and Practices 

The first phase of reform for Tennessee was to conduct an in depth evaluation 

of current policies and practices regarding psychotropic medication. The Department 

conducted this analysis with the assistance of Dr. Christopher Bellonci, an expert 

child psychiatrist and consultant provided by the Child Welfare League of America. 

Dr. Bellonci and I co-facilitated a multidisciplinary workgroup that included psychiatrists, psychologists, nurses, and other leadership and field staff from the Department of Children’s Services, the state Department of Mental Health and Developmental Disabilities, provider trade organizations, and provider agencies serving children in custody. The guiding principles developed by this group included: 


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• DCS will ensure that psychotropic medications prescribed for children in custody are used in combination with other therapeutic modalities contained in a 

multidisciplinary treatment plan. • DCS will ensure that parents and children are offered an opportunity for meaningful participation and input in the decision making process related to the possible use of psychotropic medications. • DCS will ensue that psychotropic medications are properly administered and 

that custodial children receiving the medications are properly supervised to ensure consistency and continuity in their care and treatment. • DCS will ensure that the efficacy, safety and side effects of psychotropic medications used with children in custody are tracked and documented. • DCS will ensure that psychotropic medications are not used as a means of control, punishment or discipline of children or for the convenience of the treating 

facility. • DCS will prohibit the use of psychotropic medication s on a pro re nata (as 

needed) basis without the prior authorization of the DCS Director of Medical 

and Behavioral Services or his/her designee. • DCS will ensure that direct-care staff are trained in the use, administration, 

and monitoring of psychotropic medications with children. • DCS will monitor and track the prescribing practices of psychotropic medications to include ethnic, gender, age and trends for children in DCS care. 

These principles were included in the ‘‘DCS Standards of Professional Practice for 

Serving Children and Families’’, which is a document outlining the vision of the Department to ensure quality care, appropriate service, safety and permanency for 

children and families in Tennessee. 

Second Area of Reform: Policy and Practice Development 

These principles also guided the development of five policies related to the use of 

medication, including policies about medication administration, emergency and PRN 

usage of psychotropic medication, medication errors and informed consent. The 

Brian A. Settlement Agreement outlined specific practices to follow regarding the 

process of informed consent and psychotropic medications, specifically that ‘‘whenever possible, parents shall consent to the use of medically necessary psychotropic 

medication.’’ When parents are not available or their legal rights have been terminated, then DCS regional nurses review and provide consent to medically necessary 

medication. DCS developed a statewide network of nurses to monitor healthcare for 

children in custody, including the use of psychotropic medication. 

Monitoring Guidelines and Procedures 

In addition to assisting in policy development, Dr. Bellonci drafted the ‘‘DCS 

Medication Monitoring Guidelines’’ referenced in his testimony, as a tool for DCS 

case managers to use in monitoring the psychotropic medications prescribed for the 

children in their care. As Dr. Bellonci has noted, these guidelines were not meant 

to define prescribing practices but to help inform decision making and oversight related to psychotropic medication usage for children in foster care. 

Once the DCS medication policies and monitoring guidelines were promulgated 

and shared with contract providers, DCS required each provider agency to complete 

a ‘‘self-assessment’’ of their compliance level with every practice mandated in each 

of the medication policies. The Department used these data as a baseline for ongoing monitoring that occurs each year by our internal auditors. Those providers who 

were not in compliance were also required to submit corrective action plans to be 

used by DCS for ongoing evaluation and technical assistance. In addition to annual 

site reviews, DCS also conducts unannounced site visits to residential facilities by 

multidisciplinary teams consisting of regional and central office DCS personnel. 

These site visits consist of interviews with staff and youth, as well as intensive reviews of personnel, training and clinical records to determine whether these programs are implementing the protection from harm policies (those dealing with 

psychotropic medication as well as restraint and seclusion). 

Training 

The Department developed specific training curricula for agency staff and contract 

providers in order to assist with the implementation of these protection from harm 

policies. One training focuses on educating DCS staff, providers, and resource parents about policies related to psychotropic medication usage. This computer-based 

training utilizes case vignettes, challenge questions, and expert resources to spark 

discussion among individuals serving children. Another training curriculum teaches 

resource parents how to properly administer, store, dispose of and monitor medication use for children and youth in their homes. These training modules have been 


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shared with the provider agencies caring for DCS children in TN, as the Brian A. 

Settlement Agreement suggests that all DCS staff and private agency staff serving 

children in custody should be trained similarly. 

Audits 

As part of the ongoing monitoring mandated by the Brian A. Settlement Agreement, the Technical Assistance Committee audits a sample of case records of children in custody of the state of Tennessee. Regarding psychotropic medication, these 

reviews focus on determining how many children are prescribed psychotropic medication, the ages and placements of these children, and whether or not appropriate 

informed consent was obtained for the psychotropic medications. 

The first case file review conducted by the Federal Monitor was completed in 2004 

and reviewed data from 2003. This review found that approximately 25% of children 

in custody were prescribed psychotropic medications. The next case file audit reviewed data from 2004 and was completed in 2005, finding that only 17% of children 

in the sample were prescribed psychotropic medication. This sample was somewhat 

different from the previous year, in that it reviewed children just entering the child 

welfare system who had only been in custody approximately six months. The TAC 

also conducted a review of DCS case files in 2006 (looking at practice in 2005), 

which found that 21% of children in custody were administered psychotropic medication. Despite some fluctuation, the numbers of children prescribed medication has 

declined. The majority of children prescribed psychotropic medication each year has 

been the adolescent population. 

2004 

n = 106 

2005 

n = 276 

2006 

n = 268 

Case file documents child 

was administered psychotropic medication during 

review period 25% 17% 21% 

Percent of Children in 

Each Age Range Administered Psychotropic Medication 

2004 2005 2006 

0–3 years 0% (0 of 106) 0% (0 of 81) 0% (0 of 69) 

4–6 years 11% (5 of 47) 9% (3 of 34) 3% (1 of 30) 

7–9 years 25% (15 of 59) 3% (1 of 29) 32% (6 of 19) 

10–12 years 33% (18 of 55) 24% (8 of 33) 37% (11 of 30) 

13–18 years 40% (68 of 171) 34% (34 of 99) 33% (34 of 120) 

Informed Consent for Administration of 

Psychotropic Medication 

Received 

2004 2005 2006 

Informed Consent given 69% 60% 70% 

No informed consent 33% 40% 30% 

Third Area of Reform: Tracking Data Trends 

In order to provide additional expertise, consultation, review and oversight with 

regard to psychotropic medication, TN DCS employed a Child and Adolescent Psychiatrist, Deborah Gatlin, M.D. Dr. Gatlin has established a Pharmacy and Therapeutics Committee, whose membership includes psychiatrists and pharmacists with 

special expertise related to child and adolescent care. This group reviews medication 

practice across the state and advises on issues related to mental health treatment 

for children in custody. Our various review initiatives identified children taking as 

many as eight different psychotropic medications. There appeared to be, in some instances, a lack of oversight for medication management and drug interactions. 

As a mechanism of tracking psychotropic medication usage for children in foster 

care, DCS worked with TennCare (Tennessee’s Medicaid program) and TennCare 


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Select (the Managed Care Company serving children in custody) to receive paid 

claims data for children and identified psychotropic medications. Blue Cross and 

Blue Shield provided this pharmacy data to the Department, and this information 

was matched against the child welfare database (TNKids) for each month. Summary 

data from January—December 2006 indicates that on average, 19.8% of children in 

DCS custody were prescribed at least one psychotropic medication during the calendar year. The providers prescribing the most medications to Tennessee’s custody 

children were physicians specializing in psychiatry. The classes of drugs prescribed 

the most during 2006 included antipsychotics and stimulants (e.g., Seroquel and 

Adderall). During 2006, three-fourths of the 19.8% of children on medication received only one or two psychotropic medications (44.8% and 31.0%, respectively); 

16.4% received three psychotropic medications, and less than 1% received four or 

more psychotropic medications concomitantly. A child in the custody of the State of 

Tennessee who was administered medication during 2006 was more likely to be a 

white male, adjudicated dependent and neglected, age 13 years, and prescribed approximately two psychotropic medications by a psychiatrist. The research division 

of DCS is currently analyzing the pharmacy claims data for the 2007 calendar year, 

but trends from the second quarter of 2007 indicate similar numbers of children on 

psychotropic medications (an average of 20.1%). Additionally, 2007 data show that 

of those 20% of youths receiving psychotropic medications, the majority (an average 

of 75%) are prescribed only one or two medications. 

Fourth Area of Reform: Updating Monitoring Guidelines and Protocols 

In conjunction with the Pharmacy and Therapeutics Committee, the DCS Consulting Psychiatrist, Dr. Gatlin, has formulated updated medication monitoring 

guidelines for use in Tennessee. These ‘‘Psychotropic Medication Utilization Parameters’’ were adapted form the original ‘‘DCS Medication Monitoring Guidelines’’ as 

well as the Texas Department of State Health Services standards. These parameters 

outline situations in which further review of a foster child’s medication regimen is 

warranted. These guidelines do not indicate if the treatment is inappropriate, but 

indicate that further analysis of the situation is needed. The new parameters include: 

• Four or more psychotropic medications prescribed concomitantly 

• Two or more psychotropic medications of the same class prescribed concomitantly (specifically antidepressants, antipsychotics, stimulants, and mood stabilizers) 

• Medication dose exceeds the usual recommended dose (the Pharmacy and 

Therapeutics Committee drafted a listing of commonly used psychotropic medications used in the treatment of children and adolescents, outlining maximum 

dosages) 

• Children under five years of age prescribed psychotropic medications 

Cases that fall outside of the DCS medication monitoring guidelines are reviewed 

at several levels. The state of Tennessee is fortunate to have regional health units 

staffed with nurses and psychologists in each of the 12 regions of the state. Additionally, in central office, we have our consulting child psychiatrist (Dr. Gatlin) as 

well as a pediatric nurse practitioner. Outside of DCS, we have five ‘‘Centers of Excellence for Children in State Custody’’ that are a partnership with the State of Tennessee and academic medical centers and community providers. The Centers of Excellence (COEs) were created to serve children in and at risk of custody and provide 

expert guidance for the diagnosis and treatment of medical and behavioral health 

disorders for all community providers. The COEs also offer limited direct services 

for the most complex cases of children in and at risk of custody and for situations 

in which service gaps exist. 

While reviews of individual cases that fall outside of these medication parameters 

have been reviewed at numerous levels for some time, the DCS child welfare database has now automated these reviews. Since August of 2007, when medication information is input into the database, a review by the psychiatrist is automatically 

triggered. An e-mail alert is sent to our consulting psychiatrist for further review. 

Dr. Gatlin’s reviews of these cases have typically indicated that more clinical information is needed to understand the situation, that the treatment is within reasonable clinical community standards, that consultation with a Child and Adolescent 

Psychiatrist or Center of Excellence is indicated, or the child’s case should be transferred from the Primary Care Provider (PCP) to a Psychiatrist. The majority of 

cases falling outside the psychotropic medication parameters have indicated appropriate care. The updated DCS database also mandates that consent information for 

each psychotropic medication is documented. In Tennessee, youths aged 16 years 

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ing psychotropic medications as adults. The database requires an explanation if a 

youth is 16 years of age or older and was not the person who gave consent for the 

psychotropic medication. Similarly, the Brian A. Settlement Agreement mandates 

that whenever possible, parental consent should be obtained for psychotropic medications. If parental rights are not terminated, the new data system forces an explanation if the parents did not provide the informed consent. 

The updated database also allows for more accurate tracking of health information for children in custody, including allergies, medical conditions, psychiatric diagnoses, all medications (including psychotropic), and documentation of all health 

services rendered to the child (including medical, dental, vision, and mental health). 

The system allows for a summary to be developed, which acts as a ‘‘Health Passport’’ for the child to ensure that all caregivers and providers serving the child have 

clear information on the child’s history and current health status. This summary is 

shared with case managers, healthcare providers, placement agencies, and resource 

parents. This is similar to the passport that the state of Texas has developed as a 

part of its STAR Health program. 

DCS is now working on contrasting the pharmacy claims data with the data in 

our child welfare database to ensure that we are adequately tracking all children 

in custody who receive psychotropic medications. Additionally, the Pharmacy and 

Therapeutics Committee continues to act in an advisory capacity for this process 

and will be used to review individual providers who have concerning prescribing 

practices in comparison to the drug utilization parameters used in Tennessee. 

