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Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions [Reissued on December 15, 2011]

GAO-12-201 Published: Dec 14, 2011. Publicly Released: Dec 16, 2011.
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What GAO Found

Foster children in the five states GAO analyzed were prescribed psychotropic drugs at higher rates than nonfoster children in Medicaid during 2008. The higher rates do not necessarily indicate inappropriate prescribing practices, but 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 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 GAO’s experts said have no established use for mental health conditions in infants and could result in serious adverse effects.

The six selected states’ monitoring programs for psychotropic drugs provided to foster children fall short of best principles guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP). The guidelines, which states are not required to follow, cover four categories.

  • Consent: Each state has some practices consistent with AACAP consent guidelines, such as identifying caregivers empowered to give consent.
  • Oversight: Each state has procedures consistent with some but not all oversight guidelines, which include monitoring rates of prescriptions.
  • Consultation: Five states have implemented some but not all guidelines, which include providing consultations by child psychiatrists by request.
  • 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.

Why GAO Did This Study

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. Medicaid, which is administered by states and overseen by the Department of Health and Human Services (HHS), provides prescription drug coverage to foster children.

For selected states, GAO examined (1) 2008 rates of psychotropic prescriptions for foster and nonfoster children and (2) state oversight of psychotropic prescriptions for foster children through October 2011. GAO selected Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas primarily for geographic diversity and size of the foster care population, and analyzed state Medicaid fee-for-service and foster care data from selected states for 2008. 2008 was the most recent year of prescription data available at the start of the audit. Maryland’s 2008 foster care data were unreliable and could not be analyzed. GAO contracted with expert child psychiatrists to provide a clinical perspective on our methodology and analysis, reviewed regulations and state policies, and interviewed federal and state officials. Results cannot be generalized to other states.

Reissued on December 15, 2011


Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services To improve the comprehensiveness of oversight of psychotropic drugs prescribed to foster children, the Secretary of HHS should 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.
Closed – Implemented
In response to our report, in April 2012 the HHS Administration for Children and Families (ACF) issued an Information Memorandum endorsing, among others, guidelines from the American Academy of Child and Adolescent Psychiatry (AACAP) to state agencies seeking to improve their monitoring and oversight practices for psychotropic medications. Consistent elements found in the endorsed guidelines include the need for policies containing provisions for screening, assessment, and treatment planning mechanisms, informed consent, monitoring, expertise consultation, and information sharing. ACF's endorsement of these guidelines could help provide states increased opportunities to strengthen oversight of psychotropic drug prescriptions for foster children.

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DrugsPrescription drugsFoster childrenFoster careMedicaidMental healthChild welfareHealth risksAttention deficit disordersChildren