	Introduction

Children in foster care are more likely to have mental health care needs than children generally. They are also more likely than other children to receive psychotropic medications, which are prescribed drugs that affect the brain chemicals related to mood and behavior. Psychotropic medications are used to treat a variety of mental health conditions including attention disorders, depression, anxiety, conduct disorders, and others. Children in foster care are placed in another setting that is designed to provide round-the-clock care (e.g., foster family home, group home, child care institution). Most children enter foster care because of neglect or abuse experienced at the hands of their parents, although a child's behavior problem may also be a factor in foster care placement. Maltreatment by a parent or other caregiver is stressful for children and may alter how their brains develop in ways that lead them to have more difficulty regulating their emotions and interpreting cues and communication from others. In general, children who have mental health challenges may benefit from health care services that could include psychosocial treatment, such as counseling and case management from mental health professionals. Use of Psychotropic Drugs by Children in Foster Care

Between 16% and 33% of children in out-of-home care may be using psychotropic medication on any given day, although the rate of use varies significantly based on certain factors, including the child's age, placement setting, and length of involvement with the child welfare agency. The use of psychotropics by children in foster care has come under growing scrutiny by policymakers and stakeholders in the child welfare field. Despite these concerns, some children in foster care may benefit from psychotropic medication for managing symptoms and issues associated with mental health and behavior concerns stemming from their exposure to complex trauma, particularly if this treatment is coupled with psychosocial services. Congressional Oversight

Congress has taken an interest in oversight of prescription medications used by children in foster care. Current Federal Provisions Related to the Oversight of Health Care for Children in Foster Care

As noted previously, under the Stephanie Tubbs Jones Child Welfare Services Program (Title IV-B, Subpart 1 of the Social Security Act) states must develop a coordinated strategy and oversight plan to ensure access to health care, including mental health services and dental care, for all children in foster care. The coordinated strategy must outline 
a schedule for initial and follow-up health screenings that meet reasonable standards of medical practice; how health needs identified through screenings, including emotional trauma associated with a child's maltreatment and removal from home, will be monitored and treated; how medical information for children in care will be updated and appropriately shared, which may include the development and implementation of an electronic health record; steps to ensure continuity of health care services, which may include the establishment of a medical home for every child in care; the oversight of prescription medicines, including protocols for the appropriate use and monitoring of psychotropic medications (italics added for emphasis); how the state actively consults with and involves physicians or other appropriate medical or nonmedical professionals in assessing the health and well-being of children in foster care and in determining appropriate medical treatment for the children; and steps to ensure that the components of the transition plan development process related to the health care needs of children aging out of foster care are met. The guidance noted that children in foster care may be more likely to receive psychotropic medication, and may not be prescribed psychotropics properly, because of the complexity of their symptoms and the lack of appropriate screening, assessment, and treatment. FY2017 Request: Demonstration to Address "Over-Prescription" of Psychotropic Medication for Children in Foster Care105

President Obama's FY2017 budget proposed a five-year joint initiative between CMS and ACF to reduce reliance on psychotropic medications for children in foster care and improve their well-being.
Children in foster care are children that the state has removed from their homes and placed in another setting designed to provide round-the-clock care (e.g., foster family home, group home, child care institution). The large majority of children enter foster care because of neglect or abuse at the hands of their parents. Maltreatment by a caregiver is often traumatic for children, and may lead to children having challenges regulating their emotions and interpreting cues and communication from others, among other problem behaviors. Children in foster care are more likely to have mental health care needs than children generally.
Children in foster care who have mental health needs may receive psychosocial services such as individual or group counseling and case management to improve their health. Alternatively, or in addition, a medical professional may prescribe psychotropic medications. These are prescribed drugs that affect the brain chemicals related to mood and behavior. They are used to treat a variety of mental health conditions including attention disorders, depression, anxiety, conduct disorders, and others. While psychotropic medication alone is not necessarily advised, children in foster care may more readily receive psychotropics to treat their mental health needs due to the complexity of their symptoms and the lack of appropriate screening and assessment and/or the limited availability of health care professionals trained to provide effective therapies (e.g., cognitive behavioral therapy).
Between 16% and 33% of children in out-of-home care may be using psychotropic medication on any given day, although the rate of use varies significantly based on certain factors, including the child's age, placement setting, and length of involvement with the child welfare agency. Among children generally, about 6% are taking psychotropic medications at some point during a given year. Some of the difference in prevalence of use may be explained by the higher levels of mental health risk factors among children in foster care.
The use of psychotropics by children in foster care has come under increased scrutiny by policymakers and stakeholders in the child welfare field. Little research has been conducted to show whether psychotropics are effective and safe for children who need mental health services. Despite these concerns, some children may benefit from specific psychotropic medication for managing mental and behavioral symptoms associated with their exposure to traumatic events. President Obama's FY2017 budget proposed a five-year initiative to reduce reliance on psychotropic medications for children in foster care by encouraging the use of evidence-based screening, assessment, and treatment of trauma and mental health disorders. Congress has also taken a strong interest in oversight of prescription medications used by children in care, addressing the issue in oversight hearings and other fact-finding forums.
Further, federal law (Title IV-B, Subpart 1 of the Social Security Act) requires states and other jurisdictions to describe their oversight of prescription medications for children in foster care, including specific protocols used with regard to psychotropic medication. The Department of Health and Human Services (HHS) has issued guidance about these provisions and requires jurisdictions to submit annual reports to the department that describe this oversight.