We are able to see cases in which children and youth in our custody have benefited from the oversight and monitoring processes we have put in place. One example is that of a 14 year old boy, in full guardianship, with diagnoses of Mild Mental 

Retardation, Bipolar Disorder, Impulse Control Disorder, and Psychotic Disorder. 

He was placed at a residential treatment facility but continued to require frequent 

psychiatric hospitalizations and was prescribed six psychotropic medications (two 

antipsychotics, two mood stabilizers, one sedative, and an additional medication for 

impulse control). When the DCS regional nurse reviewed these medications to give 

consent, she contacted our Child and Adolescent Psychiatrist as the medication regimen met several of the monitoring triggers. The Psychiatrist was concerned about 

the youth’s placement moves and frequent medication changes and recommended 

that his psychiatric care transfer to one of our Centers of Excellence. The youth has 

been taken off several of the psychotropic medications, is now placed in a foster 

home rather than a residential facility, and is doing fairly well. 

The State of Tennessee Department of Children’s Services has made significant 

progress regarding psychotropic medication practices for children in custody. We 

recognize that there is a high rate of mental illness associated with our population 

and that there is trauma associated with entering the foster care system. However, 

Tennessee is working to ensure that children in custody have their mental health 

needs adequately addressed and are prescribed psychotropic medication when clinically indicated. In those cases, we want to ensure that appropriate informed consent 

is given and ongoing monitoring occurs. Additionally, Tennessee is working diligently to ensure that psychotropic medication is not used inappropriately or as a 

means of control, punishment, and discipline of children or for the convenience of 

staff. 

Thank you very much for the opportunity to speak to this important issue affecting the children of our country. 

f 

Chairman MCDERMOTT. Thank you. 

I apologize for making somebody from Tennessee talk that fast! 

[Laughter.] 

Dr. LEA. I kept it under 5 minutes. 

[Laughter.] 

Chairman MCDERMOTT. Our next witness is Misty Stenslie, 

who is the Deputy Director for the Foster Care Alumni Association 

of the United States. 

Misty? 


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STATEMENT OF MISTY STENSLIE, DEPUTY DIRECTOR, 

FOSTER CARE ALUMNI OF AMERICA 

Ms. STENSLIE. As one of the twelve million adults in the United 

States who grew up in foster care, the government did service as 

my parents; This Committee, your colleagues in Congress, have 

stood in the places where our mothers and fathers belong and we 

thank you for that. 

We ask you to consider the recommendations that come from this 

panel and, in all of your decisions about foster care, to consider 

them both from a lawmaker’s point of view and from a mom or 

dad’s point of view, because you really do have that responsibility 

for us. 

So, hearing you say that you are our godfathers took me back a 

little bit, because that’s something that I’m still not used to. I felt 

it and I appreciate it. 

I am the deputy director of Foster Care Alumni of America. 

We’re a national association that brings together those of us who 

share the foster care experience to be that extended family network 

for each other. Thank you. 

We also work with other social workers, foster parents, other professionals, in order to improve foster care practice and policy for 

the ones who come after us because those really are our younger 

brothers and sisters having shared the same parents, the government. 

In addition to having grown up in foster care, I am a masterslevel social worker and I have worked in child welfare for the last 

19 years. I am also proud to be the foster mother to three young 

people who came to me in their teen-age years and are now in their 

middle twenties, 22, 23, and 26. So the thing I know the most 

about in the world is foster care, and on this topic of the use of 

psychotropic medications and anything else in the foster care system or child welfare system. There’s just not going to be a simple 

answer and I think you already know that. 

As the community of alumni of the foster care system, we do ask 

you to remember to wear your parent hat too when you’re making 

these decisions. My own childhood, I spent about 12 years total living in 30 different placements. I lived in group homes and kinship 

care and foster homes and residential treatment and juvenile correction facilities, just about at least one of every kind of placement 

that’s available. 

Through those unstable years, I had probably a couple of hundred people who were responsible for me, and I still left foster care 

at 18, even with no family, even with a couple hundred people who 

looked out for me at least for a little while. During my time in care 

I had a long list of diagnoses, including post-traumatic stress disorder, oppositional defiant disorder, conduct disorder, sleep disorder, mood disorder. I got to have a lot of those kinds of things 

too. 

Due to the instability of my living situation, it seemed like sometimes the only choice the professionals in my life could see that 

they had, because they couldn’t fix my life, would be that they 

would prescribe medication. So, over the years, I was on more 

medications than I can count. Most of the time that was without 

me knowing what they were for, how I should expect to feel difVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00031 Fmt 6633 Sfmt 6602 E:\HR\OC\45553.XXX 45553

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ferent, what side effects to watch out for, what the plan was, 

whether I was supposed to take them forever, and whether I was 

supposed to just take them this week. 

So it wasn’t until I was a senior in high school and about my 

30th placement that I even found out that I had the right to question or challenge what all those diagnoses were and what all that 

medication was about. My very last foster home dutifully gave me 

my handful of pills every night for the first week or two I was 

there. Then, one night, the foster dad said to me, ‘‘What are all 

these pills for?’’ I went, ‘‘I don’t really know. I know they’re supposed to help me sleep.’’ He said, ‘‘Why don’t you sleep?’’ I said, ‘‘I 

get really anxious at night and I have a really hard time getting 

any rest.’’ So, he said, ‘‘Let’s stay up. Let’s figure out what happens.’’ So, we made cocoa. 

We sat up playing cards half of the night, and every time there 

was a bump in the night, I had my typical anxious response, because I really did have post traumatic stress disorder. So every 

time that anxious response came up, he would explain to me what 

the noise was. He would say it’s the water softener regenerating. 

It’s the furnace kicking on. It’s the dog upstairs getting a drink of 

water and explaining these things to me that I had no way of 

knowing myself. 

The other thing that those foster parents did was they acknowledged that I was actually really smart. I was really smart to have 

figured out that if I never went to sleep too deeply, I was less likely 

to be hurt in the house where I came from and that it wasn’t a disorder in me that I had so much trouble with sleeping. It was a disorder in my life and that I really responded to my life’s realities 

in the best way I could to keep myself safe. 

So, as you’ll see in my written testimony, a lot more information, 

both about what I have to say and about what we hear from other 

alumni of the foster care system all around the country, but a few 

things I want to make sure that you know, is it’s a really common 

thing to hear from our alumni members, our brothers and sisters 

from foster care around the country, that they received diagnoses 

and medications in response to their disordered lives and we do 

know about foster children is that many of us do actually have psychiatric needs due to the trauma of abuse and neglect and the trauma of living in placement away from everything that’s familiar and 

the trauma of growing up with no family. We also know that young 

people in foster care are coming from families having histories of 

psychiatric problems, so whether it’s a result of the trauma or a 

matter of the genetic predisposition or a collision of those factors, 

we do know that children in foster care often have needs that must 

be addressed. Sometimes, medication is the very best way to do 

that, but, what we hear so much from people who actually have 

lived the experiences, the medications are way too often given as 

a substitute when we can’t give kids what they really need, and 

that’s love, stability, power, hope; someone who sees them; somebody who hears them; somebody who will stick with them. 

So I have a couple of specific recommendations I want you to 

hear. First is that consistency is the key to adequate and appropriate mental healthcare. We need stable placements. We need people who love us and who will stand with us and we need a medical 


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home. I don’t know why it’s taken so long for this country to catch 

on. I don’t know anybody who thinks it’s a bad idea. 

Why are we having such a hard time making that up? 

We need a medical home. Those of us from foster care, we don’t 

typically have things like photo albums and family scrap books. 

Sometimes the closest thing we have to that is whatever official 

records exist about us, so why don’t we put them all in one place? 

The second thing I want to make sure you hear is medication 

should not be the first option considered and should never be the 

only option considered; pills can’t change what happened to us. We 

need access to well-trained and supportive professionals who provide culturally competent services. We need ongoing access to 

healthcare even after we’ve been adopted, reunified, and especially 

after we’ve emancipated. 

We need to know about our own lives. We need access to our 

records, to information, and we need the power to seek or refuse 

the treatment that we get based on what we know and the support 

that we have. So, again, on behalf of all of us from foster care, 

thank you for standing where our parents belong. It really does 

matter. 

Thank you. 

[The prepared statement of Misty Stenslie follows:] 


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Chairman MCDERMOTT. Thank you for that testimony. 

Laurel Leslie is a physician who is at Tufts New England Medical Center Institute for Clinical Research And Health Policy. Welcome, Dr. Leslie. 

Dr. LESLIE. Thank you. 

STATEMENT OF LAUREL K. LESLIE, M.D., DEVELOPMENTALBEHAVIORAL PEDIATRICIAN, CENTER ON CHILD AND FAMILY OUTCOMES, TUFTS-NEW ENGLAND MEDICAL CENTER INSTITUTE FOR CLINICAL RESEARCH AND HEALTH POLICY 

STUDIES 

Dr. LESLIE. Mr. Chairman, thank you very much for the opportunity to testify at this hearing on the healthcare needs of children 

in foster care. As you mentioned, my name is Laurel Leslie, and 

today I am proud to speak on behalf of the American Academy of 

Pediatrics and its Task Force on Foster Care of which I am a member. 

The academy recognizes that psychotropic medication can be an 

appropriate and effective part of a treatment plan for some children in foster care. It’s critical, however, that these children receive 

thorough evaluations and comprehensive treatments that address 

all aspects of their physical, mental, developmental/educational and 

behavioral health, and that any treatment is evidenced based 

where evidence is available. 

Congress should support and fund quality, comprehensive care 

for all aspects of health and well-being of children in foster care, 

including their mental health. The few research studies available 

show rates of psychotropic medication use ranging from 13 to 50 

percent among children in foster care, which is much higher than 

the approximately 4 percent rate of youth in the general population. 

A report prepared by the government Accountability Office found 

that 15 states have identified the overuse of psychotropic medications as one of the leading issues facing their child welfare system 

in the upcoming years. Soon-to-be published data from Safe Place, 

which is in Philadelphia, also demonstrated in the Medicaid program children in foster care who have autism were more likely to 

use three or more psychotropic medications than children who 

qualified through the Supplemental Security Income program. 

These data show alarming interstate variation in prescription pattern rates of psychotropic medication used for children in foster 

care. 

It’s difficult to know from these preliminary data or the multitude of reports that are emerging in the media whether the use 

of these medications is appropriate, although at the very least, the 

use of a combination of three or more medications is controversial. 

Clearly, medication can be helpful for some children, but with the 

increasing use of these medications among the population in general there comes the added responsibility to ensure that children 

have an access to an array of treatment strategies. 

Furthermore, the failure to coordinate and provide continuity in 

services and the absence of clear guidelines and accountability to 

ensure that treatment decisions are in a child’s best interest create 

a greater risk that medications will be prescribed to control chilVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00042 Fmt 6633 Sfmt 6602 E:\HR\OC\45553.XXX 45553

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dren’s behavior in the absence of individualized service plans that 

offer these vulnerable children their best chance for success. These 

critical questions don’t have simple answers and addressing them 

will require sustained collaboration between healthcare and child 

welfare professionals as well as the funding streams to support this 

collaboration. 

Allow me to share with you three stories from my own experience 

as a clinician that demonstrate where I think we as a system have 

failed or succeeded in addressing appropriately the mental health 

needs of children in foster care. 

Four-year-old Carrie came to see me because of violent temper 

tantrums. She had broken windows, doors, and televisions, in different foster-care homes. Since she was so difficult to control, she 

had already been through multiple placements. 

Working in close collaboration with her foster parents, we were 

able to wean her down to one psychotropic medication and we educated her foster parents in intensive behavioral interventions that 

they could put in place to help shape Carrie’s behavior. However, 

when Carrie was placed for adoption in a neighboring county, neither her foster parents nor I were given the opportunity to share 

what we had learned with the adoptive parents or with any prospective medical or mental health provider who might be seeing 

her. 

Her behavior returned with a vengeance, and because her prospective parents did not know how to cope with her behavioral 

problems, that adoption fell apart within 2 weeks. She was placed 

with yet another foster family, because the family she had previously been with had already filled their beds. 

When Jenelle aged out of the foster care system, like Misty, she 

had had 22 mental health diagnoses and was on four different 

medications. She had no idea why any of the drugs were being 

given to her and she stopped them all immediately—a very dangerous move to make, considering that some psychotropic medications can have serious side effects if stopped suddenly. Jenelle met 

with me after aging out of the foster care system and asked me 

why she’d been on so many medications and why no one had ever 

taken the time to educate her about her own health or how to care 

for her healthcare needs. I did not have a good answer for her. 

