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Oversight of Psychotropic Prescriptions' which was released on 
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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

December 2011: 

Foster Children: 

HHS Guidance Could Help States Improve Oversight of Psychotropic 
Prescriptions: 

GAO-12-201: 

GAO Highlights: 

Highlights of GAO-12-201, a report to congressional requesters. 

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. Medicaid, which is administered by states and 
overseen by the Department of Health and Human Services (HHS), 
provides prescription drug coverage to foster children. 

For selected states, GAO examined (1) 2008 rates of psychotropic 
prescriptions for foster and nonfoster children and (2) state 
oversight of psychotropic prescriptions for foster children through 
October 2011. GAO selected Florida, Maryland, Massachusetts, Michigan, 
Oregon, and Texas primarily for geographic diversity and size of the 
foster care population, and analyzed state Medicaid fee-for-service 
and foster care data from selected states for 2008. 2008 was the most 
recent year of prescription data available at the start of the audit. 
Maryland’s 2008 foster care data were unreliable and could not be 
analyzed. GAO contracted with expert child psychiatrists to provide a 
clinical perspective on our methodology and analysis, reviewed 
regulations and state policies, and interviewed federal and state 
officials. Results cannot be generalized to other states. 

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. The higher rates do not necessarily indicate 
inappropriate prescribing practices, but 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 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 GAO’s 
experts said have no established use for mental health conditions in 
infants and could result in serious adverse effects. 

Figure: Psychotropic Prescription Rates for Foster and Nonfoster 
Children Age 0-17 in Medicaid Fee-for-Service in Five States: 

[Refer to PDF for image: vertical bar graph] 

Prescribed at least one psychotropic medication: 

State: Florida; 
Foster children: 22%; 
Nonfoster children: 8.2%. 

State: Massachusetts; 
Foster children: 39.1%; 
Nonfoster children: 10.2%. 

State: Michigan; 
Foster children: 21.4%; 
Nonfoster children: 9.2%. 

State: Oregon; 
Foster children: 19.7%; 
Nonfoster children: 4.8%. 

State: Texas; 
Foster children: 32.2%; 
Nonfoster children: 7.1%. 

Source: GAO analysis of state Medicaid and foster care data. 

[End of figure] 

The six selected states’ monitoring programs for psychotropic drugs 
provided to foster children fall short of best principles guidelines 
published by the American Academy of Child and Adolescent Psychiatry 
(AACAP). The guidelines, which states are not required to follow, 
cover four categories. 

* Consent: Each state has some practices consistent with AACAP consent 
guidelines, such as identifying caregivers empowered to give consent. 

* Oversight: Each state has procedures consistent with some but not 
all oversight guidelines, which include monitoring rates of 
prescriptions. 

* Consultation: Five states have implemented some but not all 
guidelines, which include providing consultations by child 
psychiatrists by request. 

* 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. 

What GAO Recommends: 

GAO recommends that HHS consider endorsing guidance for states on best 
practices for overseeing psychotropic prescriptions for foster 
children. HHS agreed with our recommendation. 

View [hyperlink, http://www.gao.gov/products/GAO-12-201]. For more 
information, contact Gregory D. Kutz at (202) 512-6722 or 
kutzg@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Foster Children Have Higher Rates of Psychotropic Drug Prescriptions 
and Indicators of Potential Health Risks: 

Selected States' Psychotropic Drug Monitoring Programs Fall Short of 
AACAP-Best Principles Guidelines: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Uses and Side Effects of Psychotropic Drugs: 

Appendix III: List of Psychotropic Drugs Used in Analysis: 

Appendix IV: Rates of Psychotropic Prescription Usage by Length of 
Time in Medicaid Fee-for-service: 

Appendix V: Additional Data on Children with Prescriptions of at Least 
One Psychotropic Drug: 

Appendix VI: Additional Data on Concomitant Prescriptions: 

Appendix VII: Additional Data on Psychotropic Drug Prescriptions 
Exceeding Maximum Recommended Doses: 

Appendix VIII: Additional Data on Psychotropic Prescriptions to 
Children Under 1 Year Old: 

Appendix IX: Additional Data on Psychotropic Drugs with Gaps in 
Prescriptions of 7 to 29 Days: 

Appendix X: Selected States' Implementation of AACAP's Best Principles 
Guidelines: 

Appendix XI: Comments from the Department of Health and Human Services: 

Appendix XII: Comments from the Florida Agency for Health Care 
Administration: 

Appendix XIII: Comments from the Massachusetts Executive Office of 
Health and Human Services: 

Appendix XIV: Comments from the Oregon Health Authority: 

Appendix XV: Comments from the Texas Health and Human Services 
Commission: 

Appendix XVI: GAO Contact and Staff Acknowledgments

Appendix XVII: Print-Friendly Version of Figure 1, Psychotropic 
Prescription Rates for Children in Five States: 

Appendix XVIII: Print-Friendly Version of Figure 2, Psychotropic Drug 
Potential Health Risk Indicators for Five Selected States: 

Tables: 

Table 1: Psychotropic Drug Classes: 

Table 2: Children Age 0-1 Year Old Prescribed Psychotropic Drugs in 
Five Selected States: 

Table 3: Percentage of Children Age 0-17 Prescribed a Psychotropic 
Drug with Three or More Gaps of 7-29 Days in Drug Claims in Five 
States: 

Table 4: State Consent Laws and Policies Compared with AACAP's Best 
Principles Guidelines: 

Table 5: State Oversight Laws and Policies Compared with AACAP's Best 
Principles Guidelines: 

Table 6: State Consultation Programs Compared with AACAP's Best 
Principles Guidelines: 

Table 7: State Information-sharing Laws and Policies Compared with 
AACAP's Best Principles Guidelines: 

Table 8: Psychotropic Drugs Used in Analysis: 

Table 9: Rates of Psychotropic Prescriptions by Length of Medicaid Fee-
for-service Coverage in Florida during 2008: 

Table 10: Rates of Psychotropic Prescriptions in Florida during 2008 
by Age of Child and Foster Care Status: 

Table 11: Rates of Psychotropic Prescriptions in Massachusetts during 
2008 by Age of Child and Foster Care Status: 

Table 12: Rates of Psychotropic Prescriptions in Michigan during 2008 
by Age of Child and Foster Care Status: 

Table 13: Rates of Psychotropic Prescriptions in Oregon during 2008 by 
Age of Child and Foster Care Status: 

Table 14: Rates of Psychotropic Prescriptions in Texas during 2008 by 
Age of Child and Foster Care Status: 

Table 15: Rates of Concomitant Psychotropic Prescriptions in Florida 
during 2008 by Number of Drugs: 

Table 16: Rates of Concomitant Psychotropic Prescriptions in 
Massachusetts during 2008 by Number of Drugs: 

Table 17: Rates of Concomitant Psychotropic Prescriptions in Michigan 
during 2008 by Number of Drugs: 

Table 18: Rates of Concomitant Psychotropic Prescriptions in Oregon 
during 2008 by Number of Drugs: 

Table 19: Rates of Concomitant Psychotropic Prescriptions in Texas 
during 2008 by Number of Drugs: 

Table 20: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Florida 
during 2008: 

Table 21: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in 
Massachusetts during 2008: 

Table 22: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in 
Michigan during 2008: 

Table 23: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Oregon 
during 2008: 

Table 24: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Texas 
during 2008: 

Table 25: Prescriptions of Psychotropic Drugs to Foster and Nonfoster 
Children Age 0-1 in Five Selected States: 

Table 26: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Florida 
during 2008: 

Table 27: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Florida during 2008: 

Table 28: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in 
Massachusetts during 2008: 

Table 29: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Massachusetts during 2008: 

Table 30: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Michigan 
during 2008: 

Table 31: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Michigan during 2008: 

Table 32: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Oregon 
during 2008: 

Table 33: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Oregon during 2008: 

Table 34: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Texas during 
2008: 

Table 35: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Texas during 2008: 

Table 36: State Consent Laws and Policies Compared with AACAP Best 
Principle Guidelines: 

Table 37: State Oversight Laws and Policies Compared with AACAP's Best 
Principle Guidelines: 

Table 38. State Consultation Programs Compared with AACAP's Best 
Principle Guidelines: 

Table 39. State Information-Sharing Laws and Policies Compared with 
AACAP's Best Principle Guidelines: 

Figures: 

Figure 1: Psychotropic Drug Prescription Rates for Five Selected 
States: 

Figure 2: Psychotropic Drug Potential Health Risk Indicators for Five 
Selected States: 

Abbreviations: 

AACAP: American Academy of Child and Adolescent Psychiatry: 

ACF: Administration for Children and Families: 

ADHD: Attention Deficit Hyperactivity Disorder: 

BPCA: Best Pharmaceuticals for Children Act: 

CFSR: Child and Family Services Review: 

CMS: Centers for Medicare & Medicaid Services: 

CWS: Child Welfare Services: 

DFPS: Texas Department of Family and Protective Services: 

FDA: Food and Drug Administration: 

HHS: Department of Health and Human Services: 

HMO: Health Maintenance Organization: 

MCPAP: Massachusetts Child Psychiatry Access Project: 

MMIS: Medicaid Management Information System: 

MMPP: Maryland Medicaid Pharmacy Program: 

NIMH: National Institute of Mental Health: 

NSCAW: National Survey of Child and Adolescent Well-Being: 

OBRA: Omnibus Budget Reconciliation Act: 

PA: Prior Authorization: 

PREA: Pediatric Research Equity Act: 

SSRI: Selective Serotonin Reuptake Inhibitors: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

December 14, 2011: 

Congressional Requesters: 

Children placed in foster care are among our nation's most vulnerable 
populations. Often having been removed from abusive or neglectful 
homes, they tend to have more numerous and serious medical and mental 
health conditions than do other children.[Footnote 1] Treatment of 
mental illness may include prescribing psychotropic drugs, such as 
antidepressants and antipsychotics. Because foster children are under 
state care, they typically receive prescription drugs and other 
medical services through Medicaid, a joint federal-state program that 
finances health care coverage for certain low-income populations. 
[Footnote 2] 

The use of psychotropic drugs has been shown to effectively treat 
mental disorders, such as attention deficit hyperactivity disorder 
(ADHD), bipolar disorder, depression, and schizophrenia. While many 
psychotropic drugs that have been approved by the Food and Drug 
Administration (FDA) as safe and effective in adults have not been 
similarly approved for children of all ages, prescribing them to 
children is legal and common medical practice in many instances. 
According to the National Institute of Mental Health (NIMH), some 
children with severe mental health conditions would suffer serious 
consequences without such medication.[Footnote 3] However, 
psychotropic drugs can also have serious side effects in adults, 
including irreversible movement disorders, seizures, and an increased 
risk for diabetes over the long term. Further, additional risks these 
drugs pose specifically to children are not well understood.[Footnote 
4] 

States are responsible for running their Medicaid and foster care 
programs, but the programs are administered at the federal level by 
the Department of Health and Human Services (HHS) through the Centers 
for Medicare & Medicaid Services (CMS) and the Administration for 
Children and Families (ACF), respectively. HHS may issue regulations, 
provide guidance on some issues, or simply provide informational 
resources for states to consider for their programs, the latter being 
the case for psychotropic drugs provided to children in state custody. 
Among these resources are best principles developed by the American 
Academy of Child and Adolescent Psychiatry (AACAP), a nonprofit 
professional association. While HHS does not require states to follow 
these guidelines, AACAP developed them as a model to help inform state 
monitoring programs for youth in state custody. AACAP guidelines point 
out that "as a result of several highly publicized cases of 
questionable inappropriate prescribing, treating youth in state 
custody with psychopharmacological agents has come under increasingly 
intense scrutiny," leading to state implementation of consent, 
authorization, and monitoring procedures.[Footnote 5] More recently, 
Congress enacted the Child and Family Services Improvement and 
Innovation Act in September 2011, requiring states that apply for 
certain federal child welfare grants to establish protocols for the 
appropriate use and monitoring of psychotropic drugs prescribed to 
foster children.[Footnote 6] 

You requested that we examine psychotropic drugs prescribed to foster 
children. In this report, for selected states we (1) compared rates of 
psychotropic drug prescriptions for foster children and nonfoster 
children covered by Medicaid in 2008, including indicators of 
potential health risks, and (2) examined federal and state oversight 
policies in effect for psychotropic drugs prescribed to foster 
children through October 2011. Our full scope and methodology is 
provided in appendix I. 

