Children in Foster Care Receive Psychotropic Medications at Higher Rates than Other Children in Medicaid

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. Among foster children who took  psychotropic medication, 13 percent took three or more 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. 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. The following describes the extent to which the selected  states’ monitoring programs in our review covered these areas. HHS concurred with the  recommendation and, in April 2012, issued guidance regarding the  oversight of psychotropic medications among children in foster care. 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. Many  states have, or are transitioning to, MCOs to administer prescription-drug  benefits, and, as our work demonstrates, selected states have taken  limited steps to plan for the oversight of drug prescribing for foster  children receiving health care through MCOs—which creates a risk that  controls instituted in recent years under fee-for-service may not remain  once states move to managed care. We recommended that the  Secretary of Health and Human Services issue guidance to state  Medicaid, child-welfare, and mental-health officials regarding prescription- drug monitoring and oversight for children in foster care receiving  psychotropic medications through MCOs. Case Studies Varied in Quality of Documentation Supporting the Use of Psychotropic Medications

		Expert Reviews of Select Foster Children’s Foster and Medical Files Found Variation in the Quality of Documentation

As part of our April 2014 report, we also contracted with two child  psychiatrists to provide clinical evaluations of 24 cases that we selected  from the population of foster children prescribed psychotropic drugs in  2008. With regard to evidence-based therapies, experts  found that 3 of 15 children who may have benefitted from such therapies  were mostly provided such services. In 11 of 15 applicable cases, the  experts found that evidence-based therapies were partially provided, such  as for instances when some psychosocial or evidence-based therapies  were documented, but other evidence-based therapies that may have  been more applicable or beneficial were not provided. In 1 of 15 cases  there was no documentation that evidence-based therapies were  provided. Our experts found in 4 of 9 infant cases  reviewed that the prescription of psychotropic medication was for non- mental-health purposes, such as to treat skin conditions, based on  documentation reviewed. However, our experts found that in 2 of 9 cases  the infants were prescribed psychotropic medications for psychiatric  reasons, and the rationale and oversight for such medications were  partially supported by documentation. Children in foster care are especially vulnerable because they more  frequently have been subjected to traumatic experiences involving abuse  or neglect and they may suffer from multiple, serious mental-health  conditions. The federal government and state governments in our review recently  have taken action to improve the oversight of psychotropic medication  prescribing to foster care children, however, continued assessment and  guidance is needed to protect this vulnerable population.
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. This testimony discusses GAO's recent work on (1) the extent to which children in foster care are prescribed psychotropic medications, (2) federal and state actions to oversee psychotropic prescribing to children in foster care, and (3) the extent to which the use of psychotropic medications was supported by foster and medical records for selected case studies of children in foster care who were prescribed these medications. This testimony is based on previous GAO reports issued from 2011 through 2014 that used various methodologies, including reviewing federal studies, analyzing Medicaid prescription claims data from five states, and contracting with two experts to review 24 case files (selected, in part, based on potential health risk indicators). The findings related to the expert reviews of 24 case files are not generalizable.

What GAO Found

In December 2012, GAO reported on the results of the Administration for Children and Families (ACF) surveys of children in contact with the child-welfare system conducted during 2008-2011. 18 percent of foster-care children were taking a psychotropic medication at the time they were surveyed. Foster children who lived in group homes or residential treatment centers had much higher rates of psychotropic medication use than those living in nonrelative foster homes or formal kin care—48 percent versus 14 percent and 12 percent, respectively, according to the surveys. 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. Among foster children who took psychotropic medication, about 13 percent took three or more psychotropic medications concurrently. About 6.4 percent of foster children took an antipsychotic medication—psychotropic medications with potentially serious side effects that are intended to treat serious mental-health conditions such as schizophrenia—and the majority were ages 6 -11. In examining prescribing at the state level, GAO found similar results in its December 2011 review. Specifically, 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, although prescribing rates varied by state.
In April 2014, GAO found the federal government and states have taken a multitude of steps to better oversee psychotropic drug prescribing for children in foster care, although more can be done as states increasingly deliver their medication benefits through Medicaid managed care. In addition, GAO found that, to varying degrees, each of the five selected states it reviewed had 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 a screening tool that may prompt a referral of the foster child for a psychiatric evaluation. GAO also found that ACF had provided webinars and technical guidance to states. However, many states have, or are transitioning to, managed care organizations (MCO) to deliver Medicaid prescription-drug benefits, and GAO found variation in the extent that the five selected states were taking steps to plan for the oversight of drug prescribing for foster children receiving these benefits through MCOs.
For an April 2014 report, GAO contracted with two child psychiatrists to review foster and medical records for 24 cases in five selected states and found varying quality in the documentation supporting the use of psychotropic medications for children in foster care. These experts found that for many of the cases the prescriptions were mostly supported by documentation. However, in some areas, such as evidence-based therapies—interventions shown to produce measureable improvements—the experts found documentation was lacking. For example, the experts found that 3 of 15 children who may have benefited from such therapies were mostly provided such services, while in 11 of the 15 cases, the experts found that evidence-based therapies were partially provided but also found that other evidence-based therapies that may have been more applicable or beneficial were not provided, based on the documents reviewed. In 1 of the 15 cases there was no documentation that evidence-based therapies were provided.

What GAO Recommends

GAO has made recommendations in prior work, including that the Secretary of Health and Human Services issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs. The Department of Health and Human Services (HHS) concurred with the recommendation and described planned actions.