Foster Children: HHS Could Provide Additional Guidance to States Regarding Psychotropic Medications
Published: 2014-05-29T00:00:00

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 of these conditions may include psychotropic drugs, but the risks these drugs pose specifically to children are not well understood. This testimony discusses GAO's recent work on (1) the extent to which children in foster care are prescribed psychotropic medications, (2) federal and state actions to oversee psychotropic prescribing to children in foster care, and (3) the extent to which the use of psychotropic medications was supported by foster and medical records for selected case studies of children in foster care who were prescribed these medications. This testimony is based on previous GAO reports issued from 2011 through 2014 that used various methodologies, including reviewing federal studies, analyzing Medicaid prescription claims data from five states, and contracting with two experts to review 24 case files (selected, in part, based on potential health risk indicators). The findings related to the expert reviews of 24 case files are not generalizable.
section_title: What GAO Found
paragraphs: In December 2012, GAO reported on the results of the Administration for Children and Families (ACF) surveys of children in contact with the child-welfare system conducted during 2008-2011. 18 percent of foster-care children were taking a psychotropic medication at the time they were surveyed. Foster children who lived in group homes or residential treatment centers had much higher rates of psychotropic medication use than those living in nonrelative foster homes or formal kin care—48 percent versus 14 percent and 12 percent, respectively, according to the surveys. The higher utilization rate among children living in group homes or residential treatment centers may be related to these children having higher rates of potential mental-health need. Among foster children who took psychotropic medication, about 13 percent took three or more psychotropic medications concurrently. About 6.4 percent of foster children took an antipsychotic medication—psychotropic medications with potentially serious side effects that are intended to treat serious mental-health conditions such as schizophrenia—and the majority were ages 6 -11. In examining prescribing at the state level, GAO found similar results in its December 2011 review. Specifically, children in foster care in Florida, Massachusetts, Michigan, Oregon, and Texas were prescribed psychotropic medications at higher rates than nonfoster children in Medicaid during 2008, although prescribing rates varied by state.
In April 2014, GAO found the federal government and states have taken a multitude of steps to better oversee psychotropic drug prescribing for children in foster care, although more can be done as states increasingly deliver their medication benefits through Medicaid managed care. In addition, GAO found that, to varying degrees, each of the five selected states it reviewed had policies and procedures designed to address the monitoring and oversight of psychotropic medications prescribed to children in foster care. For example, all five selected states' foster-care programs use a screening tool that may prompt a referral of the foster child for a psychiatric evaluation. GAO also found that ACF had provided webinars and technical guidance to states. However, many states have, or are transitioning to, managed care organizations (MCO) to deliver Medicaid prescription-drug benefits, and GAO found variation in the extent that the five selected states were taking steps to plan for the oversight of drug prescribing for foster children receiving these benefits through MCOs.
For an April 2014 report, GAO contracted with two child psychiatrists to review foster and medical records for 24 cases in five selected states and found varying quality in the documentation supporting the use of psychotropic medications for children in foster care. These experts found that for many of the cases the prescriptions were mostly supported by documentation. However, in some areas, such as evidence-based therapies—interventions shown to produce measureable improvements—the experts found documentation was lacking. For example, the experts found that 3 of 15 children who may have benefited from such therapies were mostly provided such services, while in 11 of the 15 cases, the experts found that evidence-based therapies were partially provided but also found that other evidence-based therapies that may have been more applicable or beneficial were not provided, based on the documents reviewed. In 1 of the 15 cases there was no documentation that evidence-based therapies were provided.
section_title: What GAO Recommends
paragraphs: GAO has made recommendations in prior work, including that the Secretary of Health and Human Services issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs. The Department of Health and Human Services (HHS) concurred with the recommendation and described planned actions.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work examining the use of  psychotropic drugs among children in foster care. Child mental-health  advocates, providers, and researchers have expressed concerns about  the increase in the prescribing of psychotropic medications (medications  that affect mood, thought, or behavior) for children, in part because there  is limited evidence available regarding short- and long-term safety and  efficacy for some types of medications, particularly for combinations of  these medications. Mental-health experts are especially concerned about  the recent increase in the prescribing of antipsychotic medications— psychotropic medications that are intended to treat serious mental-health  conditions such as schizophrenia and bipolar disorder—in part because  these medications can cause serious side effects, such as rapid weight  gain and the development of diabetes. Concerns about the increased  prescribing of psychotropic medications may be compounded for children  in foster care, who may be at higher risk of mental-health conditions than  other children. Children in foster care are an especially vulnerable  population because often they have been subjected to traumatic  experiences involving abuse or neglect and they may suffer from multiple,  serious mental-health conditions.