To provide a clinical perspective on our methodology and data 
analysis, we contracted with two child psychiatrists with clinical and 
research expertise in the use of psychotropic drugs in children. Dr. 
Jon McClellan is an attending psychiatrist at the Seattle Children's 
Hospital; a professor at the University of Washington School of 
Medicine; and the medical director at Washington's Child Study and 
Treatment Center, the children's psychiatric hospital for the state of 
Washington. He is board certified in psychiatry and child and 
adolescent psychiatry. Dr. Michael Naylor is an associate professor at 
the University of Illinois at Chicago, School of Medicine, and the 
director of the Behavioral Health and Welfare Program, which was 
formed to address the mental health needs of the most severely 
disturbed children in state care. He directs the Clinical Services in 
Psychopharmacology program, which provides an independent review of 
all psychotropic medication consent requests for foster children in 
Illinois. He is board certified in child and adolescent psychiatry, 
general psychiatry, and sleep disorders medicine. 

To compare rates of psychotropic drug prescriptions in foster children 
and nonfoster children covered by Medicaid, we reviewed calendar year 
2008 fee-for-service prescription claims and foster care data for 
Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas. 
[Footnote 7] At the start of our audit, 2008 data were the most recent 
calendar year prescription claims data available from CMS. These 
states were selected primarily for geographic diversity and the size 
of their foster care populations. However, we then excluded Maryland 
from our analysis due to the unreliability of its foster care data. 
Because the audit was limited to children in these nonrandomly 
selected states, the results cannot be generalized to other states or 
populations. In consultation with our experts, we developed a list of 
psychotropic drugs likely to be prescribed in the six selected states 
by reviewing each state's list of approved drugs, and a list of 
psychotropic drugs published by NIMH. Based on our experts' 
recommendations, we excluded some drugs likely to be for nonmental 
health purposes (such as anticonvulsants) from our overall analysis of 
psychotropic prescription rates, but included them in our analysis of 
concomitant prescriptions--that is, prescriptions for multiple drugs 
to be taken concurrently--and our analysis of gaps in medications. 
[Footnote 8] As such, we are likely understating the percentage of 
children prescribed psychotropic drugs for mental health purposes. See 
appendix III for the listing of psychotropic drugs used in our overall 
analysis. 

To identify prescribed drug regimens that have potential health risk 
indicators, we, among other things, consulted with our experts, 
performed literature searches, and reviewed state guidelines. Based on 
this, our final indicators of potential health risks were: concomitant 
prescriptions of five or more drugs, prescriptions exceeding dosage 
guidelines in the Psychotropic Medication Utilization Parameters for 
Texas Foster Children, and psychotropic prescriptions for children 
under 1 year old. In addition, we evaluated gaps of 7 to 29 days in 
prescriptions of a drug to identify nonadherence to drug regimens, 
which can pose significant risks to a patient. Because prescription 
claims do not include diagnosis data, we were not able to examine the 
clinical indications used to justify psychotropic prescriptions. 
Further, prescribers should weigh the benefits and drawbacks of drug 
regimens on a case-by-case basis. As such, determining the 
appropriateness of prescriptions without patient-level reviews by 
medical experts is impossible. 

To determine federal and state oversight policies in effect for 
prescribing psychotropic drugs to foster children through October 
2011, we interviewed officials from CMS, ACF, and the six selected 
states' Medicaid and foster care agencies. We also reviewed policies, 
statutes, and regulations related to the prescribing of psychotropic 
drugs to foster children. Based on a literature review and discussions 
with officials from HHS, we selected AACAP's guidelines as a basis for 
assessing the extent to which selected states were implementing 
recommended practices. 

We performed this audit from February 2010 through November 2011 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

Foster care begins when a child is removed from his or her parents or 
guardians and placed under the responsibility of a state child welfare 
agency. Removal from the home can occur because of reasons such as 
physical abuse or neglect. It can also occur when a child's own 
behavior or condition is beyond the control of his or her family or 
poses a threat to their community. As we have previously reported, 
children in foster care exhibit more numerous and serious medical 
conditions, including mental health conditions, than do other 
children.[Footnote 9] 

Foster care may be provided by a family member, caregivers previously 
unknown to the child, or a group home or institution. Ideally, foster 
care is an intermediate step towards a permanent family home. When 
reuniting the child with his or her parents or guardian is not in the 
child's best interest, caseworkers seek a new permanent home for the 
child, such as an adoptive home or guardianship. However, some 
children remain in foster care until they reach adulthood. 

Psychotropic drugs affect brain activity associated with mental 
processes and behavior. These drugs are also called psychotherapeutic 
drugs. While psychotropic drugs can have significant benefits for 
those with mental illnesses, they can also have side effects ranging 
from mild to serious. Table 1 highlights the psychotropic drug classes 
studied in this report and provides examples of drugs within those 
classes, as well as conditions treated and possible side effects. 
Specific information about each drug can be found in appendix II. 

Table 1: Psychotropic Drug Classes: 

Drug class: ADHD drugs; 
Examples of drugs: Atomoxetine (Strattera); Lisdexamfetamine 
dimesylate (Vyvanse); Methylphenidate (Ritalin, Concerta); Amphetamine 
(Adderall); Dextroamphetamine (Dexedrine, Dextrostat); 
Types of conditions treated by drug class: Attention deficit 
hyperactivity disorder; 
Examples of possible adverse side effects: Decreased appetite; 
Tics; Psychosis. 

Drug class: Anti-anxiety; 
Examples of drugs: Clonazepam (Klonopin); Lorazepam (Ativan); 
Alprazolam (Xanax); 
Types of conditions treated by drug class: Generalized anxiety 
disorder; Post-traumatic stress disorder; Social phobias; 
Examples of possible adverse side effects: Dependence; Drowsiness and 
dizziness; Blurred vision; Nightmares. 

Drug class: Antidepressants; 
Examples of drugs: Fluoxetine (Prozac); Citalopram (Celexa); 
Sertraline (Zoloft); Paroxetine (Paxil); Escitalopram (Lexapro); 
Venlafaxine (Effexor); Duloxetine (Cymbalta); Bupropion (Wellbutrin); 
Types of conditions treated by drug class: Depression; Generalized 
anxiety disorder; Obsessive-compulsive disorder; Social phobia; 
Examples of possible adverse side effects: Suicidal thoughts; 
Sleeplessness or drowsiness; Agitation; Sexual dysfunction. 

Drug class: Antipsychotics; 
Examples of drugs: Chlorpromazine (Thorazine); Haloperidol (Haldol); 
Risperidone (Risperdal); Olanzapine (Zyprexa); Quetiapine (Seroquel); 
Ziprasidone (Geodon); Aripiprazole (Abilify); 
Types of conditions treated by drug class: Bipolar disorder; 
Schizophrenia; Tourette's syndrome; 
Examples of possible adverse side effects: Rigidity (muscular tension); 
Tremor; Tardive Dyskinesia (uncontrollable movements); Diabetes; 
High cholesterol; Weight gain; Neuroleptic malignant syndrome (a life-
threatening neurological disorder most often caused by an adverse 
reaction to antipsychotic drugs). 

Drug class: Hypnotics; 
Examples of drugs: Quazepam (Doral); Zolpidem (Ambien); Eszopiclone 
(Lunesta); 
Types of conditions treated by drug class: Insomnia; Anxiety; 
Examples of possible adverse side effects: Dependence; Sleep walking. 

Drug class: Mood stabilizers; 
Examples of drugs: Lithium; Divalproex sodium (Depakote); 
Carbamazepine (Tegretol); Lamotrigine (Lamictal); Oxcarbazepine 
(Trileptal); 
Types of conditions treated by drug class: Bipolar disorder; 
Examples of possible adverse side effects: Suicidal thoughts; 
Loss of coordination; Hallucinations; Kidney, thyroid, liver, and 
pancreas damage; Polycystic ovarian syndrome; Weight gain. 

Source: NIMH, NIH, and our experts. 

Note: The drug class categorizations and the corresponding examples of 
medications used in this analysis are intended to capture the common 
uses of psychotropic drugs and were reviewed by our experts. However, 
some of the drugs may have been developed and used for different 
purposes. For example, certain anti-anxiety drugs, such as 
benzodiazepines, may also be prescribed for insomnia. Similarly, some 
medications developed to treat depression, such as selective serotonin 
reuptake inhibitors (SSRIs) and tricyclic antidepressants, may also be 
used to treat anxiety disorders. 

[End of table] 

Foster Children Have Higher Rates of Psychotropic Drug Prescriptions 
and Indicators of Potential Health Risks: 

Foster children in each of the five selected states were prescribed 
psychotropic drugs at higher rates than were nonfoster children in 
Medicaid during 2008.[Footnote 10] These states spent over $375 
million for prescriptions provided through fee-for-service programs to 
foster and nonfoster children.[Footnote 11] 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.[Footnote 12] 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 
information in 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.[Footnote 13] 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. 

Higher Rates of Psychotropic Drug Prescriptions among Foster Children: 

Foster children in Florida, Massachusetts, Michigan, Oregon, and Texas 
were prescribed psychotropic drugs at rates 2.7 to 4.5 times higher 
than were nonfoster children in Medicaid in 2008.[Footnote 14] The 
rates were higher among foster children for each of the age ranges--0 
to 5 years old, 6 to 12 years old, and 13 to 17 years old--that we 
reviewed. See figure 1 for rates by state. Although a higher 
proportion of foster children received psychotropic drug prescriptions 
compared with nonfoster children, the vast majority of children 
receiving psychotropic drug prescriptions in these states were 
nonfoster children because the population of nonfoster children is 
much larger. In addition, according to our experts the higher rates of 
psychotropic drug prescriptions among foster children do not 
necessarily mean that the prescriptions were inappropriate; 
determining so would require, at minimum, a full review of each 
child's medical history.[Footnote 15] Figure 1 shows prescription 
rates for children in each state for various age ranges. See appendix 
V for more information on psychotropic prescriptions to foster and 
nonfoster children in Medicaid. 

Figure 1: Psychotropic Drug Prescription Rates for Five Selected 
States: 

[Refer to PDF for image: interactive graphic] 

Data available in Appendix XVI. 

Source: GAO analysis of state Medicaid and foster care data. 

[End of figure] 

Through our interviews with state and federal officials and our 
experts, and our review of academic studies, we identified several 
factors that may contribute to these higher rates of prescribed 
psychotropic drug regimens. These factors included greater exposure to 
trauma before entering state care, frequent changes in foster 
placements, and varying state oversight policies. However, our 
literature search identified a relatively small number of studies that 
have been conducted to determine to what extent each of these factors 
contributes to higher prescription rates, or whether additional 
factors are involved. 

Greater exposure to trauma. Research and interviews with certain state 
officials suggest that children entering foster care have more 
emotional and behavioral issues than do nonfoster children. For 
example, an analysis of 1996 service claims in one county revealed 
that 57 percent of foster children were diagnosed with a mental 
disorder--nearly 15 times that of nonfoster children receiving 
Medicaid assistance. ADHD, depression, and developmental disorders 
were the most common diagnoses.[Footnote 16] According to the National 
Survey of Child and Adolescent Well-Being (NSCAW), 46 percent of 
children investigated by child welfare services (CWS) primarily came 
to the attention of CWS from a report of neglect, while 27 percent had 
experienced physical abuse as the most serious form of recorded 
maltreatment.[Footnote 17] According to another study based on NSCAW 
data, approximately half of youths aged 2 to 14 years with completed 
child welfare investigations had clinically significant emotional or 
behavioral problems.[Footnote 18] 

State officials and our contracted child psychiatrists stated that 
higher levels of psychotropic drug prescriptions may be appropriate to 
deal with the increased prevalence and greater severity of mental 
health conditions among foster children. Further, Dr. Naylor noted 
that past trauma creates unique treatment challenges for those with 
multiple severe symptoms. In some cases, their symptoms do not clearly 
fit into existing diagnoses, which may cause them to receive multiple 
diagnoses that change with time, foster care placement, and medical 
provider. Dr. Naylor also noted that very little research has been 
done on the use of psychotropic drugs in foster children with severe 
symptoms. This limits the information available to providers on how 
best to treat their conditions.[Footnote 19] 

Frequent changes in foster placements. Foster children who change 
placements often do not have a consistent caretaker to plan treatment, 
offer consent, and provide oversight. As we have previously reported, 
changes in placement pose significant challenges for agencies, foster 
parents, and providers with regard to providing continuity of health 
care services and maintaining uninterrupted information on children's 
medical needs and courses of treatment.[Footnote 20] Several studies 
of the use of psychotropic drugs have also noted that multiple foster 
care placements over short periods prevent an individual familiar with 
the child from coordinating and overseeing his or her long-term 
medical care.[Footnote 21] Children entering foster care may lack 
medical care prior to entry, while children with prior medical care 
may have experienced disruptions in care and have missing or 
incomplete records. (We discuss how each of the six states oversees 
psychotropic drug prescriptions in the next section that discusses 
federal and state oversight of psychotropic drugs prescribed to foster 
children.) 

