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. 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. 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.