Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions
Published: 2011-12-01T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Foster children have often been removed from abusive or neglectful homes and tend to have more mental health conditions than other children. Treatment may include psychotropic drugs but their risks to children are not well understood. Medicaid, administered by states and overseen by the Department of Health and Human Services (HHS), provides prescription drug coverage to foster children. This testimony examines (1) rates of psychotropic prescriptions for foster and nonfoster children in 2008 and (2) state oversight of psychotropic prescriptions for foster children through October 2011. GAO selected Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas primarily based on their geographic diversity and size of the foster care population. Results cannot be generalized to other states. In addition, GAO analyzed Medicaid fee-for-service and foster care data from selected states for 2008, the most recent year of prescription data available at the start of the audit. Maryland's 2008 foster care data was unreliable. GAO also used expert child psychiatrists to provide a clinical perspective on its methodology and analysis, reviewed regulations and state policies, and interviewed federal and state officials.
section_title: What GAO Found
paragraphs: Foster children in the five states GAO analyzed were prescribed psychotropic drugs at higher rates than nonfoster children in Medicaid during 2008, which according to research, experts consulted, and certain federal and state officials, could be due in part to foster children's greater mental health needs, greater exposure to traumatic experiences and the challenges of coordinating their medical care. However, prescriptions to foster children in these states were also more likely to have indicators of potential health risks. According to GAO's experts, no evidence supports the concomitant use of five or more psychotropic drugs in adults or children, yet hundreds of both foster and nonfoster children in the five states had such a drug regimen. Similarly, thousands of foster and nonfoster children were prescribed doses higher than the maximum levels cited in guidelines developed by Texas based on FDA-approved labels, which GAO's experts said increases the risk of adverse side effects and does not typically increase the efficacy of the drugs to any significant extent. Further, foster and nonfoster children under 1 year old were prescribed psychotropic drugs, which GAO's experts said have no established use for mental health conditions in infants; providing them these drugs could result in serious adverse effects. Selected states' monitoring programs for psychotropic drugs provided to foster children fall short of best principle guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP). The guidelines, which states are not required to follow, cover four categories. (1) Consent: Each state has some practices consistent with AACAP consent guidelines, such as identifying caregivers empowered to give consent. (2) Oversight: Each state has procedures consistent with some but not all oversight guidelines, which include monitoring rates of prescriptions. (3) Consultation: Five states have implemented some but not all guidelines, which include providing consultations by child psychiatrists by request. (4) Information: Four states have created websites about psychotropic drugs for clinicians, foster parents, and other caregivers. This variation is expected because states set their own guidelines. HHS has not endorsed specific measures for state oversight of psychotropic prescriptions for foster children. HHS-endorsed guidance could help close gaps in oversight of psychotropic prescriptions and increase protections for these vulnerable children. In our draft report, GAO recommended that HHS consider endorsing guidance for states on best practices for overseeing psychotropic prescriptions for foster children. HHS agreed with our recommendation. Agency comments will be incorporated and addressed in a written report that will be issued in December 2011.

section_title: Letter
paragraphs: Thank you for the opportunity to discuss psychotropic drug prescriptions  provided to foster children under state care. Children placed in foster care  are among our nation’s most vulnerable populations. Often having been  removed from abusive or neglectful homes, they tend to have more  numerous and serious medical and mental health conditions than do  other children. Treatment of mental illness may include prescribing  psychotropic drugs, such as antidepressants and antipsychotics. Because  foster children are under state care they typically receive prescription  drugs and other medical services through Medicaid, a joint federal-state  program that finances health care coverage for certain low-income  populations.