Varying state oversight policies. States surveyed by the Tufts 
Clinical and Translational Science Institute in 2010 reported on 
several challenges that may affect prescribing patterns for foster 
children. These included a lack of collaboration among state agencies, 
professionals, and organizations responsible for the care of foster 
children; the consent process for foster children, which may require 
the input of multiple individuals or organizations; and the need for 
access to up-to-date guidelines on clinical practices regarding 
psychotropic prescriptions for foster children across stakeholder 
groups, including caregivers, child welfare agencies, schools, and 
prescribers. For example, the study found that 34 of 48 states had not 
implemented a system to identify prescriptions with dosages exceeding 
current maximum recommendations set by the product manufacturer, 
professional or federal standards, or state expert panels.[Footnote 22] 

Higher Rates of Potential Health Risk Indicators among Foster Children: 

In each of the five states analyzed, psychotropic prescription claims 
data for foster children showed higher rates of potential health risk 
indicators than those of nonfoster children in Medicaid. According to 
our experts, the following three prescribing practices carry increased 
levels of risk for children; concomitant prescriptions of five or more 
medications,[Footnote 23] doses exceeding maximum levels in FDA-
approved drug labels, and prescriptions for infants.[Footnote 24] 
Figure 2 provides more information on these indicators by state. 

Figure 2: Psychotropic Drug Potential Health Risk Indicators for Five 
Selected States: 

[Refer to PDF for image: interactive graphic] 

Data available in Appendix XVII. 

Source: GAO analysis of state Medicaid and foster care data. 

[End of figure] 

Concomitant psychotropic drug prescriptions.[Footnote 25] Across the 
five states, the rate of children prescribed five or more psychotropic 
drugs concomitantly ranged from 0.11 to 1.33 percent among foster 
children compared with a lower 0.01 to 0.07 percent rate among 
nonfoster children. This translates to 1,752 children with such 
prescriptions in the five states--609 foster children and 1,143 
nonfoster children. According to our experts, the use of five or more 
drugs at once is a high-risk practice. Our experts also said that no 
evidence supports the use of five or more psychotropic drugs in adults 
or children, and only limited evidence supports the use of even two 
drugs concomitantly in children. Increasing the number of drugs used 
concurrently increases the likelihood of adverse reactions and long-
term side effects, such as high cholesterol or diabetes, and limits 
the ability to assess which of multiple drugs are related to a 
particular treatment goal.[Footnote 26] See appendix VI for more 
information on concomitant prescription rates. 

Doses Exceeding Maximum Levels in FDA-Approved Drug Labels. The rate 
of children prescribed medications exceeding maximum doses for the 
child's age as cited in the Texas Utilization Parameters, based on 
information in FDA-approved drug labels for the child's age ranged 
from 1.12 to 3.27 percent among foster children compared with a lower 
0.16 to 0.56 percent rate among nonfoster children[Footnote 27]. A 
total of 20,965 children in the five states had such a prescription--
2,165 foster children and 18,800 nonfoster children. Of children 
prescribed drugs for which there was no FDA-recommended dose for their 
age, 0.34 to 1.52 percent of foster children and 0.05 to 0.16 percent 
of nonfoster children were prescribed dosages that exceeded the 
maximum standards published in the medical literature. According to 
our experts, taking drugs at dosages exceeding levels recommended by 
the FDA and medical literature increases the potential for adverse 
side effects. Although there may be cases in which such doses are 
clinically justified, in general, there is a lack of research 
demonstrating that high dosages are more effective. In addition, our 
experts said that for some drugs, a higher dose may be less effective 
than the more moderate recommended dos[Footnote 28]e. See appendix VII 
for information on rates of prescriptions above maximum doses for the 
child's age as cited in the Texas Utilization Parameters. 

Psychotropic prescriptions for infants. The rate of children under 1 
year old prescribed a psychotropic drug ranged from 0.3 to 2.1 percent 
among foster children compared with a lower 0.1 to 1.2 percent rate 
among nonfoster children. This translates to 76 foster children and 
3,765 nonfoster children under 1 year old in the five states--a total 
of 5,265 prescriptions.[Footnote 29] Our experts said that there are 
no established mental health indications for the use of psychotropic 
drugs in infants, and providing them these drugs could result in 
serious adverse effects. According to our data, fewer than 10 infants 
in foster care and 22 nonfoster infants were prescribed clonidine--
with dosages generally used in older children--which one of our 
experts said could result in significant sedation and potential 
cardiac problems including, on rare occasions, sudden death. Fewer 
than 10 infants in foster care were prescribed an antidepressant or an 
antipsychotic, compared with 44 and 12 infants not in foster care, 
respectively. According to our experts, antidepressants and 
antipsychotics have significant potential side effects, including 
cardiovascular and metabolic problems. Anti-anxiety drugs such as 
antihistamines and benzodiazepines accounted for the vast majority of 
the prescriptions for infants. Our experts noted that these drugs 
could have been prescribed for nonmental health conditions.[Footnote 
30] For example, the antihistamines could be prescribed to treat 
allergies, itching, and skin conditions such as eczema, the 
benzodiazepines for seizures or as sedation for a medical procedure. 
While physicians may use their discretion to prescribe these drugs to 
infants, these nonmental health uses still carry the same risk of 
adverse effects, including, for antihistamines, diminished mental 
alertness and excitation in young children. According to our experts, 
because infants are at a stage in their development where they are 
potentially more vulnerable to the effect of psychotropic drugs, these 
cases raise significant concerns and warrant further review. See table 
2 and appendix VIII for more information. 

Table 2: Children Age 0-1 Year Old Prescribed Psychotropic Drugs in 
Five Selected States: 

Drug category (subclass): Anti-anxiety (antihistamines)[A]; 
Foster children: 55; 
Nonfoster children: 3,454. 

Drug category (subclass): Anti-anxiety (benzodiazepines); 
Foster children: 17; 
Nonfoster children: 254. 

Drug category (subclass): Other anti-anxiety drugs; 
Foster children: 0; 
Nonfoster children: less than 10. 

Drug category (subclass): ADHD drugs; 
Foster children: less than 10; 
Nonfoster children: 37. 

Drug category (subclass): Antidepressants; 
Foster children: less than 10; 
Nonfoster children: 44. 

Drug category (subclass): Antipsychotics; 
Foster children: less than 10; 
Nonfoster children: 12. 

Drug category (subclass): Hypnotic; 
Foster children: 0; 
Nonfoster children: less than 10. 

Drug category (subclass): Mood stabilizer; 
Foster children: 0; 
Nonfoster children: less than 10. 

Source: GAO analysis of state Medicaid and foster care data. 

Note: A total of 76 foster children and 3,765 nonfoster children, or 
3,841 children age 0 to 1, were prescribed a psychotropic drug. The 
totals in the table above do not add up to 3,841 because some infants 
were prescribed more than one psychotropic drug. 

[A] Of children prescribed antihistamines, 26 foster children and 
2,169 nonfoster children had prescriptions covering fewer than 20 
days. According to one of our experts, this more likely represents a 
nonmental health use, such as for allergies or rashes. 

[End of table] 

Claims data also raise concerns about patient adherence to prescribed 
drug regimens, which our experts noted as a patient safety matter. 
Although foster children as a group were 1.7 to 3.3 times more likely 
to have three or more gaps of 7 to 29 days between prescriptions than 
nonfoster children, this is likely related to their overall higher 
rates of psychotropic prescriptions. When comparing only those 
prescribed psychotropic drugs, nonfoster children were 1.2 to 2.0 
times more likely to have three or more gaps than foster children, 
suggesting that adherence is higher among foster children. Frequent 
gaps of 7 or more days in prescription claims have a number of 
potential causes, including a parent or caretaker's failure to fill 
prescriptions on behalf of a child in a timely manner or a lack of 
consistent access to care.[Footnote 31] Gaps in drug claims do not 
indicate that the drugs as prescribed have potential health risks. 
However, nonadherence to drug regimens can pose significant risks to a 
patient, such as reduced efficacy from undertreatment, rebound of 
symptoms, and withdrawal symptoms. For example, the sudden 
discontinuation of benzodiazepines such as alprazolam can cause 
seizures[Footnote 32] and the sudden discontinuation of SSRIs[Footnote 
33] such as paroxetine can cause a variety of problems, including 
dizziness, headaches, fatigue, and nausea.[Footnote 34] Nonadherence 
to a drug regimen can cause the drug to appear ineffective even though 
it was not taken for a full trial. For example, antidepressants 
generally take 3 to 6 weeks to have a beneficial effect on the 
patient's symptoms.[Footnote 35] Failure to take the antidepressant 
medications for a sufficient length of time may be interpreted as a 
lack of response to the treatment, which can result in the premature 
switch to or addition of other drugs. Table 3 and appendix IX provide 
more information on gaps in prescriptions for foster and nonfoster 
children by state. 

Table 3: Percentage of Children Age 0-17 Prescribed a Psychotropic 
Drug with Three or More Gaps of 7-29 Days in Drug Claims in Five 
States: 

State: Florida; 
Percent of children who had three or more gaps in drug claims: 
Foster children: 1.8; 
Nonfoster children: 1.1; 
Percent of children prescribed a psychotropic drug who had three or 
more gaps in drug claims[A]: 
Foster children: 7.8; 
Nonfoster children: 12.1. 

State: Massachusetts; 
Percent of children who had three or more gaps in drug claims: 
Foster children: 3.4; 
Nonfoster children: 1.8; 
Percent of children prescribed a psychotropic drug who had three or 
more gaps in drug claims[A]: 
Foster children: 8.4; 
Nonfoster children: 16.4. 

State: Michigan; 
Percent of children who had three or more gaps in drug claims: 
Foster children: 1.7; 
Nonfoster children: 0.9; 
Percent of children prescribed a psychotropic drug who had three or 
more gaps in drug claims[A]: 
Foster children: 7.9; 
Nonfoster children: 11.3. 

State: Oregon; 
Percent of children who had three or more gaps in drug claims: 
Foster children: 1.6; 
Nonfoster children: 0.5; 
Percent of children prescribed a psychotropic drug who had three or 
more gaps in drug claims[A]: 
Foster children: 7.7; 
Nonfoster children: 9.5. 

State: Texas; 
Percent of children who had three or more gaps in drug claims: 
Foster children: 2.2; 
Nonfoster children: 0.7; 
Percent of children prescribed a psychotropic drug who had three or 
more gaps in drug claims[A]: 
Foster children: 6.6; 
Nonfoster children: 8.6. 

Source: GAO analysis of Medicaid and foster care data for Florida, 
Massachusetts, Michigan, Oregon, and Texas. 

[A] Since we used both primary and secondary lists in our gaps 
analysis, the number of foster and nonfoster children prescribed a 
psychotropic drug is slightly higher than reported in our overall 
prescription rates, which were based on primary drugs only. 

