GAO Report: More Oversight of Foster Children’s Mental Health Care Required

A new report from the Government Accountability Office reveals that foster children’s use of psychotropic medications are better managed now than a few years ago, but prescription practices still require much more oversight. Psychotropic medications are those prescribed to treat mental health conditions, such as attention deficit hyperactivity disorder, depression, bipolar and similar disorders.

“It’s clear that too little is being done to oversee the use of psychotropic medication among kids in foster care,” said Sen. Ron Wyden (D-Ore.) in a prepared at a news conference about the report. “These children are often victims of intense trauma, and their pain cannot just be prescribed away.”

After a GAO study in 2011 found that foster youth on Medicaid were prescribed psychotropic medications at a rate higher than that of non-foster children, Senators Susan Collins (R-Maine), Chuck Grassley (R-Iowa) and John McCain (R-Ariz.) ordered this follow-up study. Both studies focused on prescription practices for foster children in Florida, Massachusetts, Michigan, Oregon and Texas.

According to Dr. Glen Elliott, the chief psychiatrist and medial director of the in Palo Alto, California, foster children are far more likely than other children to receive mental health services in general and psychoactive medications specifically, but the reasons for this are complex.

Dr. Glen Elliott, chief psychiatrist and medical director of the Children’s Health Council.

“Consider, for example, the likely causes for a child to be in foster placement such as parental substance use, parental neglect or abuse, or sudden life changes, such as the death or imprisonment of the primary caring figure,” Elliott said. “Any and all of these factors increase the risk of having a mental disorder and being behaviorally disruptive, which in turns increases the likelihood of medicines being used.”

He added that foster families also often lack the training to help children with these multiple issues, especially if they have other foster children, and the child may act out during the period of transitioning with a new family, leading to property destruction, physical aggression and threats of or even actual self-harm.

“Effective non-medication interventions are not all that well established and typically require good training on the part of the person providing treatment as well as high levels of involvement from the foster parents, who may or may not be committed to such treatments,” Elliott said. Consideration of such non-medication treatments was included in the evaluation of foster children’s care in this follow-up report.

For the report, two child psychiatrists contracted by the GAO reviewed 24 children’s cases that had been included in the 2011 report. The cases had personally identifiable information removed but otherwise included all medical and child-welfare documentation for the entire time the children had been in the foster system.

The psychiatrists’ role was to determine how well this documentation supported prescribing the medications, including a review of the screening, assessment, treatment planning and medication monitoring of the children.

In 22 of the 24 cases, the children’s records revealed mostly adequate documentation to justify the use of the medications.

However, among 15 children who might have benefitted from evidence-based therapies, only 3 children mostly received these therapies. An evidence-based therapy is an intervention that has been shown to produce measurable results through research studies. Among the other 12 children, 11 received partial therapy and one received none.

In reviewing the medication monitoring in the two dozen cases, the psychiatrists assessed whether the medication was appropriately dosed for the children and whether the use of multiple medications, where relevant, was adequately justified in their records.

Only in 13 of the 24 cases was the medication dosages mostly supported by the documentation in the records. In the other 11 cases, the dosages were only partly supported.

Among the 20 children who received multiple medications, only five had records with sufficient documentation to explain the need for several medications prescribed at once. One case had no documentation to explain the need for multiple medications, and the other 14 cases had partial documentation to support multiple drugs used at once.

One of these cases, for example, included a child prescribed four different mental health medications at the same time even though other non-medication treatments could have been tried.

Still, Collins said the report’s findings are encouraging because it reveals that states have begun implementing policies to better regulate psychotropic medication prescribing for foster children since the 2011 report.

All five states require foster children to receive medical exams and have policies aimed at providing oversight for psychotropic prescription practices for foster children.

However, the way different states run their Medicaid programs can influence how effective this oversight is. The webinars and technical guidance on this issue provided to states by the federal Department of Health and Human Services do not address third-party that administer medications.

Three of the five states use managed care organizations for medication dispensing, and two of these states have not adequately planned for medication monitoring by the managed care organizations.

The use of third-party organizations is just one of the complicating factors that can make it difficult to address issues surrounding foster children’s mental health care.

“These can be badly damaged children, both emotionally and in terms of their brain chemistry,” Elliott said. “The tools we currently have available too often simply are not up to the task, whether we’re talking medications or other kinds of interventions.”

In addition, the non-medication interventions are often costly and can be difficult to generalize into successful programs for other parts of the country. There is no single answer to what is most appropriate to help children who have had deeply traumatic experiences, Elliott said.

“It depends on the age of the child, the type of trauma, how recently the trauma occurred and who all is involved in the care,” Elliott said. Even the programs that do exist, which tend to be time- and person-intensive, don’t always work and are not universally available, he said.

“It’s easy to grow outraged at the dearth of services and low response rates, but the reality sometimes is that nothing currently available really does much good,” he said. “And, the cost can be high and not necessarily a universally accepted priority.”

To read about a new effort underway to get Congressional action on the issue of medicating foster youth, visit First Focus Campaign for Children. They have submitted a letter, backed by more than 100 organizations, to Congress on the issue. The letter can be found .

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