This testimony discusses, for selected states, (1) rates of psychotropic  drug prescriptions for foster children compared with nonfoster children  covered by Medicaid in 2008, including indicators of health risks, and (2)  federal and state oversight policies as of October 2011 for psychotropic  drugs prescribed to foster children. We have received comments on a  draft of the report this testimony is based on from the Department of  Health and Human Services (HHS) and relevant state agencies. We plan  to incorporate their comments into the report that we will issue in  December 2011. We contracted with two child psychiatrists with clinical  and research expertise in the use of psychotropic drugs in children to  provide a clinical perspective on our methodology and data analysis. To  compare rates of psychotropic drug prescriptions, we reviewed calendar  year 2008 fee-for-service prescription claims and foster care data for  Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas. At  the start of our audit, 2008 data were the most recent calendar year  prescription claims data available from the Centers for Medicare &  Medicaid Services (CMS).  These states were selected primarily for  geographic diversity and the size of their foster care populations.  However, we then excluded Maryland from our analysis due to the  unreliability of their foster care data. To identify potential health risk  indicators, we consulted with our experts, performed literature searches,  and reviewed state guidelines. The final indicators of potential health risks  were: concomitant prescriptions of five or more drugs, prescriptions  exceeding dosage guidelines in the Psychotropic Medication Utilization  Parameters for Texas Foster Children based on Food and Drug  Administration (FDA) approved labels, and psychotropic prescriptions to  children under 1 year old. In addition, we evaluated gaps of 7 to 29 days  in prescriptions of a drug to identify nonadherence to drug regimens,  which can pose significant risks to a patient.
To determine federal and state oversight policies, we interviewed officials  from CMS, the Administration for Children and Families (ACF), and the  six selected states’ Medicaid and foster care agencies. We also reviewed  policies and regulations related to the prescribing of psychotropic drugs to  foster children. Based on a literature review and discussions with officials  from HHS, we selected the American Academy of Child and Adolescent  Psychiatry’s (AACAP) guidelines as a basis for assessing the extent to  which selected states were implementing recommended practices.
We performed this audit from February 2010 through November 2011 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. Our full scope and detailed  methodology will be provided in our report that will be issued in December  2011.
subsections: section_title: Background
paragraphs: Foster care begins when a child is removed from his or her parents or  guardians and placed under the responsibility of a state child welfare  agency. Removal from the home can occur because of physical abuse or  neglect. It can also occur when a child’s own behavior or condition is  beyond the control of his or her family or poses a threat to their  community. Foster care may be provided by a family member, caregivers  previously unknown to the child, or a group home or institution. Ideally,  foster care is an intermediate step towards a permanent family home.  When reuniting the child with his or her parents or guardian is not in the  child’s best interest, caseworkers seek a new permanent home for the  child, such as an adoptive home or guardianship. However, some  children remain in foster care until they reach adulthood. As we have  previously reported, children in foster care exhibit more numerous and  serious medical conditions, including mental health conditions, than do  other children.
States are responsible for administering their Medicaid and foster care  programs; the programs are overseen at the federal level by HHS through  CMS and ACF, respectively. HHS may issue regulations, provide  guidance on some issues, or simply provide informational resources for  states to consider for their programs, the latter being the case for  psychotropic drugs provided to children in state custody. Among these  resources are best principles developed by AACAP, a nonprofit  professional association. While HHS does not require states to follow  these guidelines, AACAP developed them as a model to help inform state  monitoring programs for youth in state custody. AACAP guidelines point  out that, “as a result of several highly publicized cases of questionable  inappropriate prescribing, treating youth in state custody with  psychopharmacological agents has come under increasingly intense  scrutiny,” leading to state implementation of consent, authorization, and  monitoring procedures. More recently, Congress passed the Child and  Family Services Improvement and Innovation Act in September 2011,  requiring states that apply for certain federal child welfare grants to  establish protocols for the appropriate use and monitoring of psychotropic  drugs prescribed to foster children.
The use of psychotropic drugs has been shown to effectively treat mental  disorders, such as attention deficit hyperactivity disorder (ADHD), bipolar  disorder, depression and schizophrenia. While many psychotropic drugs  that have been approved by the FDA as safe and effective in adults have  not been similarly approved for children of all ages, prescribing them to  children is legal and common medical practice in many instances.  According to the National Institute of Mental Health (NIMH), some  children with severe mental health conditions would suffer serious  consequences without such medication. However, psychotropic drugs  can also have serious side effects in adults, including irreversible  movement disorders, seizures, and an increased risk for diabetes over  the long term. Further, additional risks these drugs pose specifically to  children are not well understood.