[End of table] 

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. Though states 
are not required to follow these guidelines, the six states we 
examined developed monitoring programs that satisfied some of AACAP's 
best principles guidelines to varying degrees. Such variation is 
expected because 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.[Footnote 36] 

HHS has provided limited guidance to the states on how to improve 
their control measures to monitor psychotropic drug prescriptions to 
foster children. Without formally endorsing specific oversight 
measures for states to implement, HHS conducts state reviews and 
provides other online resources, including the AACAP guidelines, to 
help states improve their programs. ACF performs child and family 
services reviews of states to ensure conformity with federal child 
welfare requirements--which include provisions for safety, permanency, 
and family and child well-being--and to assist states as they enhance 
their capacity to help families achieve positive outcomes.[Footnote 
37] These reviews included the examination of a limited number of 
children's case files, in part to determine whether the state foster 
care agency conducted assessments of children's mental health needs 
and provided appropriate services to address those needs. However, 
these reviews are not designed to identify specific potential health 
risk indicators related to psychotropic medications, and since they 
occur every 2 to 5 years, states cannot rely on these reviews to 
actively monitor prescriptions. In addition, ACF operates technical 
assistance centers and provides online resources such as links to 
state guidance on psychotropic drug oversight, academic studies on 
psychotropic drugs, and recordings of teleconferences related to the 
oversight of psychotropic drugs.[Footnote 38] While HHS makes a 
variety of resources available to states developing oversight programs 
for psychotropic drugs, it has not endorsed any specific guidance. In 
the absence of HHS-endorsed guidance, states have developed varied 
oversight programs that in some cases fall short of AACAP's 
recommended guidelines. 

The AACAP guidelines are arranged into four categories, including 
consent, oversight, consultation, and information sharing, that 
contain practices defined as minimal, recommended, or ideal. The 
following describes the extent to which the selected states' 
monitoring programs cover these areas. See appendix X for the full 
text of the AACAP guidelines and additional information on the 
selected states' practices consistent with these guidelines. 

Consent: According to interviews and documentation provided by state 
Medicaid and foster care officials, all six selected states have 
implemented some practices consistent with AACAP guidelines for 
consent procedures, though in varying scope and application. According 
to AACAP, the consent process should be documented and monitored to 
ensure that caregivers are aware of relevant information, such as the 
child's diagnosis, expected benefits and risks of treatments, common 
side effects, and potentially severe adverse events. Thus, states that 
do not incorporate consent procedures similar to AACAP's guidelines 
may increase the likelihood that caregivers are not fully aware of the 
risks and benefits associated with the decision to medicate with 
psychotropic drugs, and may limit the caregiver's ability to 
accurately assess and monitor the foster child's reaction to the 
drugs. Table 4 lists AACAP's guidelines relative to consent and 
illustrates the extent to which states have implemented those 
guidelines. 

Table 4: State Consent Laws and Policies Compared with AACAP's Best 
Principles Guidelines: 
Guideline: Minimal; 
Identify the parties empowered to consent for psychotropic drug 
treatment for youth in state custody in a timely fashion; 
Florida: Fully implemented; 
Maryland: Fully implemented; 
Massachusetts: Fully implemented; 
Michigan: Fully implemented; 
Oregon: Fully implemented; 
Texas: Fully implemented. 

Guideline: Minimal; 
Establish a mechanism to obtain assent for psychotropic medication 
management from minors when possible; 
Florida: Fully implemented; 
Maryland: Fully implemented; 
Massachusetts: Not implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Guideline: Recommended; 
Obtain simply written psycho-educational materials and medication 
information sheets to facilitate the consent process; 
Florida: Fully implemented; 
Maryland: Partially implemented; 
Massachusetts: Fully implemented; 
Michigan: Not implemented; 
Oregon: Fully implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Establish training requirements for child welfare, court personnel 
and/or foster parents to help them become more effective advocates for 
children in their custody[A]; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Partially implemented; 
Michigan: Not implemented; 
Oregon: Partially implemented; 
Texas: Fully implemented. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and Foster Care officials, and the AACAP's best principles 
guideline. 

[A] AACAP Best Principles Guideline states this training should 
include the names and indications for use of commonly prescribed 
psychotropic medications, monitoring for medication effectiveness and 
side effects, and maintaining medication logs. Materials for this 
training should include a written "Guide to Psychotropic Medications" 
that includes many of the basic guidelines reviewed in the 
psychotropic medication training curriculum. 

[End of table] 

Florida and Michigan provide examples of how states vary in their 
approach to monitoring consent procedures used for psychotropic drugs 
prescribed to foster children. For example, Florida requires all 
prescribers to obtain a standardized written consent form from the 
parental or legal guardian, or a court order, before a psychotropic 
drug is administered. The consent form includes the diagnosis, dosage, 
target symptoms, drug risks and benefits, drug monitoring plan, 
alternative treatment options, and discussions about the treatment 
between the child and the parent or legal guardian. Florida law 
identifies who is authorized to give consent, and obtains assent for 
psychotropic drug management from minors when age and developmentally 
appropriate. Florida provides required training to caseworkers, but 
the names and indications for use of commonly prescribed psychotropic 
drugs are not included. 

In contrast, Michigan has policies identifying who is authorized to 
give consent to foster children, but does not use a standardized 
consent form that can be used to help inform consent decisions. 
Instead, Michigan requires that caseworkers maintain in their files 
the consent forms used by individual prescribers, which likely vary in 
content and may thus vary in helpfulness to consent-givers. Moreover, 
Michigan does not have training requirements in place to help 
caseworkers, court personnel, and foster parents become more effective 
advocates for children in their custody. Training for caseworkers is 
optional, but according to an agency official, the training was 
unavailable because no trainer had been hired as of September 2011. 
Michigan does not have policies for obtaining assent from minors when 
possible, thus meeting only one of AACAP's guidelines for consent 
procedures. 

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. 
[Footnote 39] According to one study, states that implement standards 
to improve oversight of the use of psychotropic drugs may create 
enhanced continuity of care, increased placement stability, reduced 
need for psychiatric hospitalization, and decreased incidence of 
adverse drug reactions.[Footnote 40] As such, states that do not 
incorporate oversight procedures similar to AACAP's recommendations 
limit their ability to identify the extent to which potentially risky 
prescribing is occurring in the foster care population. Table 5 lists 
AACAP's guidelines relative to oversight and illustrates the extent to 
which selected states have implemented those guidelines. 

Table 5: State Oversight Laws and Policies Compared with AACAP's Best 
Principles Guidelines: 

Guideline: Minimal; 
Establish guidelines for the use of psychotropic medications for 
children in state custody; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Partially implemented; 
Michigan: Fully implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Oversight program includes an advisory committee to oversee a 
medication formulary and provide medication monitoring guidelines to 
practitioners who treat children in the child welfare system[A]; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Not implemented; 
Michigan: Partially implemented; 
Oregon: Not implemented; 
Texas: Partially implemented. 

Guideline: Ideal; 
Oversight program monitors the rate and types of psychotropic 
medication usage and the rate of adverse reactions among youth in 
state custody; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Partially implemented; 
Michigan: Partially implemented; 
Oregon: Partially implemented; 
Texas: Partially implemented. 

Guideline: Ideal; 
Oversight program establishes a process to review non-standard, 
unusual, and/or experimental psychiatric interventions with children 
who are in state custody; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Partially implemented; 
Michigan: Fully implemented; 
Oregon: Partially implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Oversight program collects and analyzes data and makes quarterly 
reports to the state or county child welfare agency regarding the 
rates and types of psychotropic medication use. Make this data 
available to clinicians in the state to improve the quality of care 
provided; 
Florida: Partially implemented; 
Maryland: Partially implemented; 
Massachusetts: Partially implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Maintain an ongoing record of diagnoses, height and weight, allergies, 
medical history, ongoing medical problem list, psychotropic 
medications, and adverse medication reactions that are easily 
available to treating clinicians 24 hours a day; 
Florida: Partially implemented; 
Maryland: Fully implemented; 
Massachusetts: Partially implemented; 
Michigan: Fully implemented; 
Oregon: Partially implemented; 
Texas: Partially implemented. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and Foster Care officials, and the AACAP's best principles guideline. 

[A] AACAP describes advisory committees as composed of agency and 
community child and adolescent psychiatrists, pediatricians, other 
mental health providers, consulting clinical pharmacists, family 
advocates or parents, and state child advocates.  

[End of table] 

Texas and Maryland provide examples of how states vary in their 
approach to oversight of psychotropic drug use among foster children. 
For example, the Texas Department of Family and Protective Services 
(DFPS) and the University of Texas at Austin College of Pharmacy 
assembled an advisory committee that included child and adolescent 
psychiatrists, psychologists, pediatricians, and other mental health 
professionals to develop psychotropic drug use parameters for foster 
children. These parameters are used to help identify cases requiring 
additional review. Factors that trigger additional reviews include 
dosages exceeding usual recommended levels, prescriptions for children 
of very young age, concomitant use of five or more psychotropic drugs, 
and prescriptions by a primary care provider lacking specialized 
training.[Footnote 41] According to the Texas foster care agency's 
data analysis, after Texas released these guidelines in 2005, 
psychotropic drug use among Texas foster care children declined from 
almost 30 percent in fiscal year 2004 to less than 21 percent in 
fiscal year 2010. Texas also analyzes Medicaid claims data to monitor 
psychotropic drug prescriptions for foster children and to identify 
any unusual prescribing behaviors. Texas provides quarterly reports to 
child welfare officials on the use of psychotropic drugs among foster 
children and treating clinicians have access to a child's medical 
records on a 24-hour basis. However, the electronic health record 
system does not always capture the child's height, weight, and 
allergies, which is optional for prescribers to enter into the system. 
This information is helpful as a child's weight may be used to 
determine the recommended dose for some medications, while allergy 
information may be used to determine whether a child should take a 
particular medication. In addition, ongoing medical problems are not 
recorded in the electronic health record system and Texas does not 
measure the rate of adverse reactions at the macro level among youth 
in state custody. 

Maryland fully applies only one of the six AACAP guidelines for 
oversight procedures and partially applies others. Maryland provides 
foster children in out-of-home placement with a "medical passport" 
that serves as a record of the child's previous and current medical 
file. Each topic included in AACAP's guidelines for maintaining 
ongoing medical records, including diagnoses, allergies, and medical 
history, is documented in the passport, and an additional copy of the 
passport is kept in the child's case record and maintained 
electronically. However, Maryland has not produced any specific 
guidelines for the use of all psychotropic prescriptions among foster 
children, thus limiting the state's ability to identify potentially 
risky prescribing practices for the foster child population.[Footnote 
42] Without guidelines for psychotropic drugs, there are no criteria 
to help agency officials monitor the appropriateness of prescriptions. 
Moreover, Maryland does not review Medicaid claims data statewide 
specifically for foster children, and therefore does not produce 
quarterly reports to identify the rate and types of drugs used in the 
foster care population that could help identify and monitor 
prescribing trends. In addition, as stated earlier, Maryland's 2008 
foster care data were found unreliable. Maryland officials told us 
that transitioning to a new records system in 2007 resulted in 
incorrect and missing data for foster children. 

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. States that do not have a 
consultation program to help link consent-givers and prescribers with 
child and adolescent psychiatrists may reduce the extent to which 
prescribers and consent-givers are informed about the expected 
benefits and risks of treatments, alternative treatments, and the 
risks associated with no treatment. Table 6 lists the AACAP guidelines 
relative to consultation programs and illustrates the extent to which 
selected states have implemented those guidelines. 

Table 6: State Consultation Programs Compared with AACAP's Best 
Principles Guidelines: 

Guideline: Recommended; 
Design a consultation program administered by child and adolescent 
psychiatrists. This program provides consultation by child and 
adolescent psychiatrists to the persons or agency that is responsible 
for consenting for treatment with psychotropic medications; 
Florida: Fully implemented; 
Maryland: Not implemented; 
Massachusetts: Partially implemented; 
Michigan: Not implemented; 
Oregon: Partially implemented; 
Texas: Partially implemented. 

Guideline: Recommended; 
The consultation program provides consultations by child and 
adolescent psychiatrists to, and at the request of, physicians 
treating this difficult patient population; 
Florida: Fully implemented; 
Maryland: Partially implemented; 
Massachusetts: Fully implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Not implemented. 