Nine year old Jacob had been in foster care for several years 

while his mother was in jail because of drug use. He had hearing 

loss, ADHD, a reading disability, and needed medical, mental 

health, and school-based services that were coordinated and we 

were able to put together. When his mother was released from jail 

I was able to transition Jacob’s care and meet together with Jacob, 

his mother, and the foster parents. 

Interestingly to me, Jacob’s mother had received no help with 

parenting while she was in jail and shared with me her own inability to set limits or discipline, as she had been a victim of child 

abuse herself, an all-too-common story. We worked with her to 

learn parenting skills, find mechanisms of coping with stress that 

did not include using substances, and take over the many care coordination needs of her son. By improving her parenting skills, we 

were able to help her better manage her child’s ADHD symptoms. 


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Mr. Chairman, in conclusion, our Nation has a moral and a legal 

responsibility to provide better care to these vulnerable children. 

The Academy has identified priorities in healthcare for children in 

foster care that include the following: 

One, all children, including children in foster care, should have 

a medical home. 

Two, comprehensive physical development and mental health assessment should be given to every child within thirty days of entering State custody. Mental health assessments should also be conducted on any child for whom psychotropic medications are being 

considered. 

Three, care coordination must be a priority. The Academy strongly supports section 421 of H.R. 5466, the Invest In KIDS Act, which 

requires states to improve care coordination for children in foster 

care. We were pleased to work closely with you, Mr. Chairman, and 

your staff, to develop this section and hope it can be passed expeditiously. 

Four, if children in State custody—am I out of time? 

Chairman MCDERMOTT. You already have been over. 

Dr. LESLIE. Okay. We feel an established protocol should be set 

up and there are details related to that in my written testimony. 

Thank you again for the opportunity to testify, and I stand, or 

sit, ready to answer any questions you may have. 

[The prepared statement of Laurel K. Leslie, M.D., follows:] 

Prepared Statement of Laurel K. Leslie, Developmental-Behavioral 

Pediatrician, Center on Child and Family Outcomes, Tufts-New England 

Medical Center Institute for Clinical Research and Health Policy Studies 

Mr. Chairman, I am grateful for the opportunity to testify at this important hearing on serving the healthcare needs of children in foster care. My name is Laurel 

Leslie, MD, MPH, FAAP, and I am proud to speak on behalf of the American Academy of Pediatrics (AAP) and its Task Force on Foster Care, of which I am a member. I am an Associate Professor of Medicine and Pediatrics at Tufts Medical Center, 

a practicing pediatrician, and a researcher on children’s mental health needs. A particular focus of my clinical work and research has been children in foster care. 

The American Academy of Pediatrics has a deep and abiding interest in the 

healthcare provided to children in the foster care system. The Academy has published a handbook on the care of foster children, Fostering Health, as well as numerous policy statements, clinical guidelines, and studies regarding child abuse, neglect, 

foster care, and family support. In addition, the Academy has recognized the unique 

challenges faced by children in foster care by designating the special healthcare 

needs of children in foster care as one of the five issues highlighted in its Strategic 

Plan for 2007–2008 and establishing a Task Force on Foster Care that will craft a 

multi-pronged strategy for the AAP to improve the health of children in foster care. 

The AAP recognizes that psychotropic medication can be an appropriate and effective part of a treatment plan for some children in foster care. It is critical, however, 

that these children receive thorough evaluations and comprehensive treatment that 

address all aspects of the child’s physical, mental, developmental/education, and behavioral health, and that are evidence-based where evidence is available. Congress 

should support and fund quality, comprehensive care for all aspects of the health 

and well-being of children in foster care, including their mental health. 

Our Nation Must Address the Health Needs of Children in Foster Care 

On any given day, approximately 540,000 children are in foster care, most of 

whom have been placed there as a result of abuse or neglect at home. Several decades of research has firmly established that the healthcare needs of children in outof-home care far exceed those of other children living in poverty. Compared with 

children from the same socioeconomic background, children in foster care have much 

higher rates of birth defects, chronic physical disabilities, developmental delays, seVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00044 Fmt 6633 Sfmt 6621 E:\HR\OC\45553.XXX 45553

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1 Committee on Early Childhood, Adoption and Dependent Care. Healthcare of Young Children in Foster Care. Pediatrics, Vol. 109, No. 3, March 2002. 2 US General Accounting Office. Foster care: health needs of many young children are unknown 

and unmet. Washington, DC: (GAO/HEHS–95–114); 1995. 3Takayama JI, Wolfe E, Coulter KP. Relationship between reason for placement and medical 

findings among children in foster care. Pediatrics. 1998;101(2):201–207. 4 Halfon N, Mendonca A, Berkowitz G. Health status of children in foster care. The experience 

of the Center for the Vulnerable Child. Archives of Pediatrics & Adolescent Medicine. 

1995;149(4):386–392. 5Simms MD. The foster care clinic: a community program to identify treatment needs of children in foster care. Journal of Developmental & Behavioral Pediatrics. 1989;10(3):121–128. 6 Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A. Assessing the health status of children entering foster care. Pediatrics 1994;93(4):594–601. 7 Hochstadt NJ, Jaudes PK, Zimo DA, Schachter J. The medical and psychosocial needs of 

children entering foster care. Child Abuse & Neglect 1987;11(1):53–62. 8 Horwitz SM, Simms MD, Farrington R. Impact of developmental problems on young children’s exits from foster care. Developmental and Behavioral Pediatrics 1994;15(2):105–10. 9Leslie LK, Gordon J, Ganger W, Gist K. Developmental delay in young children in child welfare by initial placement type. Infant Mental Health Journal 2002;23(5):496–516. 10Swire MR, Kavaler F. The health status of foster children. Child Welfare 1977;56(10):635– 

53. 11Szilagyi M. The pediatrician and the child in foster care. Pediatrics in Review 

1998;19(2):39–50. 12 Halfon N, Mendonca A, Berkowitz G. Health status of children in foster care. The experience of the Center for the Vulnerable Child. Archives of Pediatrics & Adolescent Medicine. 

1995;149(4):386–392. 13Landsverk JA, Garland AF, Leslie LK. Mental health services for children reported to child 

protective services. Vol 2. Thousand Oaks: Sage Publications; 2002. 14Glisson C. The effects of services coordination teams on outcomes for children in state custody. Adminstration in Social Work. 1994;18:1–23. 15Trupin EW, Tarico VS, Low BP, Jemelka R, McClellan J. Children on child protective service caseloads: Prevalence and nature of serious emotional disturbance. Child Abuse & Neglect. 

1993;17(3):345–355. 16 Clausen JM, Landsverk J, Ganger W, Chadwick D, Litrownik A. Mental health problems 

of children in foster care. Journal of Child & Family Studies. 1998;7(3):283–296. 17 Urquiza AJ, Wirtz SJ, Peterson MS, Singer VA. Screening and evaluating abused and neglected children entering protective custody. Child Welfare. Mar-Apr 1994;73(2):155–171. 18Garland AF, Hough RL, Landsverk JA, et al. Racial and ethnic variations in mental 

healthcare utilization among children in foster care. Children’s Services: Social Policy, Research, 

& Practice. 2000;3(3):133–146. 19Pecora P, Kessler R, Williams J, et al. Improving family foster care: findings from the Northwest Foster Care Alumni Study. Seattle, WA: Casey Family Programs, available at http:// 

www.casey.org; 2005. 20 Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) study. 

http://www.cdc.gov/od/oc/media/pressrel/r980514.htm. 21 Ibid. 22Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household 

dysfunction to many of the leading causes of death in adults. Am J Prev Med. 1998; 14:245– 

258. 

rious emotional and behavioral problems, and poor school achievement.1 In fact, 

nearly half of all children in foster care have chronic medical problems,2,3,4,5 about 

half of children ages 0–5 years in foster care have developmental delays,6,7,8,9,10,11

and up to 80% of all children in foster care have serious emotional problems.12,13,14,15,16,17,18,19

Typically, their history of abuse and neglect and the accompanying health, developmental and behavioral problems they experience have an ongoing impact on all 

aspects of their lives, even long after these children and adolescents have left the 

foster care system.20 For example, the 2005 Northwest Foster Care Alumni Study 

reported that alumni from foster care were six times more likely to suffer post-traumatic stress disorder, four times more likely to turn to substance abuse, twice as 

likely to experience depression, and more than two-and-a-half times more likely to 

be diagnosed with an anxiety disorder.21 (Figure 1) Other examples of poor health 

outcomes in adulthood that have been linked to childhood abuse and neglect include 

heart disease, tobacco use, substance abuse, sexually transmitted diseases, unintended pregnancy, delinquency, obesity, and work absenteeism.22

The healthcare needs of children in foster care are often under-identified and 

undertreated, despite the overwhelming evidence of need from research. Stark evidence that children are not receiving timely services has come from a range of studies, from the 1995 Government Accountability Office (GAO) report demonstrating 

that 1/3 of children had healthcare needs that remained unaddressed while in outof-home care, to the analysis of the National Survey of Child & Adolescent WellVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00045 Fmt 6633 Sfmt 6621 E:\HR\OC\45553.XXX 45553

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23 Burns BJ, Phillips SD, Wagner RH, et al. Mental health need and access to mental health 

services by youths involved with child welfare: a national survey. Journal of the American Academy of Child and Adolescent Psychiatry. 2004;43(8):960–970. 24Leslie LK, Kelleher KJ, Burns BJ, Landsverk J, Rolls JA. Foster care and Medicaid managed care. Child Welfare 2003;82(3):367–92. 25 Institute for Research on Women and Families. Health services for children in foster care. 

Sacramento, CA: California State University, 1998. 26 Harman JS, Childs GE, Kelleher KJ. Mental healthcare utilization and expenditures by 

children in foster care. [see comments]. Archives of Pediatrics & Adolescent Medicine. 

2000;154(11):1114–1117. 27 Halfon N, Berkowitz G, Klee L. Mental health service utilization by children in foster care 

in California. Pediatrics. 1992;89(6 Pt 2):1238–1244. 28 Ibid. 29Takayama JI, Bergman AB, Connell FA. Children in foster care in the state of Washington. 

Healthcare utilization and expenditures. JAMA. 1994;271(23):1850–1855. 30 Ibid. 31 Rubin DM, Alessandrini EA, Feudtner C, Mandell D, Localio AR, Hadley T. Placement stability and mental health costs for children in foster care. Pediatrics. 2004;113(5):1336–1341. 

Being documenting that only a quarter of the children with behavioral problems in 

foster care received mental health services within a one-year follow-up period.23

Children in foster care are at risk for having inadequate healthcare provided to 

them. Most children enter foster care under precipitous and adversarial conditions; 

little may be known about their medical history and their parents may be ambivalent about partnering with an investigative case worker to address their child’s wellbeing.24 If medical information is obtained, it may not be transmitted to subsequent 

caseworkers or foster parents who bring a child to see a clinician. As a result, physicians find themselves trying to identify and treat conditions without access to the 

child’s medical history. Appropriate treatments may be delayed or clinicians may 

need to order otherwise unnecessary laboratory work-ups or referrals to subspecialists. 

Despite a bewildering number of adults participating in these children’s lives (e.g. 

investigative case workers, social workers, birthparents and/or foster parents, primary care clinicians, specialists, school personnel, judges, lawyers, and court-appointed child advocates), they often lack a single, clearly designated individual to 

monitor their health-related needs and care. Because foster parents have no legal 

authority to make medical decisions, they are frequently not informed regarding the 

outcomes of the child’s physical and mental health assessments, including the decision to prescribe medication. 

Many children experience multiple changes during their episode in foster care, 

with more than 25% experiencing three or more placement changes per year.25 Each 

placement change results in a change in caregiver, and possibly a change in social 

worker and any involved healthcare providers, thus increasing the potential for an 

uninformed diagnosis, poor communication and coordination of health-related needs 

and inconsistent, duplicative delivery of care. 

Policymakers may find it difficult to reconcile these statistics regarding unmet 

need with other data on healthcare financing and utilization among children in foster care. Mental health service use by children in foster care is 8–11 times greater 

than that experienced by other low-income and generally high-risk children in the 

Medicaid program.26,27 Children in foster care account for 25–41% of expenditures 

within the Medicaid program despite representing less than 3% of all enrollees.28,29

The answer to this apparent contradiction lies in recent data which have shown that 

up to 90% of these costs may be accounted for by 10% of the children.30,31 The services are being shifted to the back end of the system to children living in residential 

treatment, group homes, and psychiatric facilities. A small number of children are 

receiving intensive, expensive services because the system has neglected them until 

their needs became catastrophic. This is ultimately a failure to screen adequately 

and provide services to the overwhelming majority of children who would be excellent candidates for treatment and would likely respond to more modest levels of 

treatment if such services were provided at the earliest possible time. 