Psychotropic drugs affect brain activity associated with mental processes  and behavior. These drugs are also called “psychotherapeutic” drugs.
While psychotropic drugs can have significant benefits for those with  mental illnesses, they can also have side effects ranging from mild to  serious. Table 1 highlights the psychotropic drug classes studied in this  report and provides examples of drugs within those classes, as well as  conditions treated and possible side effects.
Foster children in each of the five selected states were prescribed  psychotropic drugs at higher rates than were nonfoster children in  Medicaid during 2008. These states spent over $375 million for  prescriptions provided through fee-for-service programs to foster and  nonfoster children. The higher rates do not necessarily indicate  inappropriate prescribing practices, as they could be due to foster  children’s greater exposure to traumatic experiences and the unique  challenges of coordinating their medical care. However, psychotropic  drug claims for foster children were also more likely to show the indicators  of potential health risks that we established with our experts. According to  our experts, no evidence supports the concomitant use of five or more  psychotropic drugs in adults or children, yet hundreds of both foster and  nonfoster children were prescribed such a medication regimen. Similarly,  thousands of foster and nonfoster children were prescribed doses  exceeding maximum levels cited in guidelines based on FDA-approved  drug labels, which our experts said increases the potential for adverse  side effects, and does not typically increase the efficacy of the drugs to  any significant extent. Further, foster and nonfoster children under 1  year old were prescribed psychotropic drugs, which our experts said have  no established use for mental health conditions in infants and could result  in serious adverse effects.
subsections: section_title: Higher Rates of Psychotropic Drug Prescriptions among Foster Children
paragraphs: The kinds of drugs included in prescription data reported to CMS in 2008 varied by  state. Because the claims data we obtained from CMS contained fewer types of  medications for Michigan and Oregon, we may understate the rates of psychotropic  prescriptions for both foster and nonfoster children in those states. While rates of  psychotropic prescriptions are not comparable across states, they are comparable  between foster and nonfoster children within the same state. Similarly, the ratio of  prescriptions to foster children to prescriptions to nonfoster children is comparable across  states. history.various age ranges.
section_title: Selected States’ Psychotropic Drug Monitoring Programs Fall Short of AACAP- Best Principles Guidelines
paragraphs: Comparing the selected states’ monitoring programs for psychotropic  drugs provided to foster children with AACAP’s guidelines indicates that,  as of October 2011, each of the state programs falls short of providing  comprehensive oversight as defined by AACAP. Though states are not  required to follow these guidelines, the six states we examined had  developed monitoring programs that satisfied some of AACAP’s best  principles guidelines to varying degrees. Such variation is not surprising  given that states set their own oversight guidelines and have only recently  been required, as a condition of receiving certain federal child welfare  grants, to establish protocols for the appropriate use and monitoring of  psychotropic drugs prescribed to foster children.
HHS has provided limited guidance to the states on how to improve their  control measures to monitor psychotropic drug prescriptions to foster  children. Without formally endorsing specific oversight measures for  states to implement, HHS conducts state reviews and provides other  online resources, including the AACAP guidelines, to help states improve  their programs. ACF performs Child and Family Services Reviews  (CFSR) of states to ensure conformity with federal child welfare  requirements—which include provisions for safety, permanency, and  family and child well-being—and to assist states as they enhance their  capacity to help families achieve positive outcomes. These reviews  include the examination of a limited number of children’s case files, in part  to determine whether the state foster care agency conducted  assessments of children’s mental health needs and provided appropriate  services to address those needs. However, these reviews are not  designed to identify specific potential health risk indicators related to  psychotropic medications, and since they occur every 2 to 5 years, states  cannot rely on these reviews to actively monitor prescriptions. In addition,  ACF operates technical assistance centers and provides online resources  such as links to state guidance on psychotropic drug oversight, academic  studies on psychotropic drugs, and recordings of teleconferences related  to the oversight of psychotropic drugs. While HHS makes a variety of  resources available to states developing oversight programs for  psychotropic drugs, it has not endorsed any specific guidance. In the  absence of HHS-endorsed guidance, states have developed varied  oversight programs that in some cases fall short of AACAP’s  recommended guidelines.