Guideline: Recommended; 
The consultation program conducts face-to-face evaluations of youth by 
child and adolescent psychiatrists at the request of the child welfare 
agency, the juvenile court, or other state or county agencies 
empowered by law to consent for treatment with psychotropic 
medications when concerns have been raised about the pharmacological 
regimen; 
Florida: Not implemented; 
Maryland: Not implemented; 
Massachusetts: Fully implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and Foster Care officials, and the AACAP's best principles guideline. 

[End of table] 

Massachusetts and Oregon provide examples of how states vary their 
approach in providing expert consultations to caregivers. For example, 
Massachusetts' foster care agency started an initiative to connect 
child welfare staff to Medicaid pharmacists who can provide 
information on medications and the foster child's drug history, 
including interactions between any current and proposed drugs. In 
addition, primary care physicians who treat children, including foster 
care children, also have access to the state-funded Massachusetts 
Child Psychiatry Access Project, a system of regional children's 
mental health consultation teams designed to help pediatricians find 
and consult with child psychiatrists. Massachusetts has six child 
psychiatrists who are available to provide consultations on a part-
time basis to child welfare staff, but these consultations are not 
available for other consent-givers such as foster parents. The foster 
care agency's consultation program also provides face-to-face 
evaluations of foster children at the request of consent-givers 
concerned about a child's treatment. 

In early 2009, Oregon put a consultation program in place to help 
consent-givers make informed decisions. In 2010, Oregon's foster care 
agency shifted the responsibility for all consent decisions where the 
agency has legal custody or is the legal guardian of the child from 
foster parents to child welfare agency officials, who now have access 
to a child and adolescent psychiatrist and can seek consultations 
before making consent decisions. However, the consultation program 
does not conduct face-to-face evaluations of children--by a child and 
adolescent psychiatrist--at the request of consent-givers, nor does it 
enable prescribing physicians to consult with child and adolescent 
psychiatrists. Oregon has plans for the development of the Oregon 
Psychiatric Access Line for Kids, which would allow primary care 
physicians and nurse practitioners to consult with child 
psychiatrists, but agency officials told us the program is not 
operational due to a lack of funding. 

Information sharing: Four of the six selected states have created 
websites with information on psychotropic drugs for clinicians, foster 
parents, and other caregivers. Access to comprehensive information 
could help ensure that clinicians, foster parents, and other 
interested parties are fully informed about the use and management of 
psychotropic drugs. Table 7 lists AACAP's guidelines relative to 
information sharing and illustrates the extent to which selected 
states have implemented those guidelines. 

Table 7: State Information-sharing Laws and Policies Compared with 
AACAP's Best Principles Guidelines: 

Guideline: Ideal; 
Create a website to provide ready access for clinicians, foster 
parents, and other caregivers to pertinent policies and procedures 
governing psychotropic medication management; 
Florida: Fully implemented; 
Maryland: Not implemented; 
Massachusetts: Fully implemented; 
Michigan: Not implemented; 
Oregon: Fully implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Website includes psycho-educational materials; 
Florida: Fully implemented; 
Maryland: Not implemented; 
Massachusetts: Fully implemented; 
Michigan: Not implemented; 
Oregon: Fully implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Website includes consent forms; 
Florida: Fully implemented; 
Maryland: Not implemented; 
Massachusetts: Not implemented; 
Michigan: Not implemented; 
Oregon: Fully implemented; 
Texas: Not implemented. 

Guideline: Ideal; 
Website includes adverse effect rating forms; 
Florida: Not implemented; 
Maryland: Not implemented; 
Massachusetts: Not implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Not implemented. 

Guideline: Ideal; 
Website includes reports on prescription patterns for psychotropic 
medications; 
Florida: Not implemented; 
Maryland: Not implemented; 
Massachusetts: Not implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Guideline: Ideal; 
Website includes links to helpful, accurate, and ethical websites 
about child and adolescent psychiatric diagnoses and psychotropic 
medications; 
Florida: Fully implemented; 
Maryland: Not implemented; 
Massachusetts: Not implemented; 
Michigan: Not implemented; 
Oregon: Not implemented; 
Texas: Fully implemented. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and Foster Care officials, and the AACAP's best principles guideline. 

[End of table] 

For example, Florida's foster care agency has partnered with the 
University of South Florida to implement Florida's Center for the 
Advancement of Child Welfare Practice to provide needed information 
and support to Florida's professional child welfare 
stakeholders.[Footnote 43] The program's website is consistent with 
four of AACAP's six guidelines for information sharing. For example, 
the website includes policies and procedures governing psychotropic 
drug management, staff publications and educational materials about 
psychotropic drugs, consent forms, and links to other informative 
publications and news stories related to foster children and 
psychotropic drugs. However, the website does not provide reports on 
prescription patterns for psychotropic drugs or adverse effect rating 
forms. 

In comparison, Oregon's foster care agency developed a website that 
includes information regarding psychotropic medication, but the 
website is not updated regularly to operate as an ongoing information 
resource. The website currently has information on state policies and 
procedures governing the use of psychotropic drugs and also contains 
web links to consent forms and a medication chart that can be used as 
a psychotropic medication reference tool. However, the website does 
not meet three of the six information-sharing guidelines, including 
those on posting adverse effect rating forms, reporting prescription 
patterns, and providing links to other informative websites. States 
with less accessibility to comprehensive information may limit the 
extent to which physicians, foster parents, and other interested 
parties are informed about the use and management of psychotropic 
drugs. 

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. While 
doctors are permitted to prescribe these drugs under current laws, 
increasing the number of drugs used concurrently and exceeding the 
maximum recommended dosages for certain psychotropic drugs have been 
shown to increase the risk of adverse side effects in adults. 
Psychotropic prescriptions for infants are also of concern, due to the 
potential for serious adverse effects even when these drugs are used 
for nonmental health purposes. Comprehensive oversight programs would 
help states identify these and other potential health risks and 
provide caregivers and prescribers with the information necessary to 
weigh drug risks and benefits. The recently enacted Child and Family 
Services Improvement and Innovation Act requires states that apply for 
certain child welfare grants to establish protocols for monitoring 
psychotropic drugs prescribed to foster children. Under the act, each 
state is authorized to develop its own monitoring protocols, but HHS-
endorsed, nationwide guidelines for consent, oversight, consultation, 
and information sharing could help states close the oversight gaps we 
identified and increase protections for this vulnerable population. 

Recommendation for Executive Action: 

To improve the comprehensiveness of oversight of psychotropic drugs 
prescribed to foster children, we recommend 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 and Our Evaluation: 

We provided a draft copy of this report to HHS and the state foster 
care and Medicaid agencies of the six selected states for their 
review. Letters with comments from HHS, the Florida Agency for Health 
Care Administration, the Massachusetts Executive Office of Health and 
Human Services, the Oregon Health Authority, and the Texas Health and 
Human Services Commission are reprinted and discussed in further 
detail, when applicable, in appendices XI through XV. We also received 
e-mails with comments from officials from Florida Department of 
Children and Families (DCF), Maryland Department of Human Resources 
(DHR), and Michigan Department of Community Health (DCH), which we 
describe below. HHS and certain states also provided technical 
comments, which we incorporated as appropriate. 

HHS agreed with our recommendation and stated that ACF will issue 
guidance to the states on best practices for monitoring psychotropic 
drug prescriptions for foster children. In addition, ACF will 
disseminate to states the current best practices for use in developing 
their approaches and protocols. We strongly support these steps and 
encourage HHS to follow through on these actions. The comment letters 
from the states generally provided clarifications or further 
information on specific aspects of each state program, which we 
incorporated, as appropriate. 

In an e-mail response from the Chief of Quality Assurance, the Florida 
DCF, which administers the state's foster care program, stated that 
our report appeared factually correct based on the data sources. 
Florida DCF stated that our statement that thousands of foster and 
nonfoster infants were prescribed psychotropic medications seemed 
inflammatory, given that the number of infants in foster care 
represented was less than 100 and the report is focused on foster 
children. Florida DCF also noted that the state has very few cases of 
foster children under 1 year old prescribed a psychotropic drug, and 
stated that they had confirmed that all but one had a documented 
medical reason for the prescription. We continue to believe that the 
inclusion of both foster and nonfoster children in our total is 
appropriate, given the serious adverse effects these drugs may have in 
infants. We did not review case records for these children as part of 
this review, and thus cannot conclude whether there is a medical 
justification for these prescriptions. 

In an e-mail response from the deputy executive director of operations 
of the Maryland DHR, the agency stated that it regretted that its 
foster care data had not been usable for this report. Maryland DHR 
stated that it engaged in data cleanup and improvement following the 
2007 launch of its new information system. The agency also stated that 
it would be helpful to Maryland, and perhaps other states, to make use 
of our methodology and tools for further analysis. Maryland DHR would 
like to make use of our analysis tools for its 2010 or 2011 foster 
care data, which Maryland stated have much higher accuracy than the 
data available in 2008. The agency agreed with the need to have 
comprehensive oversight programs and established protocols for 
monitoring psychotropic drugs prescribed to foster children, but the 
costs of implementing oversight mechanisms must be supported in order 
for these new guidelines to be effective. We would be willing to share 
our methodology with Maryland and any other state to help them improve 
the monitoring of children using psychotropic medications. We also 
agree that additional oversight mechanisms may require additional 
resources to be effective. 

In an e-mail response from the director of the office of audit, 
Michigan DCH agreed with the recommendation and anticipated additional 
federal resources to be able to comply with future requirements. 

We are sending copies of this report to the Secretary of Health and 
Human Services, cognizant state agencies, and interested congressional 
committees. In addition, this report is also available at no charge on 
the GAO website at [hyperlink, http://www.gao.gov]. If you have any 
questions: 

concerning this report, please contact Gregory D. Kutz at (202) 512-
6722 or kutzg@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Key contributors to this report are listed in appendix XVI. 

Signed by: 

Gregory D. Kutz: 
Director: 
Forensic Audits and Investigative Service: 

List of Requesters: 

The Honorable Thomas R. Carper:
Chairman:
Subcommittee on Federal Financial Management, Government Information, 
Federal Services, and International Security: 
Committee on Homeland Security and Governmental Affairs:
United States Senate: 

The Honorable Susan M. Collins:
Ranking Member:
Committee on Homeland Security and Governmental Affairs:
United States Senate: 

The Honorable Scott P. Brown:
Ranking Member:
Subcommittee on Federal Financial Management, Government Information, 
Federal Services, and International Security:
Committee on Homeland Security and Governmental Affairs:
United States Senate: 

The Honorable Charles E. Grassley:
Ranking Member:
Committee on the Judiciary:
United States Senate: 

The Honorable John McCain:
United States Senate: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

Our objectives were to: (1) compare rates of psychotropic drug 
prescriptions in foster children and nonfoster children covered by 
Medicaid in 2008, including indicators of potential health risks, and 
(2) examine federal and state oversight policies in effect for 
psychotropic drugs prescribed to foster children through October 2011. 

To determine the rate of psychotropic drug prescriptions to foster and 
nonfoster children enrolled in Medicaid, we obtained Medicaid 
Statistical Information System (MSIS) claims data for prescriptions 
adjudicated between January 1 and December 31, 2008, for six selected 
states--Florida, Maryland, Massachusetts, Michigan, Oregon, and Texas. 
[Footnote 44] At the start of our audit, 2008 data were the most 
recent calendar year prescription claims data available from Centers 
for Medicare & Medicaid Services (CMS). We selected these states based 
on the following factors: (1) existence of a fee-for-service 
prescription or carve-out program reporting psychotropic drug 
prescription data to CMS,[Footnote 45] (2) geographic diversity, and 
(3) state foster care program size. The audit was limited to data on 
children in a Medicaid fee-for-service prescription or carve-out 
program for psychotropic drugs and may not generalize to other states 
or populations. 