Improvements Are Happening, But They Bring New Challenges 

Although the landmark Adoption and Safe Families Act of 1997 is rightly heralded for its focus on improving pathways to permanency and adoption for children 

in foster care, a less discussed but equally important mandate of that legislation 

was that states focus on the well-being of children under their care. This spurred 

the development of more coordinated approaches to providing healthcare to children 

in the child welfare system. The last decade has seen the emergence of different 

models of care, from healthcare and mental health professionals inserted into child 

welfare units to screen adequately and provide oversight to the healthcare needs of 


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32 Horwitz SM, Owens P, Simms MD. Specialized assessments for children in foster care. Pediatrics. 2000;106(1 Pt 1):59–66. 33Ferguson DG, Glesener DC, Raschick M. Psychotropic drug use with European American 

and American Indian children in foster care. J Child Adolesc Psychopharmacol. 2006;16(4):474– 

481. 34Zima BT, Bussing R, Crecelius G M, Kaufman A, Belin TR. Psychotropic medication treatment patterns among school-aged children in foster care. J Child Adolesc Psychopharmacol. 

1999;9(3):135–47. 35McMillen JC, Scott LD, Zima BT, Ollie MT, Munson MR, Spitznagel E. Use of mental 

health services among older youths in foster care. Psychiatr Ser. 2004;55(7):811–817. 36 Breland-Noble AM, Elbogen EB, Farmer EM, Dubs MS, Wagner HR, Burns BJ. Use of 

psychotropic medications by youths in therapeutic foster care and group homes. Psychiatr Serv. 

2004;55(6):706–708. 37Zito JM, Safer DJ, Sai D et al. Psychotropic medication patterns among youth in foster care. 

Pediatr. 2008;121(1):e157–e163. 38 Raghavan R, Zima BT, Andersen RM, Leibowitz AA, Schuster MA, Landsverk J. Psychotropic medication use in a national probability sample of children in the child welfare system. 

J Child Adolesc Psychopharmacol. 2005;15(1):97–106. 39Zima BT, Bussing R, Crecelius GM, Kaufman A, Belin TR. Psychotropic medication use 

among children in foster care: relationship to severe psychiatric disorders. Am J Public Health. 

1999;89(11):1732–5. 40Olfson M, Marcus SC, Weissman MM, Jensen PS. National trends in the use of psychotropic 

medications by children. J Am Acad Child Adolesc Psychiatry. 2002;41(5):514–21. 41 US Government Accountability Office. Child Welfare: Improving Social Service Program, 

Training, and Technical Assistance Information Would Help Address Long-standing ServiceLevel and Workforce Challenges. Washington, DC: US GAO; 2006. 42Zito JM, Safer DJ, Sai D et al. Psychotropic medication patterns among youth in foster care. 

Pediatrics 2008;121(1):e157–e163. 43David Rubin, MD, MPH, FAAP, personal communication, April 2008. 

children, to specialized health centers that provide screening services to all children 

entering out-of-home care and timely follow-up to children, particularly during periods of placement change. These units have been responsive to guidelines published 

by the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Child Welfare League of America to provide the assessment 

and referrals necessary to meet the goals for timely access to appropriate care. Specialized health programs have also been demonstrated to improve referral of children to treatment services.32

As we have begun to achieve some success in improving access to care, new challenges have emerged. One that has risen to national attention recently has been the 

concern for the overuse of psychotropic medications among our nation’s youth in 

general, with a potentially disproportionate increase among children in foster care. 

The few research studies available show rates of psychotropic medication use ranging from 13–50% among children in foster care,33,34,35,36,37,38,39 compared with approximately 4% in youth in the general population.40 In fact, a report prepared by 

the Government Accountability Office found that 15 states identified the overuse of 

psychotropic medications as one of the leading issues facing their child welfare systems in the next few years.41 Recently published data from Texas suggests that the 

use of multiple medications concurrently is occurring at high rates among children 

in foster care.42 Soon-to-be-published data from Safe Place also demonstrates that 

in the Medicaid program, children in foster care with autism were much more likely 

to use three or more psychotropic medications than children who qualified through 

the Supplemental Security Income program.43 Those data have shown alarming 

interstate variation in the prescription patterns of psychotropic medications for children in foster care across our nation. 

It is difficult to know from these preliminary analyses or the multitude of reports 

that are emerging in the media whether the use of these medications by children 

in foster care is appropriate, although at the very least the use of combinations of 

three or more medications remains controversial. Clearly, medication can be helpful 

to some children, but with the increasing use of these medications among children 

in general, there comes the added responsibility to ensure that children have access 

to an array of treatment strategies, from medication to community-based services 

that may augment or replace the need for medications in many circumstances. Furthermore, the failure to coordinate and provide continuity in services and the absence of clear guidelines and accountability to ensure that treatment decisions are 

in the child’s best interest, create a greater risk that medications will be prescribed 

to control children’s behaviors in the absence of individualized service plans that 

might offer the best chance for success. These critical questions do not have simple 

answers, and, addressing them will require sustained collaboration between 

healthcare and child welfare professionals, as well as the funding streams to support such collaboration. 


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44 American Academy of Pediatrics Medical Home Initiatives for Children With Special Needs 

Project Advisory Committee. The Medical Home. Pediatrics, Vol. 110 No. 1 July 2002. 45 American Academy of Pediatrics District II Task Force on Healthcare for Children in Foster 

Care. Fostering Health: Healthcare for Children and Adolescents in Foster Care. 2nd Edition. 

American Academy of Pediatrics, 2005. 

*Not the child’s real name. 

Children in Foster Care Must Have a Medical Home 

Beginning in the 1960s, the American Academy of Pediatrics pioneered the concept of the ‘‘medical home,’’ which is defined as ‘‘accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.’’ 44 In a 

medical home, the physician should be known to the child and family and should 

be able to develop a partnership of mutual responsibility and trust with them. In 

the case of children in foster care, a medical home can provide a critical source of 

stability and continuity in a child’s otherwise chaotic life. The medical home’s efforts 

should include the following: 

• Obtaining health records. Too many children in state care arrive in a physician’s office without any medical history or documentation. 

• Obtaining educational records. Educational records, including an Individualized Education Plan, can contain critical information about the child’s care, 

development, and physical and mental health needs and current service use. 

• Attempting to include the birth parent or legal guardian. If possible, 

close family members should be part of discussions and can often provide at 

least portions of health history, family history and consent for use of medication. 

• Communicating with the child’s caseworker, who may have access to information about the child’s health and well-being. 

• Obtaining any health history available from the foster parent. 

• Ruling out medical issues that may contribute to the behaviors of concern 

(e.g. hearing loss). 

• If appropriate, making a mental health referral to a qualified mental health 

provider. The medical home should communicate with the mental health provider. If psychotropic medication is to be prescribed, it should ideally be done 

by a child psychiatrist, psychiatric nurse practitioner, a developmental/behavioral pediatrician, or a highly skilled and knowledgeable pediatrician with access to mental health consultation. 

• Following good medical practice in medication management. Any clinician prescribing psychotropic medications for children in foster care should exercise good clinical judgment and follow evidence-based guidelines, including 

recommendations for both psychotherapeutic and psychopharmacological treatment. 

• Obtaining assent from the child or teen who has been well-informed about 

the medication. Too many children in foster care have no idea what their diagnoses are or why they are taking medication. 

• Detailed practice parameters are available through the Academy publication, 

Fostering Health.45

Experience has taught us that a medical home can play a critical role in the lives 

of children in foster care. Allow me to share three stories with you from my own 

experience as a clinician that demonstrate where we as a system have failed or succeeded in addressing appropriately the mental health needs of children in foster 

care: 

• Four-year-old Carrie* first came to see me because of violent tantrums. She had 

broken windows, doors, and televisions in previous foster homes. Because she was 

so difficult to control, she had already been through several foster care placements. 

Working in close cooperation with her foster parents, we were able to wean Carrie 

down to one psychotropic medication and educate her foster parents in intensive behavioral interventions to help shape Carrie’s behavior. However, when Carrie was 

placed for adoption in a neighboring county, neither her foster parents nor I were 

given the opportunity to share what we had learned with her adoptive parents or 

her pediatrician or mental health clinician. Her behaviors returned with a vengeance and, because her prospective parents did not know how to cope with them, the 

adoption fell apart within two weeks. Carrie was then placed with yet another foster 

family. 

• When Janelle* aged out of the foster care system, she had 22 mental health 

diagnoses and was on four different medications. She had no idea what any of the 

drugs were for and stopped all of them—a dangerous move, considering that some 


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45 

*Not the child’s real name. 

46Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The 

Medical Home. Pediatrics, Vol. 110, No. 1, July 2002. 47 American Academy of Pediatrics. Fostering Health: Healthcare for Children and Adolescents 

in Foster Care. 2nd edition. American Academy of Pediatrics, 2005. 48 American Academy of Pediatrics. Committee on Early Childhood, Adoption, and Dependent 

Care. Healthcare of young children in foster care. Pediatrics 2002;109:536–41. 49 New York State, Office of Children and Family Services. The use of psychiatric medications 

for children and youth in placement; authority to consent to medical care. 2002. Available at 

http://ocfs.state.ny.us/main/sppd/health_services/manual.asp 50 Ibid. 

psychotropic medications can have serious side effects if stopped suddenly. Janelle 

met with me after aging out of the foster care system and asked me why she had 

been on so many medications and why no one had ever taken the time to educate 

her about her own health and how to care for her health needs. I did not have a 

good answer for her. 

• Nine-year old Jacob* had been in foster care for several years while his mother 

was in jail because of drug use. He had hearing loss, Attention Deficit Hyperactivity 

Disorder, and a reading disability and needed medical, mental health, and schoolbased services which we had been able to put in place. When his mother was released from jail, I was able to transition Jacob’s care and meet together with Jacob, 

his mother, and foster parents. Interestingly, Jacob’s mother had received no help 

with parenting while in jail, and shared with me her own inability to set limits or 

discipline as she herself had been a victim of child abuse, an all-too-common story. 

We worked with her to learn parenting skills, find mechanisms of coping with stress 

that did not include substance use, and take over care coordination of the many 

needs of her son. By improving her parenting skills, we were able to help her better 

help her son to manage his ADHD symptoms. 

Recommendations 

Our nation has a moral and legal responsibility to provide better care to these 

most vulnerable children. We must ensure that, in removing them from their homes, 

we improve the health and well-being of foster children and do not further compound their hardship. While the AAP Task Force on Foster Care will issue additional recommendations in the future, the American Academy of Pediatrics has identified priorities in healthcare for children in foster care that include the following: 

Comprehensive Care for Children in Foster Care 

• All children, including children in foster care, should have a medical home that 

is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.46 For children in foster care, a medical home can 

provide a crucial source of stability, continuity of care, and information.47

• Comprehensive physical, developmental, and mental health assessments should 

be given to every child within 30 days of entering state custody.48 Mental health 

assessments should also be conducted on any child for whom psychotropic medications are being considered.49

• Care coordination must be a priority. The Academy strongly supports Section 

421 of H.R. 5466, the Invest in KIDS Act, which requires states to improve care coordination for children in foster care. We were pleased to work closely with Chairman McDermott and his staff to develop this section and hope it can be passed expeditiously. 

• The Academy is profoundly concerned that the recent Centers for Medicare 

and Medicaid Services interim final rule on Case Management Services represents a step away from care coordination. While the rule states that its purpose is to improve care coordination, the significant limits it imposes are likely to restrict state flexibility and deny the child welfare system valuable tools 

to coordinate health and related services for children in foster care. The Academy strongly endorsed the legislation passed by the House to place a moratorium on this rule. 

• Financing should reimburse healthcare professionals for the more complex and 

lengthy visits that are typical of the foster care population. Financing must also 

cover the cost of the healthcare management to ensure that this medically complex 

population receives appropriate and timely healthcare services.50


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51 Ibid. 52 Ibid. 53 American Academy of Pediatrics. Committee on Early Childhood, Adoption, and Dependent 

Care. Healthcare of young children in foster care. Pediatrics 2002;109:536–41. 54 Ibid. 