Early detection and treatment of mental-health conditions can improve a  child’s symptoms and reduce potentially detrimental effects, such as  difficulties with relationships, dropping out of school, and involvement with  the juvenile justice system. Children with mental-health conditions, such  as attention deficit hyperactivity disorder (ADHD) or depression, can be  treated with psychosocial therapies (sessions with a provider designed to  reduce symptoms and improve functioning); psychotropic medication; or a  combination of both.
Several agencies in the Department of Health and Human Services  (HHS) have responsibilities related to children’s mental-health. The  Administration for Children and Families (ACF) provides funding for and  oversees states’ child-welfare programs, which are responsible for  monitoring and coordinating mental-health services for children in foster  care, among other things. The Centers for Medicare & Medicaid Services  (CMS) oversees, and jointly finances with the states, the Medicaid  program, which provides health coverage to most children in foster care.
State Medicaid programs are required by federal law to provide coverage  for certain health services, which may include mental-health services, for  children through the Early and Periodic Screening, Diagnostic, and  Treatment (EPSDT) benefit. The Substance Abuse and Mental Health  Services Administration (SAMHSA) works to increase the quality and  availability of mental-health services, such as by awarding grants that  support the development of community-based services for children with  mental-health conditions, including children in foster care.
My testimony today relates to the use of psychotropic drugs among  children in foster care. Specifically, my remarks will focus on three areas:  the extent to which children in foster care are prescribed psychotropic  medications;  federal and state actions to oversee psychotropic medication  prescribing to children in foster care; and  results from reviews of selected case studies of children in foster care  who were prescribed these medications.
My statement is based on our previously issued reports, issued from  December 2011 to April 2014, related to psychotropic medication  prescribing among foster care children.things, we described the results of ACF’s National Survey of Child and  Adolescent Well-being II (NSCAW II), a nationally representative   For this prior work, among other  longitudinal survey of children ages 0 through 19 who were in contact with  the child welfare system. In addition, we analyzed 2008 Medicaid  prescription drug claims and foster care data for five states (Florida,  Massachusetts, Michigan, Oregon, and Texas), and contracted with two  child psychiatrists to provide clinical evaluations of 24 cases. The case  selections were based, in part, on potential health risk indicators identified  by experts. The cases cannot be generalized to the foster-care  population. The reports cited in this statement each provide detailed  information on our scope and methodology.
The work on which this statement is based was conducted in accordance  with generally accepted government auditing standards. Those standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for our audit findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
paragraphs: treatment center, depending on the child’s needs.responsible for arranging needed services, including mental-health  services. Coordinating mental-health care for children in foster care may  be difficult for both the medical provider and the caseworker depending  on the complexity of the child’s needs, and because multiple people are  making decisions on a child’s behalf. In addition, caseworkers in child- welfare agencies may have large caseloads, making it difficult for them to  ensure each child under their authority receives adequate mental-health  services.
In 2011, the Child and Family Services Improvement and Innovation Act  amended the Social Security Act to require states to identify protocols for  monitoring foster children’s use of psychotropic medications and to  address how emotional trauma associated with children’s maltreatment  and removal from their homes will be monitored and treated. requires states to address these issues in their required Annual Progress  and Services Reports (APSR) and has provided guidance detailing how  states are to address protocols for monitoring foster children’s use of   Among other  psychotropic medications as part of the state’s APSR.things, state monitoring protocols are to address  screening, assessment, and treatment planning to identify children’s  mental-health and trauma-treatment needs, including a psychiatric  evaluation, as necessary, to identify needs for psychotropic  medications; effective medication monitoring at both the client and agency level;  informed and shared decision making and methods for ongoing  communication between the prescriber, the child, caregivers, other  health-care providers, the child-welfare worker, and other key  stakeholders.
Child and Family Services Improvement and Innovation Act, Pub. L. No. 112-34, §  101(b)(1) and (2), 125 Stat. 369 (amending 42 U.S.C. § 622(b)(15)(A)).
According to ACF, child-welfare systems that choose to pursue  comprehensive and integrated approaches to screening, assessing, and  addressing children’s behavioral and mental-health needs—including the  effects of childhood traumatic experiences—are more likely to increase  children’s sense of safety and provide them with effective care.
