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. 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. 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.