• Child welfare agencies and healthcare providers should develop and implement 

systems to ensure the efficient transfer of physical, developmental, and mental 

health information among professionals who treat children in foster care.51

• Health insurance for children and adolescents in foster care must include a 

comprehensive benefits package, such as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) package, to cover the wide array of services needed 

to ensure optimal physical, emotional, developmental, and dental health.52

Mental Health Services for Children in Foster Care 

• If children in state custody are placed on medication, there should be an established protocol for obtaining consent and monitoring the use of that medication. 

Depending on the state, parties authorized to provide this consent could include 

a juvenile court officer, social services commissioner, or other authorized guardian or agency with assistance from a clinician knowledgeable of the evidence regarding psychotropic medication use. Pediatric and mental health providers 

should have ongoing communication with the child and caregivers to monitor 

treatment response, side effects and potential adverse reactions. Caseworkers 

also should maintain documentation regarding recommendations for prescriptions, changes in dosage and side effects, and child’s response to medication as 

a treatment option. Youth should be involved and educated about the risks, benefits, and side effects of taking psychotropic medications. When appropriate, the 

assent of youth should be documented in addition to consent of the caretaker 

and/or caseworker.53

• Financing should include funds for developing family-based approaches to mental health and developmental services.54

• Both the National Child Abuse and Neglect Data System (NCANDS) and the 

Adoption and Foster Care Analysis and Reporting System (AFCARS) should track 

at least basic information on the use of psychotropic medications among children in 

foster care. At present, neither system collects any data in this area. The Academy 

filed comments with the Administration on Children, Youth and Families on March 

5, 2008 that included recommendations for new AFCARS data elements on psychotropic drug prescriptions for children in foster care. 

Mr. Chairman and Members of the Subcommittee, I deeply appreciate this opportunity to offer testimony on behalf of the American Academy of Pediatrics. I stand 

ready to answer any questions you may have, and I thank you for your commitment 

to the health of the children of our nation. 

f 

Chairman MCDERMOTT. Mr. Weller points out, perhaps I could 

do some education. Green is for five minutes. When it goes to yellow, that means you got a minute. When it’s red, it’s over. It’s a 

little late for show and tell, but thank you very much for your testimony. 

Christopher Bellonci is the medical director at the Walker School 

in Needham, Massachusetts. 

STATEMENT OF CHRISTOPHER BELLONCI, M.D., 

MEDICAL DIRECTOR, THE WALKER SCHOOL 

Dr. BELLONCI. Thank you, Mr. Chairman and Members of the 

Committee. 

I am pleased to be here on National Children’s Mental Health 

Awareness Day to discuss this important issue. I am prepared to 

speak today as a child psychiatric practitioner, a consultant to the 

child welfare system, and a medical director of a residential treatment center. One possible explanation for the apparent overuse of 


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psychiatric medications for children in the child welfare system is 

the high rate of mental illness found in this population. 

Studies indicate that 60 to 85 percent of the children being 

served by the child welfare system meet criteria for a DSM4 psychiatric diagnosis. In many cases, this is related to the trauma that 

resulted in the removal from their family, but in the significant 

number of cases, the mental illness appears to have pre-dated their 

removal. These children’s families are often significantly affected 

by mental illness and substance abuse. These familial conditions 

lead to a genetic predisposition to mental illness in their children. 

This risk can then be multiplied by in utero exposure to alcohol 

and other drugs. Often, these children then suffer neglect and 

abuse, which compound their genetic and biological risk to develop 

emotional and behavioral disorders. 

Multiple placements within the foster care system add additional 

burdens to healthy emotional development and impair coordinated 

mental health treatment. Early detection and assessment of the 

mental health needs of these children are critical in order for them 

to receive necessary mental health interventions. 

Unlike mentally ill children from intact families, these children 

rely on the State to provide informed consent for their treatment, 

to coordinate treatment planning and clinical care, and to provide 

longitudinal oversight of their treatment. The State has a duty to 

perform this protective role for children in State custody. However, 

the State must also take care not to reduce access to needed and 

appropriate services. 

Many children in State custody benefit from psychotropic medications as part of a comprehensive, mental health treatment plan. As 

a result of several highly publicized cases of questionable prescribing practices, treating youth in State custody with 

psychopharmacological agents has understandably come under increased scrutiny. Many states have implemented consent, authorization and monitoring procedures for the use of psychotropic medications for children in State custody. 

Unfortunately, these policies have unintended consequences, 

such as delaying the provision of or reducing access to necessary 

medical treatment. I believe the critical question in this discussion 

is whether medication is being prescribed appropriately in ensuring 

that all the child’s mental health needs are being adequately addressed. 

Most psychoactive medications do not, as yet, have specific approval by the FDA for children under age 12. This approval requires research demonstrating safety and efficacy, and, the research so far lags behind the clinical use of these medications. 

Long-term studies are needed to adequately determine the safety 

and efficacy of psychoactive medications in this age group. 

In making decisions to prescribe such medications, child psychiatrists are often left to evaluate data from studies in adults, even 

though there are documented cases of medications that were safe 

in adults causing unanticipated side effects in children. 

The lack of data supporting current prescribing trends makes the 

informed consent process all the more critical for children in State 

custody. In my consulting work in Tennessee I drafted medication 

monitoring guidelines for use by that state’s child welfare workers. 


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These guidelines are meant to be used by child welfare caseworkers 

in their monitoring of psychotropic medications prescribed for children in care. 

They are similar to those developed in other jurisdictions; and, 

frankly coming up with a common agreement for thresholds that 

should trigger a clinical review should not be that difficult. These 

guidelines are not intended to dictate treatment decisions by individual providers. Every child or adolescent has unique needs that 

require individualized treatment planning. 

At times in my own practice, the appropriate treatment for a specific child will fall outside of the parameters of these guidelines, 

but, I would expect that if anybody questioned why a specific child 

was on a medication under my care, I could give a rational explanation. 

State child welfare agencies need to develop a second opinion capacity for times when prescribing practices fall out of established 

guidelines for community systems of care. In Tennessee the State 

contracts with five university medical centers in five different regions of the State to provide expert second-opinion capacity regarding all aspects of a child’s mental health diagnosis and treatment 

planning, including psychiatric medication. 

I’ve included the guidelines I developed for Tennessee in my 

written statement and would be happy to discuss them in more detail during the question and answer period of this hearing. 

Thank you. 

[The prepared statement of Christopher Bellonci, M.D., follows:] 

Prepared Statement of Christopher Bellonci, M.D., 

Medical Director, The Walker School, Needham, Massachusetts 

Mr. Chairman and Members of the Committee, my name is Christopher Bellonci, 

M.D. and I am pleased to be here to discuss the important issues related to psychotropic medication use among children in America’s foster care system. I am a boardcertified child and adolescent psychiatrist and the medical director at Walker, a 

multi-service agency in Needham, Massachusetts where I work directly with children in the child welfare system. I am a member of the American Academy of Child 

and Adolescent Psychiatry as well as a member of the Mental Health Advisory 

Board of the Child Welfare League of America. For several years I have been consulting to the State of Tennessee’s child welfare agency helping that State to revise 

their policies and procedures regarding psychotropic medication use and behavior 

management. 

As Dr. Zito has outlined in her testimony, children in child welfare appear to be 

prescribed psychotropic medication at higher rates than children who are not within 

the child welfare system. In Tennessee, unpublished data indicated that approximately 25% of the children in that system were taking psychiatric medication. As 

you have heard from Dr. Zito, her most recent study of children in the Texas child 

welfare system showed 34.7% of the children were taking psychiatric medications 

with 41.3% of those children on psychiatric medications taking three or more medications. 

One possible explanation for the apparent overuse of psychiatric medications for 

children in the child welfare population is the high rate of mental illness found in 

this population. Studies indicate that 60–85% of the children being served by the 

child welfare system meet criteria for a DSM–IV Psychiatric diagnosis. In many 

cases this is related to the trauma that resulted in their removal from their family 

but in a significant number of cases the mental illness appears to have predated 

their removal. With such a high prevalence of mental illness in this population, 

screening for mental disorders is superfluous and instead providers time would be 

better served moving to a comprehensive assessment of the child and family’s 

strengths and needs that can be used for treatment planning and service delivery. 

The families from which these children were removed are often significantly affected by mental illness and substance abuse. These familial conditions lead to a geVerDate Nov 24 2008 13:16 Feb 17, 2009 Jkt 045553 PO 00000 Frm 00052 Fmt 6633 Sfmt 6621 E:\HR\OC\45553.XXX 45553

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netic predisposition to mental illness in their children. This risk can be multiplied 

by in-utero exposure to alcohol and other drugs. Often these children then suffer 

neglect and abuse compounding their genetic and biological risks to develop emotional and behavioral disorders. Multiple placements within the foster care system 

add additional burdens to healthy emotional development and impair coordinated 

mental health treatment. Early detection and assessment of the mental health 

needs of these children is critical in order for them to receive necessary mental 

health interventions. 

Unlike mentally ill children from intact families, these children rely on the state 

to provide informed consent for their treatment, to coordinate treatment planning 

and clinical care, and to provide longitudinal oversight of their treatment. The state 

has a duty to perform this protective role for children in state custody. However, 

the state must also take care not to reduce access to needed and appropriate services. Many children in state custody benefit from psychotropic medications as part 

of a comprehensive mental health treatment plan. As a result of several highly publicized cases of questionable prescribing practices, treating youth in state custody 

with psychopharmacological agents has come under increased scrutiny. Many states 

have implemented consent, authorization, and monitoring procedures for the use of 

psychotropic medications for children in state custody. Unfortunately, these policies 

can have unintended consequences such as delaying the provision of, or reducing access to, necessary medical treatment. 

The critical question in this discussion is whether medication is being prescribed 

appropriately and ensuring that all of the child’s mental health needs are being adequately addressed. Most psychoactive medications prescribed for children under age 

twelve do not as yet have specific approval by the Food and Drug Administration 

(FDA); such approval requires research demonstrating safety and efficacy. Such research, so far, lags behind the clinical use of these medications. Long-term studies 

are needed to adequately determine the safety and efficacy of psychoactive medications in this age group. In making decisions to prescribe such medications child psychiatrists often are left to evaluate data from studies in adults even though there 

are documented cases of medications that were safe in adults causing unanticipated 

side-effects in children. The lack of data supporting current prescribing trends 

makes the informed consent process all the more important for children in state custody. The prescribing of multiple psychotropic medications (‘‘combined treatment’’ or 

‘‘polypharmacy’’) in the pediatric population is on the increase. Little data exist to 

support advantageous efficacy for drug combinations, used primarily to treat co-morbid conditions. The current clinical ‘‘state-of-the-art’’ supports judicial use of combined medications, keeping such use to clearly justifiable circumstances (AACAP 

policy statement 9/20/01). 

In my consulting work in Tennessee, I drafted medication monitoring guidelines 

for use by that state’s child welfare workers. The guidelines were meant to be used 

by child welfare caseworkers in their monitoring of psychotropic medications prescribed for children in care. They were not intended to dictate treatment decisions 

by providers. Every child or adolescent has unique needs that require individualized 

treatment planning. At times, the appropriate treatment for a specific child will fall 

outside the parameters of these guidelines. State child welfare agencies need to develop a second opinion capacity for times when prescribing practices fall out of established guidelines or community standards of care. In Tennessee, the state contracted with four university medical centers in four different regions of the state to 

provide expert second opinion capacity regarding all aspects of a child’s mental 

health diagnosis and treatment including psychiatric medication. 

It was the intent of the following guidelines that children in care receive necessary mental health treatment, including psychotropic medications, in a rational 

and safe manner. The guidelines reflect common practice wisdom in the field of 

child psychiatry: 

• Medication should be integrated as part of a comprehensive treatment plan that 

includes: 

• Appropriate behavior supports and treatment 

• Symptom and behavior monitoring 

• Communication between the prescribing clinician and the youth, parents, 

guardian, foster parents, child welfare case manager, therapist(s), pediatrician, school staff and any other relevant members of the child or youth’s 

treatment team 

• Medication decisions should be appropriate to the diagnosis of record, based on 

specific indications (i.e., target symptoms), and not made in lieu of other treatments or supports that the individual needs. There should be an effort, over 


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time, to adjust medication dosages to the minimum dosage at which a medication remains effective and side effects are minimized. Periodic attempts at taking the child off medication should also be tried and, if not, the rationale for 

continuing the medication should be documented. 

• Medication decisions need to be based upon adequate information, including 

psychiatric history and assessment, medication history, medical history including known drug allergies and consideration of the individual’s complete current 

medication regimen (including non-psychoactive medications, e.g., antibiotics). 

• Polypharmacy, or the use of multiple psychiatric medications, should be avoided. 