We obtained data on persons enrolled in Medicaid and/or receiving 
Medicaid services during calendar year 2008, and children in foster 
care during calendar year 2008, from the respective agencies in each 
of the six selected states. We identified psychotropic prescription 
claims for foster children and nonfoster children by matching the MSIS 
claims data with the Medicaid and foster care files and using national 
drug code information in the Medicaid data. For the purpose of our 
analysis, we defined foster children as any child under age 18 as of 
July 1, 2008, and in foster care for a period of 30 or more 
consecutive days during calendar year 2008, and excluded children in 
foster care less than 30 days during 2008 from our analysis. We 
included only claims filled while the child was in foster care. We 
defined nonfoster children as any child under age 18 as of July 1, 
2008, not in foster care at any time during calendar year 2008. Due to 
a small percentage of missing or incorrect identifiers in the foster 
care data, some children from the Medicaid files could not be 
correctly matched to foster care records. The result is an 
underestimate of the number of foster children and an overestimate of 
nonfoster children. 

We developed a list of psychotropic drugs likely to be prescribed in 
the six selected states by reviewing each state's list of approved 
drugs, and a list of psychotropic drugs published by the National 
Institute of Mental Health (NIMH).[Footnote 46] We verified the active 
ingredient for each drug in databases published by the Food and Drug 
Administration (FDA) or Thomson Reuters. The list was then reviewed by 
our two contracted child psychiatrists with clinical and research 
experience in the prescription of psychotropic drugs to children. 
Based on their recommendations, we developed a primary list of 
psychotropic drugs comprised of attention deficit hyperactivity 
disorder (ADHD) drugs, antidepressants, certain anti-anxiety drugs, 
antipsychotics, combination drugs, hypnotics, and mood stabilizers for 
our analysis of prescription rates of at least one psychotropic 
medication, and dosages exceeding FDA maximum recommended therapeutic 
doses. We counted a prescription for any primary drug in our analysis 
of prescription rates; we did not require that the prescription cover 
a minimum number of days.[Footnote 47] We also developed a secondary 
list of drugs--anticonvulsants, antiparkinson drugs, anti-enuretics, 
sleep aids, and certain anti-anxiety drugs--for our analysis of 
concomitant prescriptions. When paired with a primary psychotropic 
drug, these medications counted toward the total number of drugs 
prescribed concomitantly. When used alone or in combination with other 
secondary medications, they did not count as concomitant 
prescriptions.[Footnote 48] This may result in a slight underestimate 
of the prescription of concomitant psychotropic drugs; however, this 
should not differ between the foster and nonfoster care populations. 
These MSIS prescription claims data do not include diagnosis codes, 
and therefore, we cannot be sure that all the drugs in our analysis 
were prescribed for mental health purposes. By eliminating secondary 
drugs such as anticonvulsants from our analysis of prescription rates 
for one or more drugs, we likely understate the percentage of children 
prescribed psychotropic drugs for mental health purposes. We used both 
our primary and secondary lists when examining gaps in medications. 

The five states differed in the types of prescriptions included in the 
claims data we analyzed. Because Medicaid is a state-administered 
program, each state has its own formulary of the drugs that it covers, 
including which drugs are covered by its fee for service or through 
its managed care. Generally, prescription claims paid for on a fee-for-
service basis were reported to CMS by the five states during 2008, and 
therefore were included in the data we obtained from CMS and analyzed. 
In Florida and Massachusetts, prescriptions for those individuals not 
enrolled in a health maintenance organization (HMO) were reported to 
CMS, and we analyzed only these children.[Footnote 49] In addition, we 
found certain states through their formularies and prescription drug 
carve outs covered more drugs from our psychotropic list than other 
states. As such, while rates of psychotropic prescriptions are not 
comparable across states, they are comparable between foster and 
nonfoster children within the same state. Similarly, the ratio of 
prescriptions to foster children to prescriptions to nonfoster 
children is comparable across states. 

We used MSIS prescription claims data to calculate the total amount 
paid by state Medicaid programs for prescriptions on the primary list 
of psychotropic drugs used in our analysis for children in foster care 
for 30 days or more and nonfoster children in Medicaid during 2008. 
This amount paid includes only claims paid for by a fee-for-service 
program and does not include manufacturer rebates or other costs such 
as managed care. We obtained additional information about drug dosages 
and administration routes from Thomson Reuters' Red Book.[Footnote 50] 
We did not evaluate relative rates of usage for brand name and generic 
drugs in our analysis. 

We examined the concomitant prescription of five or more drugs with 
unique active ingredients. We did not allow for overlapping 
prescriptions of the same drug. We counted a drug as prescribed 
continuously if within 3 consecutive calendar months, the 
prescription(s) had at least 84 days supply within that time period. 
Requiring a minimum of 84 days resulted in a more conservative 
estimate of concomitant prescriptions by eliminating cases in which a 
patient was prescribed a new drug without finishing the previous 
supply, thereby creating the appearance of concurrent use. For 
example, when one or more prescriptions for the same drug were filled 
before the days' supply of the previous prescription had elapsed, we 
assumed that the subsequent prescriptions had been saved and used in 
sequence, with no overlapping days. Where the total days supply 
exceeded 84 days for a 3-month consecutive period, we counted this as 
continuous use.[Footnote 51] We added the number of unique active 
ingredients prescribed continuously for each 3-month period (i.e., two 
kinds of the same drug counted as one active ingredient). We did not 
count concomitant prescriptions of a brand name and generic drug with 
the same active ingredient. 

We developed indicators of potential health risks based on input from 
our child psychiatrists; a literature review; state guidelines; and 
interviews with officials from CMS, state Medicaid and foster care 
offices, NIMH, and professional medical associations. The final 
indicators of potential health risks were: concomitant prescriptions 
of five or more drugs, prescriptions exceeding dosage guidelines in 
the Psychotropic Medication Utilization Parameters for Texas Foster 
Children, and psychotropic prescriptions to children under 1 year old. 
In addition, we evaluated gaps of 7 to 29 days in prescriptions of a 
drug to identify nonadherence to drug regimens, which can pose 
significant risks to a patient. Analysis of only 1 year of claims data 
prevented us from determining whether a single drug was tried before 
adding additional drugs in all cases. Additionally, data limitations 
prevented us from comparing prescribing patterns for foster youth in 
different settings, and lack of pharmacy claims for hospitalized youth 
prevented us from examining prescribing patterns for these children or 
comparing hospitalized foster and nonfoster youth. 

To determine whether children were prescribed psychotropic drugs 
exceeding FDA maximum recommended therapeutic doses for their age or 
standards published in medical literature for their age, we used the 
dosage guidelines in the 2010 Texas Utilization Parameters. We 
excluded anticonvulsants and dosages based on the child's weight from 
our analysis. To identify children for whom there was no FDA-
recommended dose and who exceeded the next relevant standard, we 
defined the next relevant standard as the published guidelines for the 
child's age or next highest age range, the FDA-recommended dose for 
the next highest age range, or the published standards for a different 
version of the drug (i.e., standards for the extended release version 
of the drug). We calculated rates of psychotropic prescriptions to 
children age 0 to 1 in the same way that we calculated psychotropic 
prescription rates for other age groups. See discussion above for 
definition of foster children and nonfoster children and the kinds of 
drugs included in this analysis. 

We also examined drugs prescribed to foster or nonfoster children to 
identify gaps in the dispensing of the drugs. In consultation with our 
experts, we defined a gap in prescriptions as 7 to 29 days between the 
last day of the first prescription and the fill date of the next 
prescription. We examined gaps across prescriptions for the same 
active ingredient, regardless of dosage. Similar to our concomitant 
analysis, when one or more prescriptions for the same drug were filled 
before the days supply of the previous prescription had elapsed, we 
assumed that the subsequent prescriptions had been saved and used in 
sequence, with no overlapping days. This methodology may understate 
gaps for patients with two prescriptions for different versions of the 
same medication, such as a drug and its extended release version. In 
this case, a break in one of the medications would not appear as a gap 
if the prescription for the other drug continued to be filled. 
Conversely, prescribers may reduce the dosage of a medication without 
writing a new prescription, which could appear as a gap in 
prescriptions. For example, if a patient had been prescribed two 10 mg 
doses per day, and was adjusted down to a single dose of 10 mg per 
day, the next prescription would be filled later than expected, 
appearing as a gap. Finally, children who exited and reentered 
Medicaid in a 30-day period during the course of the year would appear 
to have a gap in their prescriptions. If a child had three such gaps, 
he or she would have been included in the rate of children with three 
or more gaps in a medication, although it is not possible to know from 
prescription claims data whether the child had other prescription 
coverage during the time he or she was not in Medicaid. 

To identify federal requirements and guidance related to the oversight 
of psychotropic drugs, we interviewed officials from CMS and the 
Administration for Children and Families (ACF), and reviewed laws and 
regulations. To determine the design of controls over psychotropic 
medications prescribed to foster children in each of the six selected 
states, we reviewed state statutes and policies or regulations related 
to the prescription of psychotropic drugs to foster children, and 
interviewed officials from the six selected states' Medicaid and child 
welfare agencies. Finally, we interviewed officials from the American 
Academy of Child and Adolescent Psychiatry (AACAP) to obtain an 
understanding of their methods for developing best practice guidelines 
for providing psychotropic drugs to foster children. We selected 
AACAP's "Position Statement on Oversight of Psychotropic Medication 
Use for Children in State Custody: A Best Principles Guideline" as a 
standard against which to compare state program frameworks based on a 
literature review and our discussions with officials from NIMH and 
CMS. However, states have legal discretion to administer Medicaid and 
foster care programs, and are not required to implement controls based 
on these best principles guidelines. 

We performed this audit from February 2010 through November 2011 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

We performed data checks to determine the reliability of the MSIS 
prescription claims data provided by CMS, state Medicaid files 
provided by Medicaid agencies in the six selected states, databases of 
children in foster care provided by child welfare agencies in the six 
selected states, and Thomson Reuters Red Book. While a small number of 
Medicaid and foster care records may contain inaccurate personal data 
or prescription information likely resulting from data entry errors, 
based on our discussions with agency officials and our own testing, we 
concluded that the data elements in five of the six states used for 
this report were sufficiently reliable to address our audit 
objectives. However, we determined through data tests, interviews, and 
reviews of state audit reports that data on children in Maryland 
foster care during 2008 were unreliable. For example, our electronic 
tests of Maryland data found 8,869 children in foster care as of 
September 30, 2008--16 percent more than the 7,613 children that 
Maryland reported to ACF for that year. In addition, state audits in 
2008 reported duplicate records with different identifying numbers for 
the same child, records showing children who had exited foster care as 
still enrolled in the program, and personal information for the parent 
recorded as that of the child. We therefore concluded that the 
Maryland foster care data were unreliable and excluded Maryland from 
our analysis of rates of psychotropic prescriptions. 

[End of section] 

Appendix II: Uses and Side Effects of Psychotropic Drug[Footnote 52]s: 

Psychotropic drugs are used to treat the symptoms of mental health 
conditions such as schizophrenia, depression, bipolar disorder 
(sometimes called manic-depressive illness), anxiety disorders, and 
ADHD. These drugs cannot cure mental disorders, but they can treat the 
symptoms to help people feel better so they can function. For our 
analyses, we included drugs in the following categories: (1) ADHD, (2) 
anti-anxiety, (3) antidepressants, (4) antipsychotics, (5) hypnotics, 
and (6) mood stabilizers and any medications that combine two or more 
of these categories.[Footnote 53] The following information was taken 
primarily from NIMH's 2008 Mental Health Medications guide, and 
provides the common uses and potential side effects for each type of 
psychotropic drug:[Footnote 54] 

Attention Deficit Hyperactivity Disorder (ADHD) drugs are prescribed 
to individuals who are hyperactive, impulsive, and easily distracted. 
These drugs are used to help individuals focus, work, and learn, and 
may also improve physical coordination. These drugs include 
nonstimulant drugs such as atomoxetine (Strattera), guanfacine 
(Intuniv), and clonidine (Kapvay), and stimulant drugs such as 
methylphenidate (Ritalin, Metadate, Concerta, Daytrana), amphetamine 
(Adderall), and lisdexamfetamine dimesylate (Vyvanse). Stimulants can 
cause side effects such as decreased appetite and sleep problems, and 
less frequently, tics or personality changes. Most minor side effects 
can be eliminated by lowering the drug dosage. More seriously, there 
are possible rare side effects associated with the use of ADHD drugs. 
ADHD patients also have a slightly higher risk for drug-related 
psychiatric side effects, such as hearing voices, having 
hallucinations, becoming paranoid, or becoming manic. 

