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Children's Mental Health: Concerns Remain about Appropriate Services for Children in Medicaid and Foster Care

GAO-13-15 Published: Dec 10, 2012. Publicly Released: Jan 09, 2013.
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What GAO Found

An annual average of 6.2 percent of noninstitutionalized children in Medicaid nationwide and 4.8 percent of privately insured children took one or more psychotropic medications, according to GAO's analysis of 2007-2009 data from the Department of Health and Human Services' (HHS) Medical Expenditure Panel Survey (MEPS). MEPS data also showed that children in Medicaid took antipsychotic medications (a type of psychotropic medication that can help some children but has a risk of serious side effects) at a relatively low rate--1.3 percent of children--but that the rate for children in Medicaid was over twice the rate for privately insured children, which was 0.5 percent. In addition, MEPS data showed that most children whose emotions or behavior, as reported by their parent or guardian, indicated a potential need for a mental health service did not receive any services within the same year. The Centers for Medicare & Medicaid Services (CMS) and many states have initiatives under way to help ensure that children receive appropriate mental health treatments. However, CMS's ability to monitor children's receipt of mental health services is limited because CMS does not collect information from states on whether children in Medicaid have received services for which they were referred. GAO recommended in 2011 that CMS identify options for collecting such data from state Medicaid programs. Findings in this report underscore the continued importance of CMS's monitoring of children's receipt of mental health services.

HHS's Administration for Children and Families (ACF) reported that 18 percent of foster children were taking psychotropic medications at the time they were surveyed, although utilization varied widely by the child's living arrangement. ACF also reported that 30 percent of foster children who may have needed mental health services did not receive them in the previous 12 months. HHS agencies are taking steps to promote appropriate mental health treatments for foster children, such as by sending information to states on psychotropic medication oversight practices.

HHS's National Institutes of Health spent an estimated $1.2 billion on over 1,200 children's mental health research projects during fiscal years 2008 through 2011. Most of the funding--$956 million--was awarded by the National Institute of Mental Health, with more research projects studying psychosocial therapies than psychotropic medications. Other HHS agencies spent about $16 million combined on children's mental health research during this period.

HHS reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

Why GAO Did This Study

Experts have concerns that children with mental health conditions do not always receive appropriate treatment, including concerns about appropriate use of psychotropic medications (which affect mood, thought, or behavior) and about access to psychosocial therapies (sessions with a mental health provider). These concerns may be compounded for low-income children in Medicaid and children in foster care (most of whom are covered by Medicaid)--populations who may be at higher risk of mental health conditions. Within HHS, CMS oversees Medicaid, and ACF supports state child welfare agencies that coordinate health care for foster children.

GAO was asked to provide information on children's mental health. This report examines (1) the use of psychotropic medications and other mental health services for children in Medicaid nationwide, and related CMS initiatives; (2) HHS information on the use of psychotropic medications and other mental health services for children in foster care nationwide, and related HHS initiatives; and (3) the amount HHS has invested in research on children's mental health.

GAO analyzed data from HHS's MEPS --a national household survey on use of medical services--from 2007 through 2009 for children covered by Medicaid and private insurance. GAO reviewed two recent ACF foster care reports with data from a national survey conducted during 2008 through 2011. GAO analyzed data from HHS agencies that conduct or fund research and interviewed HHS officials and children's mental health providers, researchers, and advocates.

For more information, contact Katherine Iritani at (202) 512-7114 or

Full Report

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