• When a recommendation is made for a child to take more than one medication 

from the same class (e.g., two anti-psychotic medications), the recommendation 

should be supported by an explanation from the prescribing clinician and may 

warrant review by a consultant to the child welfare system. 

• A child taking more than three psychotropic medications should prompt an explanation from the prescribing clinician and may warrant review by a consultant to the child welfare system. 

• Medication dosages should be kept within FDA guidelines (when available). The 

clinical wisdom, ‘‘start low and go slow’’ is particularly relevant when treating 

children in order to minimize side effects and to observe for therapeutic effects. 

Any deviations from FDA guidelines should be supported by an explanation 

from the prescribing clinician and may warrant review by a consultant to the 

child welfare system. 

• Unconventional treatments should be avoided. Medications that have more data 

regarding safety and efficacy are preferred over newly FDA-approved medications. 

• Medication management requires the informed consent of the parents or guardians (unless parental rights have been terminated in which case the state must 

provide informed consent) and must address risk/benefits, potential side effects, 

availability of alternatives to medication, prognosis with proposed medication 

treatment and without medication treatment and the potential for drug interactions. 

• The risk versus benefit of a medication trial needs to be considered and continually reassessed, and justification should be provided, where the benefit of a 

medication comes with certain risks or negative consequences. 

• Children on psychotropic medications should be seen by their prescribing clinician no less that once every three months. This is a bare minimum and children 

in acute settings, displaying unsafe behavior, experiencing significant side effects, starting on SRI’s or not responding to a medication trial or in an active 

phase of a medication trial should be seen more frequently. 

• If laboratory tests are indicated to monitor therapeutic levels of a medication 

or to monitor potential organ system damage from a medication these lab studies should be performed every three months at a minimum (maintenance 

phase). If the medication is being initiated, these lab studies will need to be performed more frequently until a baseline is achieved. 

In addition to developing the guidelines, a computerized, interactive state-of-theart training curriculum was developed for all child welfare staff in Tennessee. The 

curriculum used clinical vignettes to teach child welfare staff about the revised 

psychotropic medication policies and procedures as well as the medication guidelines. The Department is also working to update its information technology system 

to be able to embed the guidelines into their database so that when a child’s psychiatric medications fall out of the guidelines an alert is sent to the case manager 

or supervisory staff. This system would work similar to a pharmacy’s computer program alerting the pharmacist to possible medication contraindications. 

State child welfare agencies should create websites that can provide ready access 

for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psycho-educational materials 

about psychotropic medications, consent forms, adverse effect rating forms, reports 

on prescription patterns for psychotropic medications, and links to helpful, accurate, 

and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications (AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Practices Guideline). 

States should develop the capacity to monitor the rate and types of psychotropic 

medication usage by children in state care as well as the rate of adverse reactions 

to prescribed medications. States should establish a process to review non-standard, 

unusual, and/or experimental psychiatric interventions with children who are in 

state custody. States should collect and analyze data and make quarterly reports to 


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the state or county child welfare agency regarding the rates and types of psychotropic medication being prescribed to children in their care. Making this data available to clinicians in the state could serve as a vehicle to improve the quality of care 

provided to children in state custody. 

Thank you for the opportunity to address this important area of concern impacting America’s most vulnerable youth. 

f 

Chairman MCDERMOTT. Thank you. 

Mr. Weller, would you like to ask the first question? 

Mr. WELLER. Sure, Mr. Chairman, recognizing that the delay of 

our hearing may have made it difficult for other Members of the 

Subcommittee to attend because of various obligations in their 

schedules, can I ask unanimous consent that Members of the Subcommittee have five legislative days to submit questions to the witnesses for the record? 

Chairman MCDERMOTT. Without objection, it’s ordered. 

Mr. WELLER. I should say written questions to the panelists. 

Ms. Stenslie, thank you for your testimony. You had personal experiences both as a foster youth, but also as a foster parent, and 

clearly you are very committed to foster children because of your 

role with the alumni association. 

You know, Mr. Chairman, she spoke eloquently about the need 

for the ability of foster youth to be able to somehow maintain their 

records if they’re going to change foster homes, and be able to take 

those medical records with them if they change positions as well. 

Of course, we’ve been working in the Ways and Means Committee 

and there’s been a bipartisan effort on electronic records and other 

capabilities with technology we have. I’ve often wondered why can’t 

we do that. So perhaps that’s an area you and I can work together 

on. 

Ms. Stenslie, why do so many foster youth end up being prescribed medication, both from your personal experience, but also 

from your observation? 

Ms. STENSLIE. I’m glad you asked that and I don’t think there’s 

a really predictable answer, but what I’ve seen in the foster care 

system, a lot of times we end up doing things to make it easier for 

the adults. The adults are overworked and they’re underpaid, and 

they have all kinds of commitment and idealism when they start. 

Then they get squashed by our system and how hard it is to work 

in, and I’ve been there. 

So we do a lot of things in child welfare to try to make things 

easier for the adults; and, so, I think a lot of times managing a 

young person’s behavior through the use of medication is a way to 

try to make it possible for foster parents to stick with this kid just 

a little longer, or for the group home to not send them to a higher 

level of care, that we do it so the adults in their lives can figure 

out how to cope with them. 

I think that a lot of times medication is used as a chemical restraint for children whose behavior get out of control. Dr. Leslie 

talked about a little girl who broke windows and televisions, and 

certainly we know that’s not safe or healthy for anybody, but, we 

also know that we can’t take away what she went through by giving her a pill. So, maybe the pill is the stopgap measure, but we 


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have to help her figure out how to negotiate what she went 

through, because her reality is not going to change. 

Mr. WELLER. I have a 20-month-old daughter and there’s days 

we’re a little tired when we get home. So, I think I understand 

where you’re coming from on that. 

You state in your testimony: ‘‘Over the years, I was on more 

medications than I can count, usually without my knowing what 

the meds were for, how I should expect to feel, side effects to watch 

out for, or any plan for follow-up.’’ You had questions. 

Did anyone in your life ever give you answers to those questions? 

Ms. STENSLIE. No. It wasn’t until I was an adult and I was in 

college that I actually found a therapist myself and she told me 

that I would be able to go and get some of my records and find out 

what all of that was about, because I didn’t leave the system with 

any of that information. So she helped me to at least get a clinical 

profile from my last stint in placement; and, it said right on there 

that I had post-traumatic stress disorder and depression. That’s 

something that no one ever told me. 

Mr. WELLER. Your caseworker never discussed this with you, 

your foster parents never discussed it with you? 

Ms. STENSLIE. No. 

Mr. WELLER. Your doctor never discussed it with you that prescribed the medicine? 

Ms. STENSLIE. No. 

Mr. WELLER. For me it’s very frustrating, because for a better 

job and better life, a person needs a high school diploma, and so 

many foster youths go from school to school to school. It makes it 

difficult for them not only to socialize, but to develop friends. 

Ms. Stenslie. I’ve been to at least 25 schools. 

Mr. WELLER. 25 schools in your own personal experience. 

How many doctors did you encounter during that period of time? 

You went to 25 different schools? 

Ms. STENSLIE. Right. Probably fewer than you would expect, 

because much of that time I was completely without health or mental healthcare, so I didn’t have as many doctors as I did social 

workers, because the social workers were required. The doctors 

were seen as a luxury. 

Mr. WELLER. So, do you think the process worked in your own 

experience or as it currently exists does it work for kids when it 

comes to their exposure to psychotropic drugs that may be prescribed in their case? 

Ms. STENSLIE. I think it works for some. I think there are a 

lot of really highly qualified and invested doctors out there; and, 

obviously, many of them are here today, but I think it takes a special set of skills and knowledge to be competent in dealing with 

youth who come from very highly traumatized backgrounds. 

I think you also have to, on top of the trauma informed care expertise, know about foster care, because it brings its own set of life 

circumstances that you can’t possibly understand unless you purposely tried to. 

Mr. WELLER. Thank you. 

Mr. Chairman, you’ve been generous and my red light’s been on 

for some time. 

[Laughter.] 


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Mr. WELLER. Thank you. 

Chairman MCDERMOTT. Thank you. 

In listening to this it’s interesting that I had written down the 

same questions that Mr. Weller explored. That is, why is it we 

can’t have a medical home? So I’d like to move to the pros here for 

a second and ask. Well, not that you’re not a pro, because you are 

a social worker, but those of you who have been roaming around 

the country looking at various systems, where have they gotten it 

together best? 

I understand there may be some desire to pump your own balloon, but if you could give us a clue as to where they have figured 

out how to coordinate the records and get a decent review system 

of what’s going on and maybe peripherally get the kids involved in 

understanding what it is they’re on and why, because that really 

is a part of the medical home situation. So I’d like to hear what 

you think. 

Does it take a law suit like Tennessee to bring you up to the tips 

of your toes? Or, is there someplace where they really worked it 

out? So, it’s really a blue book question for any one of you to jump 

in on. I’d like to hear what we should look at to emulate or encourage or, whatever. 

Dr. LESLIE. I’d be happy to comment on something. I’m not 

going to be commenting from the State level but just from what 

you asked initially about what is the medical home. So just for everyone’s review, what we see is a medical home is a site where 

your care is continuous, coordinated, accessible, comprehensive. 

That’s what should make a medical home. So, from the pediatrician’s perspective, there’s about three models I would say out there, 

again, from the pediatric perspective of what is a medical home. 

Several communities have come up with systems where there are 

multiple disciplines of people located at those settings where 

they’re evaluating kids. So, you have somebody who is looking for 

developmental problems; somebody who is looking for educational 

problems; somebody who is looking at mental health; somebody 

who is looking at what medications a child is on for chronic health 

problems, and all that is put together. L.A. has one of those systems. Philadelphia does. Connecticut does; where kids who are entering foster care come and are evaluated in a comprehensive manner and then followed on a more routine basis over time. 

That’s not always feasible in every community. In Rochester, for 

example, we have what some would call a foster care champion, 

Moira Szilagyi, has set up a clinic that specifically addresses the 

needs of children in foster care, so she may not be a part of a comprehensive center, but she is doing that on her own as a clinician. 

That’s a second example. 

A third example would be mechanisms of making sure kids are 

evaluated in getting evidenced-based treatments in partnerships 

with other settings. Some states or counties have set up where 

child welfare and mental health, or child welfare and Medicaid, 

partner together around meeting those needs. Massachusetts, for 

example, somewhat like Tennessee, has just hired a whole group 

of nurses who are going to work and provide oversight within child 

welfare for what are the medical problems and what medications 

children are on. That would be a third example where it is actually 


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housed in Medicaid mental health or child welfare. I think those 

are three different models. 

The other thing I’d say is I think the comprehensiveness of care 

is really important to stress. One of the things I was very lucky 

about when I mainly worked in California, but we worked to develop highly evidenced-based treatments for children in foster care. 

So, for example, I was lucky as a clinician to be able to refer a child 

and their foster parent to a program that’s been developed out of 

Oregon where they actually train foster parents in the 16-week session on how to handle behavior problems. We’ve been able to show 

that 80 percent of children will respond to that. About 20 don’t, 

and those are the kids that have pretty serious mental disorders 

and need more than what a foster parent can provide, but that’s 

using the person who’s with the child the most as an intervention 

agent and I’d be happy to share information with that with any of 

you as well. 

Dr. LEA. Tennessee has been mentioned several times, so I want 

to make sure that I get a chance to comment. I think we’ve done 

some things right. The law suit has given us some financial means 

to make some steps that might otherwise not have been available. 

We also appreciate the house support of the moratorium on TCM 

as we’re facing losing $73 Million for the care that we provide kids. 

I think we’ve been able to do, one of the things Dr. Leslie mentioned, was all children coming into custody getting a health 

screening within 30 days. That is something that we mandate and 

is done at our health department within links onto mental health 

health assessments in the community as needed. 

I mentioned in both my written and oral testimony about the 

centers of excellence that we have, those were actually created by 

a different lawsuit that we have but have really served us well. 

They were created specifically for kids in imminent risk of custody 

and our most complex cases go there. 

Those kids that have not only numerous mental health diagnoses 

that are aggressing in treatment, not progressing in treatment, nobody knows what to do with. Foster parents are at a loss, and the 

team of professionals that are psychology, neurology, medical take 

a look at that child. They do provide some ongoing care. Unfortunately, they are not able to see every child coming into custody or 

provide ongoing care for every child who remains in custody, but 

they have been a fabulous resource above and beyond the nurses, 

psychologists and psychiatrists that we have in-house in Tennessee. 