The AACAP guidelines are arranged into four categories, including  consent, oversight, consultation, and information sharing, that contain  practices defined as minimal, recommended, or ideal. The following  describes the extent to which the selected states’ monitoring programs  cover these areas.
Consent: According to interviews and documentation provided by state  Medicaid and foster care officials, all six selected states have  implemented some practices consistent with AACAP guidelines for  consent procedures, though in varying scope and application. According  to AACAP, the consent process should be documented and monitored to  ensure that caregivers are aware of relevant information, such as the  child’s diagnosis, expected benefits and risks of treatments, common side  effects, and potentially severe adverse events. Thus, states that do not  incorporate consent procedures similar to AACAP’s guidelines may  increase the likelihood that caregivers are not fully aware of the risks and  benefits associated with the decision to medicate with psychotropic drugs,  and may limit the caregiver’s ability to accurately assess and monitor the  foster child’s reaction to the drugs. Table 4 lists AACAP’s guidelines  relative to consent and illustrates the extent to which states have  implemented those guidelines.
Florida and Michigan provide examples of how states vary in their  approach to monitoring consent procedures used for psychotropic drugs  prescribed to foster children. For example, Florida requires all prescribers  to obtain a standardized written consent form from the parental or legal  guardian, or a court order, before a psychotropic drug is administered.  The consent form includes the diagnosis, dosage, target symptoms, drug  risks and benefits, drug monitoring plan, alternative treatment options,  and discussions about the treatment between the child and the parent or  legal guardian. Florida law identifies who is authorized to give consent,  and obtains assent for psychotropic drug management from minors when  age and developmentally appropriate. Florida provides required training  to caseworkers, but the names and indications for use of commonly  prescribed psychotropic drugs are not included.
In contrast, Michigan has policies identifying who is authorized to give  consent to foster children, but does not use a standardized consent form  that can be used to help inform consent decisions. Instead, Michigan  requires that caseworkers maintain in their files the consent forms used  by individual prescribers, which likely vary in content and may thus vary in  helpfulness to consent givers. Moreover, Michigan does not have training  requirements in place to help caseworkers, court personnel, and foster  parents become more effective advocates for children in their custody.  Training for caseworkers is optional, but according to an agency official,  the training was unavailable because no trainer had been hired as of  September 2011. Michigan does not have policies for obtaining assent  from minors when possible, thus meeting only one of AACAP’s guidelines  for consent procedures.
Oversight procedures: Each of the six states has developed some  procedures similar to AACAP’s guidelines for overseeing psychotropic  drug prescriptions for foster children, as evidenced by interviews and  documentation provided by state Medicaid and foster care officials.
According to one study, states that implement standards to improve  oversight of the use of psychotropic drugs may create enhanced  continuity of care, increased placement stability, reduced need for  psychiatric hospitalization, and decreased incidence of adverse drug  reactions. As such, states that do not incorporate oversight procedures  similar to AACAP’s recommendations limit their ability to identify the  extent to which potentially risky prescribing is occurring in the foster care  population. Table 5 lists AACAP’s guidelines relative to oversight and  illustrates the extent to which selected states have implemented those  guidelines.
