Children enter foster care when they have been removed from their parents or guardians for reasons such as abuse or neglect, and placed under the responsibility of a state child welfare agency. The agency generally places the child in the home of a relative, with unrelated foster parents, or in a group home or residential treatment center, depending on the child’s needs. Child welfare caseworkers at the agency are typically responsible for coordinating placement and needed support services for these children, including those for mental health. If a child is determined to be in need of mental health services, the caseworker is generally responsible for arranging such services to be provided by primary care physicians, child psychiatrists, or other mental health providers. State courts, typically juvenile or family courts, are also frequently involved in decisions regarding a child’s removal, placement, and services. Most children in foster care are eligible for Medicaid, and those enrolled may receive physical and mental health services through a variety of service delivery and provider payment systems, such as fee-for-service and managed care. In the traditional fee-for-service delivery system, the state Medicaid agency manages the program and reimburses physicians directly and on a retrospective basis for each health service delivered. Under a managed care model, states contract with one or more managed care organizations and prospectively pay the organizations a fixed monthly fee per patient to provide or arrange for defined health services, which may include mental health services and prescription medications. These organizations, in turn, pay physicians. States are primarily responsible for administering their child welfare and foster care programs, consistent with applicable federal laws and regulations, which include some requirements that relate to ensuring the well-being of children served by these programs. For example, title IV-E of the Social Security Act authorizes federal funding to states to help cover the costs of operating their foster care and certain other programs. In addition, title IV-B of the Social Security Act authorizes federal funds to support state child welfare programs and services. Both of these programs establish various requirements that participating states must comply with in order to receive the federal funding. The Fostering Connections to Success and Increasing Adoptions Act of 2008 amended title IV-B to add a requirement that states develop a plan for the ongoing oversight and coordination of health care services for children in foster care, including mental health and oversight of prescription medications. The Child and Family Services Improvement and Innovation Act amended this provision to require that these plans include protocols for the appropriate use and monitoring of psychotropic medications. HHS’s ACF is responsible for monitoring state implementation of title IV-E and IV-B programs. For example, ACF conducts reviews of state child welfare and foster care programs every 5 years to ensure conformity with requirements under these federal programs. ACF also monitors state compliance with title IV-B plan requirements, including the health care oversight and coordination plan, through its review of states’ five-year Child and Family Services Plans and Annual Progress and Services Reports. In addition, ACF’s mission is to promote the economic and social well-being of families, children, individuals, and communities through funding, guidance, training, and technical assistance. Under the Medicaid program, states are required to provide eligible children under age 21 with coverage for certain health services, which may include mental health services, through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Specifically, federal law requires coverage of periodic screening services, including a comprehensive health and developmental history of both physical and mental health development, a comprehensive physical exam, appropriate immunizations, laboratory tests, and health education. The EPSDT benefit also covers treatment services necessary to correct or ameliorate any identified physical or mental illnesses or conditions. HHS’s CMS oversees state Medicaid programs and provides federal matching funds for eligible services. On an annual basis, states are required to report to CMS information on their Drug Utilization Review programs, including prescribing patterns, cost savings generated by the programs, an assessment of the programs’ impact on quality of care, and program operations, including information on new innovative practices adopted by states. CMS includes these reports on its website. In addition, state mental health agencies are generally responsible for planning and operating state mental health systems, and play an important role in administering, funding, and providing treatments. These agencies may manage mental health-related federal grants and may work with other state agencies—such as state Medicaid agencies— to identify and treat mental health conditions. They may also contract directly with physicians to deliver treatments or may contract with county or city governments responsible for the delivery of treatments within their local areas. HHS’s SAMHSA engages in activities intended to help improve the behavioral health of children in foster care. Such efforts include grants that support the development of community-based services for children with mental health