Children in foster care who are enrolled in Medicaid may receive services  generally through one of two distinct service-delivery and financing  systems—managed care or fee-for-service. Under a managed-care  model, states may contract with a managed-care organization (MCO) and  prospectively pay the MCO a fixed monthly fee per patient to provide or  arrange for most health services, which may include prescription-drug  benefits. The MCOs, in turn, pay providers. In the traditional fee-for- service delivery system, the Medicaid program reimburses providers  directly and on a retrospective basis for each service delivered.
section_title: Children in Foster Care Receive Psychotropic Medications at Higher Rates than Other Children in Medicaid
paragraphs: In December 2012, we reported information on national levels of  psychotropic drug use among foster care children based on the results of  the NSCAW II. According to the results from NSCAW II, 18 percent of  foster-care children were taking a psychotropic medication at the time  they were surveyed. Additionally, foster children who lived in group  homes or residential treatment centers had much higher rates of  psychotropic medication use than foster children living in nonrelative  foster homes or formal kin care—48 percent versus 14 percent and 12  percent, respectively. The higher utilization rate among children living in  group homes or residential treatment centers may be related to these  children having higher rates of potential mental-health need—about 69  percent had a potential mental-health need compared to about 44 percent  of children living in nonrelative foster homes. Another study found that  child welfare workers were more likely to place children with behavior  problems in a group-living arrangement than with a foster family.  NSCAW II data showed that 30 percent of foster children with a potential  mental-health need had not received any mental-health services, such as  treatment at an outpatient mental-health center or with a mental-health  professional or family doctor, within the previous 12 months or since the  start of the child’s living arrangement, if less than 12 months.
In December 2012 we also found that in addition to reporting on overall  use of psychotropic medications, the NSCAW II included information on  concurrent use of psychotropic medications and on the use of  antipsychotics by foster children. Among foster children who took  psychotropic medication, 13 percent took three or more psychotropic  medications concurrently. The American Academy of Child &  Adolescent Psychiatry (AACAP) has noted that there is a lack of research  on the efficacy of taking multiple psychotropic medications concurrently.  NSCAW II survey findings also showed that 6.4 percent of foster children  took an antipsychotic medication and that the majority were ages 6  through 11.
Mental-health researchers and others have stated that there  is a need for further research on the safety and effectiveness of  antipsychotics for children, particularly the long-term effects.
In December 2011, we reported findings from our analysis of five states’  Medicaid prescription drug data that found children in foster care in  Florida, Massachusetts, Michigan, Oregon, and Texas were prescribed  psychotropic medications at higher rates than nonfoster children in  Medicaid during 2008. Specifically, we found that among these states  foster children were prescribed psychotropic drugs at rates 2.7 to 4.5  times higher than were nonfoster children in Medicaid in 2008. The rates  were higher among foster children for each of the age ranges—0 to 5  years old, 6 to 12 years old, and 13 to 17 years old—that we reviewed.  According to research, experts we consulted, and certain federal and  state officials we interviewed as part of our December 2011 report, this  could be due in part to foster children’s greater exposure to traumatic  experiences, frequent changes in foster placements, and varying state  oversight policies.
See Julie M. Zito et al., Psychotropic Medication Patterns Among Youth in Foster Care,  Pediatrics. vol.121, no. 1 (2008), 157–163. or medical literature maximum dosages for children and adolescents.  Our experts said that this increases the risk of adverse side effects and  does not typically increase the efficacy of the drugs to any significant  extent. Further, foster and nonfoster children under 1 year old were  prescribed psychotropic drugs, which experts consulted said have no  established use for mental-health conditions in infants and providing them  these drugs could result in serious adverse effects. These experts also  said that the prescriptions could have been prescribed for non-mental- health reasons, such as for seizures, and to treat allergies, itching, or  other skin conditions.
section_title: HHS and States Have Made Progress in Improving Oversight of Psychotropic Prescriptions, but Additional Guidance Could Help Officials Manage Psychotropic Medications
paragraphs: In December 2011, we found that six selected states’ monitoring  programs for psychotropic drugs provided to foster children fell short of  best principles guidelines published by the AACAP. The guidelines,  which states were not required to follow at the time of this report, covered  four categories. The following describes the extent to which the selected  states’ monitoring programs in our review covered these areas.
Consent: Each state had some practices consistent with AACAP  consent guidelines such as identifying caregivers empowered to give  consent.
Oversight: Each state had procedures consistent with some but not all  oversight guidelines, which include monitoring rates of prescriptions.
Consultation: Five states had implemented some but not all  guidelines, which include providing consultations by child psychiatrists  by request.
Information: Four states had created web-sites about psychotropic  drugs for clinicians, foster parents, and other caregivers.