Texas and Maryland provide examples of how states vary in their  approach to oversight of psychotropic drug use among foster children.  For example, the Texas Department of Family and Protective Services  (DFPS) and the University of Texas at Austin College of Pharmacy  assembled an advisory committee that included child and adolescent  psychiatrists, psychologists, pediatricians, and other mental health  professionals to develop psychotropic drug use parameters for foster  children. These parameters are used to help identify cases requiring  additional review. Factors that trigger additional reviews include dosages  exceeding usual recommended levels, prescriptions for children of very  young age, concomitant use of five or more psychotropic drugs, and  prescriptions by a primary care provider lacking specialized training.  According to the Texas foster care agency’s data analysis, after Texas  released these guidelines in 2005, psychotropic drug use among Texas  foster care children declined from almost 30 percent in fiscal year 2004 to  less than 21 percent in fiscal year 2010. Texas also analyzes Medicaid  claims data to monitor psychotropic drug prescriptions for foster children  and to identify any unusual prescribing behaviors. Texas provides  quarterly reports to child welfare officials on the use of psychotropic drugs  among foster children and treating clinicians have access to a child’s  medical records on a 24-hour basis. However, the electronic health  record system does not always capture the child’s height, weight, and  allergies, which is optional for prescribers to enter into the system. This  information is helpful as a child’s weight may be used to determine the  recommended dose for some medications, while allergy information may  be used to determine whether a child should take a particular medication.  In addition, ongoing medical problems are not recorded in the electronic  health record system and Texas does not measure the rate of adverse  reactions at the macro level among youth in state custody.
Maryland fully applies only one of the six AACAP guidelines for oversight  procedures and partially applies others. Maryland provides foster children  in out-of-home placement with a “medical passport” that serves as a  record of the child’s previous and current medical file. Each topic included  in AACAP’s guidelines for maintaining ongoing medical records, including  diagnoses, allergies, and medical history, is documented in the passport,  and an additional copy of the passport is kept in the child’s case record  and maintained electronically. However, Maryland has not produced any  specific guidelines for the use of all psychotropic prescriptions among  foster children, thus limiting the state’s ability to identify potentially risky  prescribing practices for the foster child population. Without guidelines  for psychotropic drugs, there are no criteria to help agency officials  monitor the appropriateness of prescriptions. Moreover, Maryland does  not review Medicaid claims data statewide specifically for foster children,  and therefore does not produce quarterly reports to identify the rate and  types of drugs used in the foster care population that could help identify  and monitor prescribing trends. In addition, as stated earlier, Maryland’s  2008 foster care data were found unreliable. Maryland officials told us  that transitioning to a new records system in 2007 resulted in incorrect  and missing data for foster children.
Consultation program: According to interviews and documentation  provided by state Medicaid and foster care officials, five of the six states  have implemented some of AACAP’s guidelines for consultation, but only  one of the six selected states has implemented a consultation program  that ensures all consent givers and prescribers are able to seek advice  from child and adolescent psychiatrists before making consent decisions  for foster children. States that do not have a consultation program to help  link consent givers and prescribers with child and adolescent psychiatrists  may reduce the extent to which prescribers and consent givers are  informed about the expected benefits and risks of treatments, alternative  treatments, and the risks associated with no treatment. Table 6 lists the  AACAP guidelines relative to consultation programs and illustrates the  extent to which selected states have implemented those guidelines.
Massachusetts and Oregon provide examples of how states vary their  approach in providing expert consultations to caregivers. For example,  Massachusetts’s foster care agency started an initiative to connect child  welfare staff to Medicaid pharmacists who can provide information on  medications and the foster child’s drug history, including interactions  between any current and proposed drugs. In addition, primary care  physicians who treat children, including foster care children, also have  access to the state-funded Massachusetts Child Psychiatry Access  Project, a system of regional children’s mental health consultation teams  designed to help pediatricians find and consult with child psychiatrists.  Massachusetts has six child psychiatrists who are available to provide  consultations on a part-time basis to child welfare staff, but these  consultations are not available for other consent givers such as foster  parents. The foster care agency’s consultation program also provides  face-to-face evaluations of foster children at the request of consent givers  concerned about a child’s treatment.
In early 2009, Oregon put a consultation program in place to help consent  givers make informed decisions. In 2010, Oregon’s foster care agency  shifted the responsibility for all consent decisions where the agency has  legal custody or is the legal guardian of the child from foster parents to  child welfare agency officials, who now have access to a child and  adolescent psychiatrist and can seek consultations before making  consent decisions. However, the consultation program does not conduct  face-to-face evaluations of children—by a child and adolescent  psychiatrist—at the request of consent givers, nor does it enable  prescribing physicians to consult with child and adolescent psychiatrists.  Oregon has plans for the development of the Oregon Psychiatric Access  Line for Kids, which would allow primary care physicians and nurse  practitioners to consult with child psychiatrists, but agency officials told us  the program is not operational due to a lack of funding.