conditions and information sharing on psychotropic medication practices. Many stakeholders may be involved in ensuring appropriate mental health treatments for children in foster care (see fig. 1). Psychotropic medications can have significant benefits for those with mental health conditions by affecting brain activity associated with mental processes and behavior. However, they can also have side effects ranging from mild to serious, depending on the class and type of medication used. According to the American Academy of Child & Adolescent Psychiatry (AACAP), medications for attention deficit hyperactivity disorder (ADHD), such as amphetamines (e.g., Adderall) and methylphenidate (e.g., Ritalin and Concerta), can reduce symptoms such as hyperactivity in children as well as improve their attention and increase their ability to get along with others. These medications have been widely tested in children and are generally considered safe; however, ADHD medications have also been associated with side effects such as sleeplessness, loss of appetite, tics, agitation, hallucinations, liver problems, and suicidal thoughts. In addition, antidepressants, such as fluoxetine (e.g., Prozac) and sertraline (e.g., Zoloft) can be used to treat conditions such as depression and anxiety. However, possible adverse side effects include agitation, sleeplessness or drowsiness, and suicidal thoughts. The use of antipsychotics—one class of psychotropic medication—has been of particular concern. Antipsychotic medications, such as aripiprazole (e.g., Abilify) and risperidone (e.g., Risperdal), were developed to treat conditions such as bipolar disorder or schizophrenia. However, possible adverse side effects can be serious, including increased levels of cholesterol, rapid weight gain, and the development of diabetes or irreversible movement disorders. Mental health researchers and others have stated the need for further research on the safety, effectiveness, and long-term effects of antipsychotics for children. Psychosocial services are mental health treatments that generally involve therapy sessions with a mental health professional that are designed to reduce patients’ emotional or behavioral symptoms. Such therapies may be used instead of, or in combination with, psychotropic medications to treat children with mental health conditions. Several large, federally funded studies have demonstrated that treatment with a combination of a psychosocial therapy and a psychotropic medication can be more effective than either treatment alone for certain conditions. Further, psychosocial services shown to be effective in treating mental health conditions may be referred to as evidence-based therapies. While there is no standard definition of what constitutes “evidence-based,” some federal agencies and provider organizations, such as SAMHSA and AACAP, evaluate and compile information on available therapies. In response to concerns about psychotropic prescribing practices for children, especially involving those in foster care, AACAP has developed multiple resources to promote the appropriate and safe use of these medications. For physicians, AACAP issued best practice guidelines in 2009 that establish key activities before and after prescribing psychotropic medications to children (see fig. 2). Building on these guidelines for physicians, AACAP developed best practice guidelines for states in 2012 and 2015, with support and partial funding from SAMHSA, that establish practices for overseeing the use of psychotropic medications for children in foster care as well as other children in state custody. An overarching principle outlined in AACAP guidelines is that the use of psychotropic medications for these children should be part of a holistic and collaborative mental health treatment approach that recognizes (1) the biological, psychological, and social factors that may impact a child; (2) trauma-informed care principles that acknowledge the prevalence and impact of trauma, and a commitment to minimize its effects and avoid additional traumatization; and (3) child- serving agencies as part of a system of care for the child, and services that should be youth-guided, home and community-based, integrated across systems, data-driven, and outcome-oriented, among other things. HHS issued an Information Memorandum to states in April 2012 to provide guidance to states on complying with the statutory requirement to develop protocols for the appropriate use and monitoring of psychotropic medications. The memorandum cited our previous work that raised concerns about states’ efforts to oversee the use of psychotropic medications among children in foster care. This memorandum identified policy statements and guidelines from AACAP, the American Academy of Pediatrics, and the state of Texas, among others, and discussed consistent elements among these sets of guidelines. These elements, summarized below, include the need for state policies to contain provisions for: screening, assessment, and treatment planning mechanisms to identify children’s mental health and trauma-treatment needs; informed and shared decision-making and methods for ongoing communication among the physician, child, family, and other key stakeholders; effective medication monitoring; availability of mental health expertise and consultation; and mechanisms for sharing up-to-date information and educational materials related to mental health and trauma-related interventions, including psychotropic medications.