Anti-anxiety drugs are prescribed to individuals to treat post-
traumatic stress disorder, generalized anxiety disorder, obsessive 
compulsive disorder, panic disorder, and social phobias. 
Benzodiazepines, one type of anti-anxiety drug, include drugs such as 
clonazepam (Klonopin), lorazepam (Ativan), and alprazolam 
(Xanax).[Footnote 55] The most common side effects for benzodiazepines 
are drowsiness and dizziness. Other side effects include upset 
stomach, blurred vision, headache, confusion, grogginess, and 
nightmares. Another anti-anxiety drug used to treat generalized 
anxiety disorders is buspirone (Buspar).[Footnote 56] Unlike 
benzodiazepines, however, it takes at least 2 weeks for buspirone to 
begin working. Possible side effects of buspirone include dizziness, 
headaches, nausea, nervousness, lightheadedness, excitement, and 
trouble sleeping. 

Antidepressants are prescribed to treat individuals who suffer from 
depression. All antidepressants contain an FDA box warning--the most 
serious type of warning--to alert users to the increased risk of 
suicidal thinking or attempts in children, adolescents, and young 
adults taking this type of drug. 

Older antidepressant medications cause more side effects than newer 
classes of antidepressants, but they may be the best medication for 
some people. Older generations of antidepressants include tricyclics 
and tetracyclics, such as protriptyline (Vivactil) and trimipramine 
(Surmontil), and monoamine oxidase inhibitors (MAOIs), such as 
isocarboxazid (Marplan) and phenelzine (Nardil). These drugs can cause 
side effects such as dry mouth, constipation, bladder problems, sexual 
problems, blurred vision, and drowsiness. MAOIs can interact with 
various foods or drugs high in tyramine--including certain cheeses, 
wines, pickles, and over-the-counter medications--to produce severe 
hypertension. 

Other types of antidepressants include selective serotonin reuptake 
inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline 
(Zoloft), and serotonin and norepinephrine reuptake inhibitors (SNRIs) 
such as venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and 
SNRIs can cause side effects such as agitation, serotonin syndrome, 
and sexual dysfunction, as well as headache, nausea, and sleeplessness 
or drowsiness when the patient first begins taking the drugs. Another 
type of antidepressant that acts on the neurotransmitter dopamine is 
called bupropion (Wellbutrin). Bupropion can cause side effects such 
as drowsiness, dry mouth, dizziness, headache, nausea, seizures, chest 
pain, and confusion. 

Antipsychotic drugs are used to treat schizophrenia, bipolar 
disorders, irritability in autism, and depression. The first 
generation of antipsychotics, also known as "typical" antipsychotics, 
includes chlorpromazine (Thorazine) and haloperidol (Haldol). Typical 
antipsychotics can cause side effects such as rigidity, persistent 
muscle spasms, tremors, and restlessness and, with long-term use, 
tardive dyskinesia. The second generation of antipsychotics, or 
"atypical" antipsychotics, includes risperidone (Risperdal), 
quetiapine (Seroquel), and aripiprazole (Abilify). While typical 
antipsychotics are more likely to cause movement disorders, such as 
uncontrollable muscle spasms that in some cases cannot be cured , 
atypical antipsychotics can cause weight gain and changes in 
metabolism, potentially leading to an increased risk of diabetes and 
high cholesterol. Both typical and atypical antipsychotics can also 
cause drowsiness, dizziness when changing positions, blurred vision, 
rapid heartbeat, sensitivity to the sun, skin rashes, and menstrual 
problems. 

Hypnotics cause sleep or partial loss of consciousness, and are used 
to treat insomnia and some anxiety disorders. Benzodiazepine hypnotics 
include drugs such as flurazepam (Dalmane), quazepam (Doral), and 
triazolam (Halcion).[Footnote 57] Benzodiazepine hypnotics can be 
addictive and are associated with side effects such as daytime 
drowsiness, a hungover feeling, and the worsening of certain breathing 
problems. Nonbenzodiazepine hypnotics include drugs such as Zaleplon 
(Sonata), Zolpidem (Ambien), and Eszopiclone (Lunesta). These 
hypnotics may be less addictive than benzodiazepines but can cause 
side effects such as driving, making phone calls, or eating while 
asleep. 

Mood stabilizers are drugs used to treat individuals with bipolar 
disorder (also known as manic-depressive illness). Lithium and 
anticonvulsant drugs can both be used as mood stabilizers. 

Lithium was the first mood stabilizer approved by the FDA in the 1970s 
for treating both manic and depressive episodes. Lithium can cause 
several side effects, and some of them may become serious. These side 
effects include: loss of coordination, excessive thirst, frequent 
urination, blackouts, seizures, slurred speech, irregular or pounding 
heartbeat, hallucinations, changes in vision, rashes, swelling of the 
face or limbs, and low thyroid function (hypothyroidism). 

Anticonvulsant drugs are also used as mood stabilizers. These drugs 
were originally developed to treat seizures, but they were found to 
help control moods as well. One anticonvulsant commonly used as a mood 
stabilizer is divalproex sodium (Depakote). Other anticonvulsants used 
as mood stabilizers are carbamazepine (Tegretol), lamotrigine 
(Lamictal) and oxcarbazepine (Trileptal). Like antidepressants, these 
drugs also have an FDA warning to alert users to the increased risk of 
suicidal thinking or behaviors in individuals taking this type of 
drug. Some other serious side effects of these drugs include damage to 
the liver and pancreas (divalproex sodium), polycystic ovarian 
syndrome (divalproex sodium), and serious skin rash (lamotrigine). 

[End of section] 

Appendix III: List of Psychotropic Drugs Used in Analysis: 

The following table lists the type of psychotropic drug and drug 
ingredients for all drugs used in the analysis. 

Table 8: Psychotropic Drugs Used in Analysis: 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Amphetamine aspartate, Amphetamine 
sulfate, Dextroamphetamine saccharate, Dextroamphetamine sulfate[A]. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Atomoxetine hydrochloride. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Clonidine. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Dexmethylphenidate hydrochloride. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Dextroamphetamine sulfate. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Guanfacine hydrochloride. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Lisdexamfetamine dimesylate. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Methamphetamine. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Methylphenidate hydrochloride. 

Type of psychotropic drug: ADHD Drugs; 
Psychotropic drug ingredient: Pemoline. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Alprazolam. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Buspirone hydrochloride. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Chlordiazepoxide hydrochloride. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Clonazepam. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Clorazepate dipotassium. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Diazepam. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Diphenhydramine hydrochloride. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Hydroxyzine. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Lorazepam. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Meprobamate. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Oxazepam. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Prazosin hydrochloride. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Propranolol hydrochloride. 

Type of psychotropic drug: Anti-anxiety; 
Psychotropic drug ingredient: Quazepam. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Carbamazepine. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Divalproex sodium. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Gabapentin. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Lamotrigine. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Oxcarbazepine. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Topiramate. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Valproate sodium. 

Type of psychotropic drug: Anticonvulsant; 
Psychotropic drug ingredient: Valproic acid. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Amitriptyline hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Amoxapine. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Bupropion hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Citalopram hydrobromide. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Clomipramine hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Desipramine hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Desvenlafaxine succinate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Doxepin hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Duloxetine hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Escitalopram oxalate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Fluoxetine hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Fluvoxamine maleate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Imipramine. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Isocarboxazid. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Maprotiline hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Mirtazapine. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Nefazodone hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Nortriptyline hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Paroxetine. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Phenelzine sulfate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Protriptyline hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Selegiline. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Sertraline hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Tranylcypromine sulfate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Trazodone hydrochloride. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Trimipramine maleate. 

Type of psychotropic drug: Antidepressants; 
Psychotropic drug ingredient: Venlafaxine. 

Type of psychotropic drug: Anti-enuretic; 
Psychotropic drug ingredient: Desmopressin acetate. 

Type of psychotropic drug: Antiparkinson; 
Psychotropic drug ingredient: Amantadine hydrochloride. 

Type of psychotropic drug: Antiparkinson; 
Psychotropic drug ingredient: Benztropine mesylate. 

Type of psychotropic drug: Antiparkinson; 
Psychotropic drug ingredient: Trihexyphenidyl hydrochloride. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Aripiprazole. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Chlorpromazine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Clozapine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Droperidol. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Fluphenazine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Haloperidol. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Loxapine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Mesoridazine besylate. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Molindone hydrochloride. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Olanzapine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Paliperidone. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Perphenazine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Pimozide. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Quetiapine fumarate. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Risperidone. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Thioridazine. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Thiothixene. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Trifluoperazine hydrochloride. 

Type of psychotropic drug: Antipsychotics; 
Psychotropic drug ingredient: Ziprasidone. 

Type of psychotropic drug: Combination anti-anxiety and antidepressant; 
Psychotropic drug ingredient: Amitriptyline and Chlordiazepoxide. 

Type of psychotropic drug: Combination antipsychotic and 
antidepressant; 
Psychotropic drug ingredient: Amitriptyline and Perphenazine. 

Type of psychotropic drug: Combination antipsychotic and 
antidepressant; 
Psychotropic drug ingredient: Olanzapine and Fluoxetine hydrochloride. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Estazolam. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Eszopiclone. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Flurazepam hydrochloride. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Midazolam hydrochloride. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Ramelteon. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Temazepam. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Triazolam. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Zaleplon. 

Type of psychotropic drug: Hypnotic; 
Psychotropic drug ingredient: Zolpidem tartrate. 

Type of psychotropic drug: Mood stabilizer; 
Psychotropic drug ingredient: Lithium. 

Type of psychotropic drug: Sleep aid; 
Psychotropic drug ingredient: Melatonin. 

Source: GAO. 

[A] Amphetamine aspartate, amphetamine sulfate, dextroamphetamine 
saccharate, and dextroamphetamine sulfate are medications indicated 
for treatment of ADHD and, as such, were considered as a single 
ingredient for purposes of our review. 

[End of table] 

[End of section] 

Appendix IV: Rates of Psychotropic Prescription Usage by Length of 
Time in Medicaid Fee-for-service: 

This appendix presents detailed information on rates of psychotropic 
prescriptions by the length of time a child was in a Medicaid fee-for-
service program. In Michigan, Oregon, and Texas, psychotropic 
prescriptions were always covered by a fee-for-service program; in 
Florida and Massachusetts, prescriptions were covered by either 
Medicaid fee-for-service or a managed care program. In our analysis of 
Florida's Medicaid program, we found that children in foster care for 
30 days or more averaged 7.47 months of fee-for-service coverage 
compared to 5.02 months for nonfoster children. To determine the 
impact of different lengths of time in fee-for-service on rates of 
psychotropic prescription usage, we conducted an analysis that 
adjusted for length of time in fee-for-service in Florida. Table 9 
shows the rates of psychotropic prescription usage for children under 
18 by length of time in fee-for-service. 

Table 9: Rates of Psychotropic Prescriptions by Length of Medicaid Fee-
for-service Coverage in Florida during 2008: 

Length of time in Medicaid fee-for-service: 3-5 months; 
Foster children age 0-17, in care for 30 or more days: 
Population: 899; 
Percentage with 1 or more psychotropic prescription: 6.7; 
Nonfoster children age 0-17: 
Population: 87,161; 
Percentage with 1 or more psychotropic prescription: 2.8; 
Ratio of percentage with 1 or more psychotropic prescriptions of 
foster to nonfoster children: 2.4. 

Length of time in Medicaid fee-for-service: 6-8 months; 
Foster children age 0-17, in care for 30 or more days: 
Population: 1,338; 
Percentage with 1 or more psychotropic prescription: 11.8; 
Nonfoster children age 0-17: 
Population: 71,505; 
Percentage with 1 or more psychotropic prescription: 4.1; 
Ratio of percentage with 1 or more psychotropic prescriptions of 
foster to nonfoster children: 2.9. 

Length of time in Medicaid fee-for-service: 9-12 months; 
Foster children age 0-17, in care for 30 or more days: 
Population: 16,817; 
Percentage with 1 or more psychotropic prescription: 24.1; 
Nonfoster children age 0-17: 
Population: 456,219; 
Percentage with 1 or more psychotropic prescription: 11.0; 
Ratio of percentage with 1 or more psychotropic prescriptions of 
foster to nonfoster children: 2.2. 