Information sharing: Four of the six selected states have created  websites with information on psychotropic drugs for clinicians, foster  parents, and other caregivers. Access to comprehensive information can  help ensure that clinicians, foster parents, and other interested parties are  fully informed about the use and management of psychotropic drugs.  Table 7 lists AACAP’s guidelines relative to information sharing and  illustrates the extent to which selected states have implemented those  guidelines.
For example, Florida’s foster care agency has partnered with the  University of South Florida to implement Florida’s Center for the  Advancement of Child Welfare Practice to provide needed information  and support to Florida’s professional child welfare stakeholders. The  program’s website is consistent with four of AACAP’s six guidelines for  information sharing. For example, the website includes policies and  procedures governing psychotropic drug management, staff publications  and educational materials about psychotropic drugs, consent forms, and  links to other informative publications and news stories related to foster  children and psychotropic drugs. However, the website does not provide  reports on prescription patterns for psychotropic drugs or adverse effect  rating forms.
In comparison, Oregon’s foster care agency developed a website that  includes information regarding psychotropic medication, but the website is  not updated regularly to operate as an ongoing information resource. The  website currently has information on state policies and procedures  governing the use of psychotropic drugs and also contains web links to  consent forms and a medication chart that can be used as a psychotropic  medication reference tool. However, the website does not meet three of  the six information-sharing guidelines, including those on posting adverse  effect rating forms, reporting prescription patterns, and providing links to  other informative websites. States with less accessibility to  comprehensive information may limit the extent to which physicians,  foster parents, and other interested parties are informed about the use  and management of psychotropic drugs.
section_title: Conclusions
paragraphs: The higher rates of psychotropic drug prescriptions among foster children  may be explained by their greater mental health needs and the  challenges inherent to the foster care system. However, thousands of  foster and nonfoster children in the five states we analyzed were found to  have prescriptions that carry potential health risks. While doctors are  permitted to prescribe these drugs under current laws, increasing the  number of drugs used concurrently and exceeding the maximum  recommended dosages for certain psychotropic drugs have been shown  to increase the risk of adverse side effects in adults. Prescriptions for  infants are also of concern, due to the potential for serious adverse  effects even when these drugs are used for non-mental health purposes.  Comprehensive oversight programs would help states identify these and  other potential health risks and provide caregivers and prescribers with  the information necessary to weigh drug risks and benefits. The recently  enacted Child and Family Services Improvement and Innovation Act  requires states to establish protocols for monitoring psychotropic drugs  prescribed to foster children. Under the act, each state is authorized to  develop its own monitoring protocols, but HHS-endorsed, nationwide  guidelines for consent, oversight, consultation, and information sharing  could help states close the oversight gaps we identified and increase  protections for this vulnerable population.
section_title: Recommendation for Executive Action
paragraphs: In our draft report, we recommended that the Secretary of HHS evaluate  our findings and consider endorsing guidance to state Medicaid and child  welfare agencies on best practices for monitoring psychotropic drug  prescriptions for foster children, including guidance that addresses, at  minimum, informed consent, oversight, consultation, and information  sharing.
We have received written comments on our draft report from HHS and  relevant agencies in 6 states.  In written comments, HHS agreed with our  recommendation and provided technical comments, which we  incorporated as appropriate.  In written comments and exit conferences,  staff from state Medicaid and foster care agencies provided comments on  key facts from the report.  Agency comments will be incorporated and  addressed in a written report that will be issued in December 2011.
Chairman Carper, Ranking Member Brown, and Members of the  Subcommittee, this completes my prepared statement. I would be  pleased to respond to any questions that you may have at this time.
section_title: GAO Contacts
paragraphs: For additional information about this testimony, please contact Gregory D.  Kutz at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this statement.
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