Chairman MCDERMOTT. Ms. Stenslie, you commented that at 

one point you wound up in detention, to some kind of a detention 

situation. 

I worked for a number of years at the center in the State of 

Washington where we dealt with all the kids who came through 

the juvenile justice system. We gave them a comprehensive workup at that point. I don’t think we had a comprehensive work-up. 

This was Cascadia; that’s now closed. I don’t know whether they’re 

still doing that in the State or not. 

Did you receive anything different when you got to that level of 

dysfunction? 


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Ms. STENSLIE. You know, I’m not so sure, because people 

weren’t discussing that with me directly. So I don’t know for sure. 

In those correctional facilities there were certainly more people 

with doctor in their title than I had seen in other kinds of places; 

and, so, as an adult, someone who has worked in those systems, 

I know that there was more mental healthcare available right 

there on campus, but I don’t know that I actually received it. 

I do remember very vividly standing in line with nearly every 

other resident of those facilities at eight o’clock every night and 

eight o’clock every morning to each get our little white paper pills 

in a little white cup. I’m not aware of receiving any more or better 

health or mental healthcare while I was there. The fact that I grew 

up without knowing about what my own diagnoses were and what 

the meds were for, I’d have to say as an adult then learning about 

that PTSD diagnosis, then I was able to take some control about 

it. 

Then I went and did some research and found out what it was 

and was able to look at those books and to ask questions and say, 

you know what? That does describe me and there are some ways 

to fix that out there and I’m not just crazy and I’m not just destined for a whole life of nightmares and not sleeping at night. Then 

I could claim what belonged to me and get rid of what didn’t and 

address it, but I had no chance to even do that until somebody 

talked to me. 

Chairman MCDERMOTT. Dr. Thompson? 

Dr. THOMPSON. Well, medical home also would be the 

naysayer. It’s the new buzz word. We went through chronic care 

management. We went through disease management and now 

we’re at medical home, and quite frankly, I’m still perplexed about 

what this is, but I think it’s a good idea. For me it’s three things. 

I absolutely agree with records management, whether it’s electronic or whether it has to be portable and it has to go, because 

how can you really tell what’s going on. The other thing I think is 

missing is medical home has to be putting the client at the center 

with mental health, medical, and family services integrated. 

Most of the time, I don’t know of any service that actually mixes 

and matches all those three together well. I think there are pieces 

and parts and we’re trying to find those. We certainly are trying, 

but we haven’t figured out Washington State. 

Chairman MCDERMOTT. What’s the place that you wind up 

with the problem in coordinating the three? 

Dr. THOMPSON. Well, I think its contracts are separate. Budgets are separate. You fund mental health differently than medical 

and sometimes differently than family services; and, therefore, you 

contract differently. There are multiple mixes of people in this discussion and there is not really good integration. That’s fundamentally what I see. 

So when you can write contracts and funding streams where they 

all have to talk, then I think that’s a medical home. Whoever 

wants to be at the center, at the top, whatever, fine, but, right now, 

I see it as, ‘‘Is it the pediatrician that wants to be at the center?’’ 

As far as I’m concerned, the client’s at the center, and 

everybody’s got to talk around that client. My take-home point is 

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agement to the families and the clients. I’ll take that home, and 

that’s going to happen. 

The third thing is standards. You can send him off to a medical 

home, but if we don’t all agree on what the standards are, what 

the care is, and we see it in our State, in some places it’s a whole 

bunch of meds. In some places it’s not many meds. In some places 

it’s meds combined with mental health treatment. So I think standards are really important. I know it’s probably a dirty word, but, 

people have got to. What we demand of banking and what we demand of our automobile industry and our space industry is that 

we’ve got to take an industrial approach or an engineering approach. There can’t be the standard of variation that we see in 

medicine. 

I know that’s probably not the best thing to say, but as I look 

at it, we’ve got to do what we’ve done really well in banking and 

automobile; and, we can push that into medical. I think we’re going 

to do a much better job. 

Chairman MCDERMOTT. Is that happening in the pediatrics association, the National Association of Pediatrics? 

Dr. LESLIE. In terms of setting standards? 

Chairman MCDERMOTT. Yes. 

Dr. LESLIE. Well, both the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics routinely publish guidelines on what’s appropriate treatment and try 

to get those into the community. 

Chairman MCDERMOTT. So you’ve got the guidelines. You’ve 

published them. They simply are not filtering down to the practitioners or there’s no oversight. 

Dr. BELLONCI. There’s a great deal of variability, and I don’t 

know that any of the states have all the components that I would 

like to see implemented. I think there are good examples of some 

best practice and merging some of what you’ve heard today. 

This doesn’t have to be that complicated. We need to have 

screening at intake and point of removal. Was the child already diagnosed with a psychiatric condition? Are they already taking psychiatric medication so they continue on those, if they had a preexisting condition? 

Do they have an emerging trauma related to the removal itself? 

If you believe the statistics that 60 to 85 percent of these kids 

are going to be diagnosed with a psychiatric condition, when I was 

trained in medical school you skipped screening and you just go to 

comprehensive assessment of their needs and strengths and move 

to treatment planning, because why waste your dollars screening 

at such a high incidence rate? 

We then need to have comprehensive treatment plans that may 

include medication recommendations, but, states should not assume that just because a doctor is prescribing this psychiatric 

medication that that precludes their need to have a second opinion 

capacity. I think there are some very scary stories of medication 

practices that you’re hearing about. 

I recently admitted a three-year-old who was on three psychiatric 

medications including lithium; and, when I brought that to the attention to the child welfare agency I couldn’t even get a response 


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from them. The child left on a small dose of a stimulant medication. 

There needs to be informed consent by knowledgeable, trained, 

child welfare staff if and only if the parent or guardian can’t be 

there. There clearly needs to be information sharing with the child 

themselves, even when I’m working with four and 5-year-olds as 

best as I can in a developmentally appropriate way. I’ll talk about 

why I am giving them that medication and what they should expect, and what they might need to look for. I meet with them frequently to monitor their side effects or their response. 

There needs to be an IT system that can actually tell the child 

welfare system what are the medications these children are taking 

in the individual case as well as in the aggregate. Then there needs 

to be a Committee that actually reviews that data periodically so 

that they can inform practice and engage the child psychiatric community. 

Chairman MCDERMOTT. Thank you all for your testimony. 

Mention was made of the section in the Invest in KIDS Act about 

the healthcare coordination and Mr. Weller and I are working on 

trying to bring. We may not get the huge bill out of here. This Congress is a little bit confusing in terms of trying to do something big, 

but we’re trying to do some thing that we think can help the system, particularly in this area before the end of the session. 

So, thank you very much for not only coming but waiting and 

participating and we thank you for coming. Thank you very much. 

The meeting is adjourned. 

[Whereupon, at 1:37 p.m., the Subcommittee was adjourned.] 

[Responses to Questions for the Record posed by Chairman 

McDermott to Julie M. Zito, Ph.D. follow:] 


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[Responses to Questions for the Record posed by Chairman 

McDermott to Christopher Bellonci, M.D. and Laurel K. Leslie, 

M.D., MPH follow:] 


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[Responses to Questions for the Record posed by Chairman 

McDermott to Tricia Lea, Ph.D. follow:] 


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[Responses to Questions for the Record posed by the Subcommittee to Misty Stenslie follow:] 


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[Responses to Questions for the Record posed by Chairman 

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[Submissions for the Record follow:] 


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1Simms, M.D., Dubowitz, H., & Szailagyi, M.A. (2000). Needs of children in the foster care 

system. Pediatrics , 106 (Supplement), 909–918. 

f 

Statement of Bruce Lesley 

Mr. Chairman, Ranking Member Weller and Members of the House Subcommittee 

on Income Security and Family Support, thank you for this opportunity to submit 

comments for the record regarding the May 8, 2008 hearing on the Utilization of 

Psychotropic Medication for Children in Foster Care. 

First Focus is a bipartisan advocacy organization committed to making children 

and their families a priority in federal policy and budget decisions. Our organization 

is dedicated to the long-term goal of substantially reducing the number of children 

entering foster care, and working to ensure that our existing system of care protects 

children and adequately meets the needs of families in the child welfare system. We 

are especially concerned with ensuring access to appropriate and high-quality health 

and behavioral healthcare for foster children. 

As you know, children who have been abused or neglected often have a range of 

unique physical and mental health needs far greater than other high-risk populations, including physical disabilities and developmental delays. For instance, foster 

children are more likely than other Medicaid children to experience emotional and 

psychological disorders and have more chronic medical problems. In fact, studies 

suggest that nearly sixty percent of children in foster care experience a chronic medical condition, and one-quarter suffer from three or more chronic health conditions.1


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1Kavaler, F. and Swire, M.R. (1983). Foster Child Healthcare. Lexington, MA: Lexington 

Books; 1983. 3 dosReis, S., Zito, J.M., Safer, D.J., & Soeken, K.L. (2001). Mental health services for foster 

care and disabled youth. American Journal of Public Health , 91, 1094–1099. 4 Raghavan, R., Zima, B.T., Anderson, R.M., Leibowitz, A.A., and Schuster, M.A. (2005). Psychotropic medication use in a national probability sample of children in the child welfare system. Journal of Child and Adolescent Psychopharmacology, 15, p. 97–106. 5 dos Reis, S., Zito, J.M., Safer, J.M., Gardner, D.J., Puccia, J.F., Owens, K.B., and Pamela, 

L. (2005). Multiple psychotropic medication use for youths: a two-state comparison. Journal of 

Child and Adolescent Psychopharmacology, 15 (1), p. 68–77. 6 dosReis, S., Magno Zito, J., Safer, D.J., and Soeken, K.L. (2001). Mental Health Services for 

Youths in Foster Care and Disabled Youths. American Journal of Public Health, Vol. 91, No. 7. 7Zito, J.M., and Safer, D.J. External Review: A pharmacoepidemiologic analysis of Texas foster 

care. 8Zito, J.M., and Safer, D.J. External Review: A pharmacoepidemiologic analysis of Texas foster care. 9Stayhorn, C.K., Texas Comptroller of Public Accounts (2006). Texas healthcare claims 

study—special report: Foster children. 10Zima, B.T., Bussing, R., Crecelius, G.M., Kaufman, A., and Belin, T.R. (1999). Psychotropic 

medication use among children in foster care: Relationship to severe psychiatric disorder. American Journal of Public Health, vol. 89, No. 11. 11 University of Iowa, Public Policy Center (2004). Health policy brief: A study of Iowa’s children in foster care. No. 4. 12Green, D.L., Hawkins, W., and Hawkins, M. (2005). Medication of children and youth in 

foster care. Journal of Social Work in Disability and Rehabilitation. 13Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Magder, L., Soeken, K., Boles, M., Lynch, 

F., and Riddle, M.A. (2003). Psychotropic practice patterns for youth: a 10-year perspective. Archives of Pediatrics & Adolescent Medicine, 157(1): 14–6. 14Olfson, M., Marcus, S.C., Weissman, N.M., and Jensen, P.S. (2002). National trends in the 

use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry. 41(5): 514–21. 

