Removal from the home can occur because of physical abuse or  neglect. As we have  previously reported, children in foster care exhibit more numerous and  serious medical conditions, including mental health conditions, than do  other children. Further, additional risks these drugs pose specifically to  children are not well understood. Foster children in each of the five selected states were prescribed  psychotropic drugs at higher rates than were nonfoster children in  Medicaid during 2008. These states spent over $375 million for  prescriptions provided through fee-for-service programs to foster and  nonfoster children. The higher rates do not necessarily indicate  inappropriate prescribing practices, as they could be due to foster  children’s greater exposure to traumatic experiences and the unique  challenges of coordinating their medical care. However, psychotropic  drug claims for foster children were also more likely to show the indicators  of potential health risks that we established with our experts. According to  our 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 were prescribed such a medication regimen. Similarly,  thousands of foster and nonfoster children were prescribed doses  exceeding maximum levels cited in guidelines based on FDA-approved  drug labels, which our 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 our experts said have  no established use for mental health conditions in infants and could result  in serious adverse effects. Selected States’ Psychotropic Drug Monitoring Programs Fall Short of AACAP- Best Principles Guidelines

Comparing the selected states’ monitoring programs for psychotropic  drugs provided to foster children with AACAP’s guidelines indicates that,  as of October 2011, each of the state programs falls short of providing  comprehensive oversight as defined by AACAP. Such variation is not surprising  given that states set their own oversight guidelines and have only recently  been required, as a condition of receiving certain federal child welfare  grants, to establish protocols for the appropriate use and monitoring of  psychotropic drugs prescribed to foster children. Oversight procedures: Each of the six states has developed some  procedures similar to AACAP’s guidelines for overseeing psychotropic  drug prescriptions for foster children, as evidenced by interviews and  documentation provided by state Medicaid and foster care officials. In addition, as stated earlier, Maryland’s  2008 foster care data were found unreliable. Consultation program: According to interviews and documentation  provided by state Medicaid and foster care officials, five of the six states  have implemented some of AACAP’s guidelines for consultation, but only  one of the six selected states has implemented a consultation program  that ensures all consent givers and prescribers are able to seek advice  from child and adolescent psychiatrists before making consent decisions  for foster children. Information sharing: Four of the six selected states have created  websites with information on psychotropic drugs for clinicians, foster  parents, and other caregivers. Conclusions

The higher rates of psychotropic drug prescriptions among foster children  may be explained by their greater mental health needs and the  challenges inherent to the foster care system. However, thousands of  foster and nonfoster children in the five states we analyzed were found to  have prescriptions that carry potential health risks. Recommendation for Executive Action

In our draft report, we recommended that the Secretary of HHS 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. Agency comments will be incorporated and  addressed in a written report that will be issued in December 2011.
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 may include psychotropic drugs but their risks to children are not well understood. Medicaid, administered by states and overseen by the Department of Health and Human Services (HHS), provides prescription drug coverage to foster children. This testimony examines (1) rates of psychotropic prescriptions for foster and nonfoster children in 2008 and (2) state oversight of psychotropic prescriptions for foster children through October 2011. GAO selected Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas primarily based on their geographic diversity and size of the foster care population. Results cannot be generalized to other states. In addition, GAO analyzed Medicaid fee-for-service and foster care data from selected states for 2008, the most recent year of prescription data available at the start of the audit. Maryland's 2008 foster care data was unreliable. GAO also used expert child psychiatrists to provide a clinical perspective on its methodology and analysis, reviewed regulations and state policies, and interviewed federal and state officials.

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, which 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 risk of 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; providing them these drugs could result in serious adverse effects. Selected states' monitoring programs for psychotropic drugs provided to foster children fall short of best principle guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP). The guidelines, which states are not required to follow, cover four categories. (1) Consent: Each state has some practices consistent with AACAP consent guidelines, such as identifying caregivers empowered to give consent. (2) Oversight: Each state has procedures consistent with some but not all oversight guidelines, which include monitoring rates of prescriptions. (3) Consultation: Five states have implemented some but not all guidelines, which include providing consultations by child psychiatrists by request. (4) 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. In our draft report, GAO recommended that HHS consider endorsing guidance for states on best practices for overseeing psychotropic prescriptions for foster children. HHS agreed with our recommendation. Agency comments will be incorporated and addressed in a written report that will be issued in December 2011.