Although psychosocial therapies may be effective for many children, the  Institute of Medicine and others have reported that a shortage of mental  health providers in general is a major factor affecting access to services,  especially for children. Children in Medicaid Took Psychotropic Medications at a Higher Rate Than Those with Private Insurance, and Most Children in Medicaid with a Potential Mental Health Need Did Not Receive Services

On average, 6.2 percent of noninstitutionalized children in Medicaid  nationwide took psychotropic medications during a calendar year from  2007 through 2009, and 21 percent of those children took an  antipsychotic medication. CMS and states have made efforts to ensure that children  receive appropriate mental health services, but CMS’s ability to monitor  their receipt of services for which they were referred is limited because  CMS does not collect information from states on whether children in  Medicaid have received services for which they were referred. The  comparable rate for privately insured children was lower—4.8 percent. About 14 Percent of Children in Medicaid Had a Potential Mental Health Need, but Most Did Not Receive Mental Health Services

Our analysis of national survey data from 2007 through 2009 indicated  that 14 percent of noninstitutionalized children in Medicaid and 9 percent  of noninstitutionalized privately insured children had a potential mental  health need. CMS has initiated activities to help ensure that children in Medicaid  receive appropriate mental health services. For example, CMS has begun  working with states to improve their monitoring of the prescribing of  psychotropic medications, and in August 2012 the agency issued an  Informational Bulletin to states titled, “Collaborative Efforts and Technical  Assistance Resources to Strengthen the Management of Psychotropic  Medications for Vulnerable Populations.” The bulletin provided a link to  additional information on the CMS website that discusses practices some  states have employed to enhance the ability of their Drug Utilization  Review programs to monitor psychotropic medication prescribing, such as  using Drug Utilization Reviews to identify and contact providers whose  prescribing patterns vary significantly from recommended standards of  care for children.Measures Program, CMS is working with states to collect data on three   In addition, through its voluntary Pediatric Quality  quality measures related to mental health, including receipt of follow-up  care for children prescribed ADHD medication. HHS is taking several steps to promote  appropriate mental health treatment for foster children. ACF Reported That 18 Percent of Foster Children Took Psychotropic Medications

ACF reported that 18 percent of foster children were taking one or more  psychotropic medications at the time they were surveyed, although  utilization varied widely by living arrangement.children who lived in group homes or residential treatment centers had  much higher rates of psychotropic medication use than foster children   ACF reported that foster  living in nonrelative foster homes or formal kin care—48 percent versus  14 percent and 12 percent, respectively. ACF Reported That 30 Percent of Foster Children with a Potential Mental Health Need Did Not Receive Mental Health Services

ACF reported that 30 percent of foster children with a potential mental  health need had not received any mental health services within the  previous 12 months or since the start of the child’s living arrangement, if  less than 12 months. 1.) Most NIH Funding for Children’s Mental Health Research Was Spent by NIMH

During fiscal years 2008 through 2011, NIH spent about $1.2 billion to  support over 1,200 children’s mental health research projects, most of   NIMH accounted for 81 percent—about  which were supported by NIMH.$956 million—of NIH’s funding for children’s mental health research. 2.) About half of NIMH-sponsored research projects (482) examined mental  health treatments for children, with more projects studying psychosocial  therapies than psychotropic medications. Other HHS Agencies Spent an Estimated $16 Million on Children’s Mental Health Research Projects

Together, FDA, AHRQ, and CDC spent about $16 million on research  projects on children’s mental health in fiscal years 2008 through 2011. Children in  Medicaid and in foster care are prescribed these medications at higher  rates than other children. Agency Comments

HHS did not comment on our findings but provided technical comments,  which we incorporated as appropriate. Appendix I: Methodology Used to Analyze the Medical Expenditure Panel Survey

To provide information on the use of psychotropic medications and other  mental health services by children covered by Medicaid, the Children’s  Health Insurance Program (CHIP), and private insurance, we analyzed  nationwide data from the Medical Expenditure Panel Survey (MEPS) from  2007 through 2009. Medicaid and CHIP: Reports for Monitoring Children’s Health Care  Services Need Improvement.
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.

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.