In addition, nearly 70% of children in foster care exhibit moderate to severe mental 

health problems,2 and 40% to 60% are diagnosed with at least one psychiatric disorder.3

Given that a large number of children in foster care exhibit behavioral problems, 

it is not all too surprising to see high psychotropic medication usage rates for this 

population. Studies have shown that kids in foster care are prescribed psychotropic 

medications at a much higher rate than other children—2 to 3 times higher.4 Yet 

youth in foster care are often prescribed two or three medications, the effects of 

which are not well-known in combination.5 In fact, in the Medicaid program, children in foster care are much more likely to use psychotropic medications than children who qualify through other aid categories.6

A number of states have reported alarmingly high rates of psychotropic medication use for foster children. For instance, in 2004, 37.3% of children in the Texas 

foster care system were prescribed psychotropic medications.7 In a random sample 

of 472 Texas foster children prescribed psychotropic medications, researchers Zito 

and Safer found that 41.3% received 3 or more different psychotropic medication 

classes concomitantly, and 15.9% received 4 or more.8 Furthermore, in 2006, Texas 

Comptroller for Public Accounts, Carole Keeton Stayhorn issued a comprehensive 

special report on the treatment of foster children in the state. The report found that 

psychotropic drugs accounted for well over 76% of all medications prescribed to 

Texas children in foster care, and a number of the medications prescribed to children in care had shown little to no efficacy in research studies.9

Similarly, a California study found that in comparison to a statewide sample of 

children enrolled in Medicaid, children in foster care were nearly 3 times more likely to receive psychotropic medication. Additionally, their use of methylphenidate (a 

prescription stimulant commonly used to treat ADD and ADHD) in the past year 

was twice as high as the national estimates.10 A study of Iowa’s foster care population found that 42% of children in foster care had been prescribed psychotherapeutic medication within the 20 month study period.11 A 2001 study of a Florida county foster care population found that 23% of the sample was using medication at the time, and, 57% of the sample had multiple prescriptions.12

Nationally, we see a similar and all too disturbing trend. Prescriptions for psychotropic medications have increased dramatically for children with behavioral and 

emotional problems over the last 20 years, a trend evident for younger age groups— 

even preschoolers.13,14,15 Many have expressed alarm about the safety, efficacy and 

long-term consequences of psychotropic medication use in children, especially concerning younger age groups.16,17,18 Specifically, researchers have voiced concerns 

about the effects of these medications on the developing brain, and the safety and 


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12Green, D.L., Hawkins, W., and Hawkins, M. (2005). Medication of children and youth in 

foster care. Journal of Social Work in Disability and Rehabilitation. 13Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Magder, L., Soeken, K., Boles, M., Lynch, 

F., and Riddle, M.A. (2003). Psychotropic practice patterns for youth: a 10-year perspective. Archives of Pediatrics & Adolescent Medicine, 157(1): 14–6. 14Olfson, M., Marcus, S.C., Weissman, N.M., and Jensen, P.S. (2002). National trends in the 

use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry. 41(5): 514–21. 15Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Boles, M., and Lynch, F. (2000). Trends 

in the prescribing of psychotropic medications to preschoolers. JAMA, Vol 283, No. 8. 16 Vitiello, B. (1998). Pediatric psychopharmacology and the interaction between drugs and the 

developing brain. Can J Psychiatry, 43:582–584. 17 Jensen, P.S. (1998). Ethical and pragmatic issues in the use of psychotropic agents in young 

children. Can J Psychiatry,43:585–588. 18Greenhill, L.L. (1998). The use of psychotropic medication in preschoolers: indications, safety, and efficacy. Can J Psychiatry, 43:576–581. 19Schirm, E., Tobi, H., de Jong-van den Berg, L.T. (2003) Risk factors for unlicensed and offlabel drug use in children outside the hospital. Pediatrics, 111(2):291—5. 20Foster Care: Health Needs of Many Young Children Are Unknown and Unmet. (May 26, 

effectiveness of medications tested in adults for attenuating behavioral and emotional symptoms in children. 

Moreover, between 50% and 75% of psychotropic drugs are not approved for use 

in children or adolescents.19 For certain newer classes of drugs, medications have 

not been licensed for use in children. As a result, providers are often prescribing 

drugs for children ‘‘off-label’’—the practice of prescribing meds for use other than 

the intended indication. 

Overmedication for children in foster care is especially a concern given that they 

often go without adequate healthcare, little monitoring or adjustment of medications, and are offered few alternative treatment options, such as psychotherapy. In 

fact, a 1995 Government Accountability Office (GAO) report found that despite regulations requiring comprehensive routine healthcare for foster care children, 12 percent receive no routine healthcare and 32 percent have unmet needs.20 Moreover, 

in a recent survey, HHS found that more than 30 percent of foster care cases reviewed did not demonstrate the provision of adequate services to children.21

A study by Stahmer and colleagues found that although toddlers and preschoolers in child welfare exhibit significant developmental and behavioral needs, 

few receive services. In fact, in this sample, 41.8% of toddlers and 68.1% of preschoolers exhibited deficits, yet only 22.7% received services.22 The National Survey 

of Child & Adolescent Well-being similarly documented that only a quarter of children exhibiting behavioral problems in out-of-home care actually received mental 

health services within a one-year follow-up period.23 Comparable findings have been 

reported by a number of other researchers. For instance, Zima and colleagues (2000) 

found that 80% of children in a random sample received a psychiatric diagnosis, but 

only half actually received mental health or special education services.24

Moreover, data indicate that psychotropic medication use in foster children is 

often not appropriately monitored. In a sample of over 1,100 child welfare case files 

reviewed, more than half of the children were taking at least one psychotropic medication. Sadly, forty-four percent of these children had no record of a medical evaluation and had not received a medical diagnosis. In addition, proper consent for administering medication had been obtained in less than half of the cases.25

We have a unique responsibility when it comes to foster children. Children in foster care are legal wards of the state courts or social service agencies, and it is our 

responsibility to ensure that every child in foster care receives the services, resources, and supports he or she needs. No child should be prescribed psychotropic 

medication without proper consent. It is critical that a child receives a comprehensive medical evaluation and a medical diagnosis before beginning treatment for a 

mental or behavioral disorder. Non-pharmacological interventions (e.g. psychotherapy) should be considered as an alternative to psychotropic medication, or if appropriate, in combination with pharmaceutical treatment. Children on psychotropic 

medications should receive routine follow-up care and their prescription dosages 

should be regularly monitored and adjusted as appropriate. Any potential side-effects of medications should also be carefully monitored. 

A recent GAO report identified over-prescribing of psychotropic medications to foster children as one of the leading issues facing child welfare systems in the coming 

years.26 We urge you to request a GAO report on the practice of prescribing psychotropic medications for foster children to determine if these prescriptions are safe and 

cost effective, and examine the practice of prescribing these medications to young 

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cations ‘‘off-label’’ and the frequency of prescribing concomitant use of psychotropic 

medications for this population. 

We believe that it is also important to invest in long-term drug safety investigations, provide ongoing clinical monitoring of psychotropic medication use in children, 

and develop the most appropriate and effective treatments possible for children in 

foster care. 

In closing, Mr. Chairman and Members of the committee, First Focus stands prepared to work with you to ensure that the healthcare needs of foster children are 

adequately met. We thank you for your leadership in addressing this critical issue, 

and protecting the health and welfare of our most vulnerable children. We look forward to working with you to ensure better care for our nation’s foster children. If 

you have any additional questions, please contact Shadi Houshyar, VP for child welfare policy at First Focus, at (202) 657–0678. 

Sincerely, 

Bruce Lesley 

f 

President 

Statement of Jody Leibmann 

Children’s Law Center of Los Angeles is a nonprofit public interest legal organization that serves as the voice for abused and neglected youth in the largest foster 

care system in the nation. Our committed attorneys represent over 25,000 abused 

and neglected children in the Los Angeles County foster care system. 

In addition to our daily advocacy on behalf of each child’s individual needs and 

circumstances, we also take the knowledge and experience gained through our work 

to advocate for broader system reforms. In this vein, we are heartened and encouraged by the commitment of the Subcommittee on Income Security and Family 

Support to improve the lives of the more than half a million children living in 

the nation’s foster care system and specifically to address the deficiencies in the current process regarding foster youth and psychotropic medications. 

We hope to draw your attention to three specific issues that we believe require 

attention and reform: 

(1) Improved court oversight of psychotropic medications prescribed to foster 

youth; (2) Increased youth participation in the decision-making and monitoring process around the use of psychotropic medications; (3) Continuity of mental healthcare; 

and (4) Improved data collection and tracking. 

Introduction 

Unfortunately, as a result of the trauma they have experienced, many youth in 

foster care suffer from mental and emotional problems that can jeopardize their 

safety, well-being, success in school, and may keep them from finding stable homes. 

For some of these children, psychotropic medications are a key part of effective mental healthcare. However, careful evaluation and monitoring are essential to ensure 

that these medications are safe and effective, and that they are not over or under 

utilized. To achieve this goal, we direct your attention to three main deficiencies in 

our system as it operates today. 

Court Oversight 

Since the Court is considered the de facto ‘‘parent’’ of children in the foster care 

system, judges should have the authority to approve or deny any request by a doctor 

to have a foster child take a psychotropic medication. In order for the Court to make 

an informed decision, it is critical that the physician or healthcare professional requesting that the child take psychotropic medications submit a written request to 

the Court upon having conducted a full examination of the child. After reviewing 

the request against the Court’s broader observations of the child throughout the duration of the case, Courts must then be sureto make orders for any needed therapy 

or behavioral intervention to run concurrent with the medication, and to put a plan 

in place to provide for regular monitoring of how well the medication is working— 

or not working—along with any side effects the youth is experiencing. Finally, the 

child’s social worker should be required to submit regular reports to the court—at 

a minimum at each statutorily required review hearing—which include regular updates regarding progress in therapy and when the child was last seen by his or her 

physician so that the court can make orders that are based on updated, accurate 

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Youth Participation 

Youth experience a great deal of frustration and anxiety when they are excluded 

from the decision making process and are not given an opportunity to communicate 

with the judge or to ask questions. Similarly, both judges and attorneys report that 

without the child’s participation it is difficult to know exactly what is happening in 

the child’s life and how a prescribed medication may be impacting a child’s affect 

or demeanor. It has been our experience that when children and youth are able to 

attend their hearings they actively ask questions, engage in discussion with the 

judge, and leave with an understanding of why certain decisions, such as the decision to have a child take a powerful medication, have been made. Further, the Court 

can learn a great deal by observing in-person changes in the child’s demeanor, affect 

or attitude. 

When it comes to psychotropic medications—powerful drugs that often involve serious side effects—it is critical that youth have the opportunity to provide input to 

the Court. This can best be accomplished by including them in the approval and 

monitoring process over these medications. While a doctor is the best person to decide which medication may be most appropriate for a child based on his or her medical history, weight, and other physical factors, for many foster youth who often 

move frequently between placements, the judge may be the only constant and consistent observer of that child’s behavior and demeanor. Having the youth come to 

Court is therefore a critical component of ensuring appropriate Court oversight of 

the psychotropic medication process. 

Youth should also be given age-appropriate information about medications as well 

as the right to be heard in court and to object to a medication request. 

Continuity of Care 

Continuity of health and mental healthcare is a major issue for foster children. 

They often move from home to home, and may see many different doctors and therapists. Some of our clients report that doctors who prescribed their medications spent 

little time with them and did not know their health history or prior medications. 

Some clients have been on medications for many years, starting when they were 

very young, have been prescribed multiple medications at the same time, and have 

experienced serious side effects. 

Issues such as insurance or Medicare coverage determinations should not impact 

the quality of mental healthcare that foster youth receive. Our recommendation is 

to implement a system whereby children able to establish trusting relationships 

with qualified therapist, and that they continue to receive treatment from that therapist for as long as possible. In the event that the youth has to see a different provider, the transition should be done as quickly and smoothly as possible without a 

delay in treatment. Finally, treatment should continue on a regular, uninterrupted 

basis until it is no longer necessary. Placement changes and other factors unrelated 

to mental health should not control or cause arbitrary changes in therapists or 

treatment plans. 

Data Collection 

A cohesive system of data collection and tracking is the only way to ensure that 

true system reform is occurring and that outcomes for our foster youth with regard 

to psychotropic medications are improving. As such, child welfare agencies should 

be equipped with the resources to maintain records, optimally via an electronic 

database, that is regularly updated whenever there is a change in the child’s medication or medications and contains information not only regarding all of the medications the child is taking, but also the dosage, target symptoms for which the medications were prescribed, the child’s response to each medication, any side effects experienced, and the names and contact information of all treating physicians and mental healthcare providers. 

Conclusion 

It is our hope that your consideration of our recommendations will lead to concrete reforms so that our juvenile courts have complete and accurate information 

and are better able to provide needed oversight of the use of psychotropic medications for foster youth; foster youth will have a better understanding and opportunity 

to participate in important medical decisions that impact their quality of life; and 

data tracking will lead to a better continuity of mental healthcare for our most vulnerable population. 

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89 

Statement of Tara Thomson 

I am a Mother of four Children and a 71 year old mother that I have to care for 

without child support. I am on unemployment and it is about to end this month. 

I am going to lose it all if I can find a decent job. I lost my car and I am bankrupt. 

I have applied for foodstamps. Please help as we are Americans and why do we have 

to suffer anymore. I am a good mother and great daughter. I love my country and 

would like to see our fellow Americans have a better opportunity to make it in a 

bad economy. Plus would’nt make since to extend as when people do start spending 

the rebate checks and hopefully by then more jobs will be restored as well as more 

work needed to fill the demand for employers that have more business due to increased spending. It makes a lot of since we need to help this country get it back 

together. WE THE PEOPLE right . . . must I say anymore. . . . Give it a chance 

and I promise you will see a drop in homeless and straving kids and bankruptcy. 

Please help us. . . . 

Respectfully, 

Florida residences and Clearwater communities . . . 

Tara Thomson and family . . . 

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