We found that this variation was expected because states set their own  guidelines, and, at the time of our 2011 report, HHS had not yet endorsed  specific measures for state oversight of psychotropic prescriptions for  children in foster care. We recommended that HHS consider endorsing  guidance for states on best practices for overseeing psychotropic  prescriptions for children in foster care. HHS concurred with the  recommendation and, in April 2012, issued guidance regarding the  oversight of psychotropic medications among children in foster care. HHS  has also undertaken collaborative efforts to provide guidance and  promote information sharing among states. health screening tools and providing therapies that address trauma, which  seek to ensure that the mental-health needs of children in foster care are  appropriately met. See figure 1 below for a list of initiatives undertaken  since our December 2011 report by ACF, CMS, and SAMHSA.
In our April 2014 follow-up report, we also found that, to varying degrees,  each of the five selected states we reviewed has policies and procedures  designed to address the monitoring and oversight of psychotropic  medications prescribed to children in foster care. For example:
All five selected states’ foster-care programs use some type of  functional assessment or screening tool, such as the Child and  Adolescent Needs and Strengths (CANS), for screening and  treatment planning, which may prompt a referral for a psychiatric  evaluation as deemed appropriate.
All five of the selected states have designed a mechanism to  coordinate and share some or all Medicaid prescription claims data  with the state’s foster-care agency to help monitor and review cases  based on varying criteria, such as prescriptions for children under a  particular age, high dosages, or concurrent use of multiple  medications.
Three of five states—Florida, Massachusetts and Texas—included in our  April 2014 review use, or are transitioning from fee-for-service to, MCOs  to administer prescription-drug benefits for mental-health medications.  Medicaid officials from two of those three states reported that their states  had conducted limited planning to ensure appropriate oversight of MCOs  administering psychotropic medications.
ACF, CMS, and SAMHSA have developed guidance for state Medicaid,  child-welfare, and mental-health officials related to the oversight of  psychotropic medications that underscored the need for collaboration  between state officials to improve prescription monitoring. However, we  found in April 2014 that this guidance does not address oversight within  the context of a managed-care environment, in which states rely on a  third party to administer benefits such as psychotropic medications. Many  states have, or are transitioning to, MCOs to administer prescription-drug  benefits, and, as our work demonstrates, selected states have taken  limited steps to plan for the oversight of drug prescribing for foster  children receiving health care through MCOs—which creates a risk that  controls instituted in recent years under fee-for-service may not remain  once states move to managed care. In our April 2014 report, we  concluded that additional guidance from HHS that helps states prepare  and implement monitoring efforts within the context of a managed-care  environment could help ensure appropriate oversight of psychotropic  medications to children in foster care. We recommended that the  Secretary of Health and Human Services issue guidance to state  Medicaid, child-welfare, and mental-health officials regarding prescription- drug monitoring and oversight for children in foster care receiving  psychotropic medications through MCOs. HHS concurred with the  recommendation and described planned actions to address it, such as  having CMS work with other involved agencies to coordinate guidance  between CMS and other HHS agencies.
section_title: Case Studies Varied in Quality of Documentation Supporting the Use of Psychotropic Medications
subsections: section_title: Expert Reviews of Select Foster Children’s Foster and Medical Files Found Variation in the Quality of Documentation
paragraphs: As part of our April 2014 report, we also contracted with two child  psychiatrists to provide clinical evaluations of 24 cases that we selected  from the population of foster children prescribed psychotropic drugs in  2008. The case selections were based, in part, on potential health risk  indicators, such as concurrent use of five or more psychotropic  medications, doses higher than the maximum levels cited in guidelines  developed by Texas based on FDA-approved labels or medical literature  maximum dosages for children and adolescents, and children less than 1  year old prescribed psychotropic drugs. Our experts’ reviews of 24 foster  children’s foster and medical files in five selected states found that the  quality of documentation supporting the prescription of psychotropic  medication usage varied with respect to (1) screening, assessment, and  treatment planning; (2) medication monitoring; and (3) informed and  shared decision making.
Screening, Assessment, and Treatment Planning. Our experts’  evaluation of this category included whether medical pediatric exams and  evidence-based therapies—which are interventions shown to produce  measureable improvements—were provided as needed, according to  records.exams were mostly supported by documentation. For example, in one  case with mostly supporting documentation, experts found that a child  with a history of behavioral and emotional problems had records  documenting a medical pediatric exam and thorough psychological  assessments, with comprehensive discussions of diagnostic issues and  medication rationale. With regard to evidence-based therapies, experts  found that 3 of 15 children who may have benefitted from such therapies  were mostly provided such services. In 11 of 15 applicable cases, the  experts found that evidence-based therapies were partially provided, such  as for instances when some psychosocial or evidence-based therapies  were documented, but other evidence-based therapies that may have  been more applicable or beneficial were not provided. In 1 of 15 cases  there was no documentation that evidence-based therapies were  provided.
Our experts found in 22 of 24 cases that medical pediatric  Medication Monitoring. Our experts’ evaluation of this category included  the appropriateness of medication dosage and the rationale for  concurrent use of multiple medications, according to records. Our experts  found appropriateness of medication dosages was mostly supported by  documentation in 13 of 24 cases and partially supported in the other 11  cases. The rationale for concurrent use of multiple medications was  mostly supported in 5 of the 20 cases where multiple medications were  used, but 14 of 20 cases included documentation that partially supported  concurrent use, and 1 case did not include documentation to support  concurrent use. For example, in one case with partially supporting  documentation, our experts found that a child was prescribed four  psychotropic drugs concurrently, when nonmedication interventions could  have been considered.
Informed and Shared Decision Making. Our experts’ evaluation of this  category included whether informed consent and communication between  treatment providers occurred, according to records. Our experts found  that informed-consent decisions were mostly documented in 5 of 23  applicable cases. In 11 of 23 cases, our experts found partial  documentation of informed consent—such as when some, but not all,  medications prescribed to the child included documentation of informed  consent—and 7 other cases did not include any documentation of  informed consent. For example, in one case, our experts reported there  was no documentation of informed consent, psychiatric evaluation,  psychiatric diagnosis, or monitoring of antipsychotic medication. In this  case, the child was prescribed an antianxiety medication (buspirone), an  antipsychotic medication (risperidone), and an ADHD medication  (clonidine) at 4 years of age, presumably to treat psychiatric symptoms  that interfered with his functioning, including short attention span,  wandering off, self-injury, and aggression. However, our experts noted  the documentation was too sparse to determine why the psychotropic  medications were prescribed, and the indications, monitoring, and side  effects could not be evaluated. In addition, our experts found that  communication between treatment providers was mostly documented in  15 of 23 applicable cases. However, communication between treatment  providers was partially documented in 5 of 23 cases, and there was no  evidence that such communication occurred in 3 of 23 cases. Foster  children can experience frequent changes in their living placements,  which can lead to a lack of continuity in mental-health care, and new  providers may not have the medical history of the patient.  This lack of  stability can lead to treatment disruptions and can increase the number of  medications prescribed.
section_title: Some Prescriptions in Infant Cases Were for Non-Mental-Health Reasons, but Others Were for Psychiatric or Unclear Reasons
paragraphs: Of the 24 cases reviewed, 9 were infant cases that our experts evaluated  to determine whether the prescriptions were for psychiatric or non-mental- health reasons. Our experts agreed that prescriptions of psychotropic  medications to infants carries significant risk as there are no established  mental-health indications for the use of psychotropic medications in  infants and the medications have the potential to result in serious adverse  effects for this age group. Our experts found in 4 of 9 infant cases  reviewed that the prescription of psychotropic medication was for non- mental-health purposes, such as to treat skin conditions, based on  documentation reviewed. However, our experts found that in 2 of 9 cases  the infants were prescribed psychotropic medications for psychiatric  reasons, and the rationale and oversight for such medications were  partially supported by documentation. In 3 of 9 infant cases, our experts  were unable to discern whether the psychotropic medications were  prescribed to infants for mental-health purposes or for some other  medical reason, based on documentation reviewed.
In conclusion, early detection and treatment of mental-health conditions  can improve a child’s symptoms and reduce potentially detrimental  effects, such as difficulties with relationships, dropping out of school, and  involvement with the juvenile justice system. Despite the need for  treatment, child mental-health advocates, providers, and researchers  have expressed concern about the increase in prescribing of psychotropic  medications for children because of limited information on the safety and  efficacy of the medications being prescribed in the child population.  Children in foster care are especially vulnerable because they more  frequently have been subjected to traumatic experiences involving abuse  or neglect and they may suffer from multiple, serious mental-health  conditions. Our analysis of national survey data, state Medicaid data, and  a sample of case files indicates that concerns raised by providers,  advocates, and others about potentially inappropriate prescribing of  psychotropic medications for children in foster care may be warranted.  The federal government and state governments in our review recently  have taken action to improve the oversight of psychotropic medication  prescribing to foster care children, however, continued assessment and  guidance is needed to protect this vulnerable population.
Chairman Reichert, Ranking Member Doggett, and Members of the  Committee, this completes my prepared statement. I would be pleased to  respond to any questions that you may have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information on this testimony, please contact Stephen Lord at  (202) 512-6722 or lords@gao.gov or Katherine Iritani at (202) 512-7114  or iritanik@gao.gov. Individuals making key contributions to this testimony  include Lori Achman, Assistant Director; Matthew Valenta, Assistant  Director; Scott Clayton; and Linda Miller.
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