Length of time in Medicaid fee-for-service: 1-12 months; 
Foster children age 0-17, in care for 30 or more days: 
Population: 19,484; 
Percentage with 1 or more psychotropic prescription: 22.0; 
Nonfoster children age 0-17: 
Population: 686,103; 
Percentage with 1 or more psychotropic prescription: 8.2; 
Ratio of percentage with 1 or more psychotropic prescriptions of 
foster to nonfoster children: 2.7. 

Length of time in Medicaid fee-for-service: Children enrolled in 
Medicaid fee-for-service or managed care organization during 2008; 
Foster children age 0-17, in care for 30 or more days: 
Population: 32,806; 
Nonfoster children age 0-17: 
Population: 1,526,020. 

Source: GAO analysis of Florida Medicaid and foster care data. 

[End of table] 

[End of section] 

Appendix V: Additional Data on Children with Prescriptions of at Least 
One Psychotropic Drug: 

This appendix presents detailed information on rates of foster and 
nonfoster children prescribed at least one psychotropic drug in the 
five states during 2008. In the tables below, rates for foster and 
nonfoster children can be compared within the same state and the ratio 
of prescriptions to foster children to prescriptions to nonfoster 
children can be compared across states. However, prescription rates 
cannot be compared across states. Percentages and ratios are rounded 
to the nearest tenth, and therefore the reported ratio may be slightly 
different than the ratio of the rounded percentages. 

Table 10: Rates of Psychotropic Prescriptions in Florida during 2008 
by Age of Child and Foster Care Status: 

Age: Children 0-17 (Under 18); 
Foster children: 
Number: 4,281; 
Percent: 22.0; 
Nonfoster children: 
Number: 56,408; 
Percentage: 8.2; 
Ratio of foster to nonfoster children: 2.7. 

Age: Children 13-17; 
Foster children: 
Number: 2,093; 
Percent: 36.8; 
Nonfoster children: 
Number: 17,549; 
Percentage: 11.9; 
Ratio of foster to nonfoster children: 3.1. 

Age: Children 6-12; 
Foster children: 
Number: 1,758; 
Percent: 31.2; 
Nonfoster children: 
Number: 28,690; 
Percentage: 12.3; 
Ratio of foster to nonfoster children: 2.5. 

Age: Children 0-5 (Under 6); 
Foster children: 
Number: 430; 
Percent: 5.3; 
Nonfoster children: 
Number: 10,169; 
Percentage: 3.3; 
Ratio of foster to nonfoster children: 1.6. 

Source: GAO analysis of Florida Medicaid and foster care data. 

[End of table] 

Table 11: Rates of Psychotropic Prescriptions in Massachusetts during 
2008 by Age of Child and Foster Care Status: 

Age: Children 0-17 (Under 18); 
Foster children: 
Number: 3,814; 
Percentage: 39.1; 
Nonfoster children: 
Number: 22,041; 
Percentage: 10.2; 
Ratio of foster to nonfoster children: 3.8. 

Age: Children 13-17; 
Foster children: 
Number: 2,599; 
Percentage: 53.4; 
Nonfoster children: 
Number: 10,265; 
Percentage: 14.7; 
Ratio of foster to nonfoster children: 3.6. 

Age: Children 6-12; 
Foster children: 
Number: 1,095; 
Percentage: 44.8; 
Nonfoster children: 
Number: 10,455; 
Percentage: 12.1; 
Ratio of foster to nonfoster children: 3.7. 

Age: Children 0-5 (Under 6); 
Foster children: 
Number: 120; 
Percentage: 4.9; 
Nonfoster children: 
Number: 1,321; 
Percentage: 2.2; 
Ratio of foster to nonfoster children: 2.2. 

Source: GAO analysis of Massachusetts Medicaid and foster care data. 

[End of table] 

Table 12: Rates of Psychotropic Prescriptions in Michigan during 2008 
by Age of Child and Foster Care Status: 

Age: Children 0-17 (Under 18); 
Foster children: 
Number: 4,360; 
Percentage: 21.0; 
Nonfoster children: 
Number: 74,188; 
Percentage: 7.9;
Ratio of foster to nonfoster children: 2.7. 

Age: Children 13-17; 
Foster children: 
Number: 2,220; 
Percentage: 35.0; 
Nonfoster children: 
Number: 30,118; 
Percentage: 13.1; 
Ratio of foster to nonfoster children: 2.7. 

Age: Children 6-12; 
Foster children: 
Number: 1,802; 
Percentage: 26.7; 
Nonfoster children: 
Number: 39,917; 
Percentage: 11.5; 
Ratio of foster to nonfoster children: 2.3. 

Age: Children 0-5 (Under 6); 
Foster children: 
Number: 338; 
Percentage: 4.4; 
Nonfoster children: 
Number: 4,153; 
Percentage: 1.1; 
Ratio of foster to nonfoster children: 3.8. 

Source: GAO analysis of Michigan Medicaid and foster care data. 

[End of table] 

Table 13: Rates of Psychotropic Prescriptions in Oregon during 2008 by 
Age of Child and Foster Care Status: 

Age: Children 0-17 (Under 18); 
Foster children: 
Number: 2,119; 
Percentage: 19.7; 
Nonfoster children: 
Number: 11,731; 
Percentage: 4.8; 
Ratio of foster to nonfoster children: 4.1. 

Age: Children 13-17; 
Foster children: 
Number: 1,177; 
Percentage: 43.3; 
Nonfoster children: 
Number: 5,991; 
Percentage: 12.0; 
Ratio of foster to nonfoster children: 3.6. 

Age: Children 6-12; 
Foster children: 
Number: 831; 
Percentage: 23.4; 
Nonfoster children: 
Number: 5,022; 
Percentage: 6.2; 
Ratio of foster to nonfoster children: 3.8. 

Age: Children 0-5 (Under 6); 
Foster children: 
Number: 111; 
Percentage: 2.5; 
Nonfoster children: 
Number: 718; 
Percentage: 0.6; 
Ratio of foster to nonfoster children: 3.9. 

Source: GAO analysis of Oregon Medicaid and foster care data. 

[End of table] 

Table 14: Rates of Psychotropic Prescriptions in Texas during 2008 by 
Age of Child and Foster Care Status: 

Age: Children 0-17 (Under 18); 
Foster children: 
Number: 11,699; 
Percentage: 32.2; 
Nonfoster children: 
Number: 185,329; 
Percentage: 7.1; 
Ratio of foster to nonfoster children: 4.5. 

Age: Children 13-17; 
Foster children: 
Number: 4,740; 
Percentage: 58.2; 
Nonfoster children: 
Number: 53,142; 
Percentage: 11.4; 
Ratio of foster to nonfoster children: 5.1. 

Age: Children 6-12; 
Foster children: 
Number: 5,488; 
Percentage: 45.8; 
Nonfoster children: 
Number: 93,466; 
Percentage: 10.6; 
Ratio of foster to nonfoster children: 4.3. 

Age: Children 0-5 (Under 6); 
Foster children: 
Number: 1,471; 
Percentage: 9.1; 
Nonfoster children: 
Number: 38,721; 
Percentage: 3.1; 
Ratio of foster to nonfoster children: 2.9. 

Source: GAO analysis of Texas Medicaid and foster care data. 

[End of table] 

[End of section] 

Appendix VI: Additional Data on Concomitant Prescriptions: 

This appendix presents detailed information on rates of psychotropic 
drugs prescribed concomitantly to foster and nonfoster children under 
18 years old during 2008. We considered two or more drugs with unique 
active ingredients to be prescribed concomitantly if each prescription 
was filled with a 3-month overlap, defined as 84 days to account for 
prescriptions that are filled late and 28-day prescriptions. We did 
not count two drugs with the same active ingredient such as a brand 
name drug and its generic equivalent. We did count combination drugs, 
which have two active ingredients in a single dose, as concomitant 
prescriptions.[Footnote 58] 

In the tables below, rates for foster and nonfoster children can be 
compared within the same state and the ratio of prescriptions to 
foster children to prescriptions to nonfoster children can be compared 
across states. However, prescription rates cannot be compared across 
states. Percentages and ratios are rounded to the nearest tenth, and 
therefore the reported ratio may be slightly different than the ratio 
of the rounded percentages. 

Table 15: Rates of Concomitant Psychotropic Prescriptions in Florida 
during 2008 by Number of Drugs: 

Children 0-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 715; 
Percentage: 3.7; 
Nonfoster children: 
Number: 4,689; 
Percentage: 0.7; 
Ratio of foster to nonfoster children: 5.4. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 323; 
Percentage: 1.7; 
Nonfoster children: 
Number: 1,863; 
Percentage: 0.3; 
Ratio of foster to nonfoster children: 6.1. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 93; 
Percentage: 0.5; 
Nonfoster children: 
Number: 564; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 5.8. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 18; 
Percentage: 0.1; 
Nonfoster children: 
Number: 137; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.6. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 37; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 3.8. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: 11; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 1149; 
Percentage: 5.9; 
Nonfoster children: 
Number: more than 7,301; 
Percentage: 1.1; 
Ratio of foster to nonfoster children: 5.6. 

Children 13-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 376; 
Percentage: 6.6; 
Nonfoster children: 
Number: 1,727; 
Percentage: 1.2; 
Ratio of foster to nonfoster children: 5.6. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 182; 
Percentage: 3.2; 
Nonfoster children: 
Number: 819; 
Percentage: 0.6; 
Ratio of foster to nonfoster children: 5.7. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 55; 
Percentage: 1.0; 
Nonfoster children: 
Number: 307; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 4.6. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 11; 
Percentage: 0.2; 
Nonfoster children: 
Number: 74; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 3.8. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 22; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 2.4. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 624; 
Percentage: 11.0; 
Nonfoster children: 
Number: more than 2,949; 
Percentage: 2.0; 
Ratio of foster to nonfoster children: 5.5. 

Children 6-12: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 315; 
Percentage: 5.6; 
Nonfoster children: 
Number: 2,680; 
Percentage: 1.1; 
Ratio of foster to nonfoster children: 4.9. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 138; 
Percentage: 2.4; 
Nonfoster children: 
Number: 988; 
Percentage: 0.4; 
Ratio of foster to nonfoster children: 5.8. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 37; 
Percentage: 0.7; 
Nonfoster children: 
Number: 249; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 6.2. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: 62; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.7. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 15; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 5.5. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 490; 
Percentage: 8.9; 
Nonfoster children: 
Number: more than 3994; 
Percentage: 1.7; 
Ratio of foster to nonfoster children: 5.2. 

Children 0-5: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 24; 
Percentage: 0.3; 
Nonfoster children: 
Number: 282; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 3.2. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 56; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 2.0. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.7. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: [Empty; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 24; 
Percentage: 0.3; 
Nonfoster children: 
Number: more than 338; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 3.0. 

Source: GAO analysis of Florida Medicaid and foster care data. 

Note: Percentages are rounded to the nearest tenth. 

[End of table] 

Table 16: Rates of Concomitant Psychotropic Prescriptions in 
Massachusetts during 2008 by Number of Drugs: 

Children 0-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 711; 
Percentage: 7.3; 
Nonfoster children: 
Number: 2,586; 
Percentage: 1.2; 
Ratio of foster to nonfoster children: 6.1. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 558; 
Percentage: 5.7; 
Nonfoster children: 
Number: 1,171; 
Percentage: 0.5; 
Ratio of foster to nonfoster children: 10.6. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 249; 
Percentage: 2.5; 
Nonfoster children: 
Number: 430; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 12.8. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 97; 
Percentage: 1.0; 
Nonfoster children: 
Number: 118; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 18.2. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: 26; 
Percentage: 0.3; 
Nonfoster children: 
Number: 31; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 18.6. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 12.3. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 1641; 
Percentage: 16.9; 
Nonfoster children: 
Number: more than 4,336; 
Percentage: 2.0; 
Ratio of foster to nonfoster children: 8.4. 

Children 13-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 473; 
Percentage: 9.7; 
Nonfoster children: 
Number: 1,103; 
Percentage: 1.6; 
Ratio of foster to nonfoster children: 6.2. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 368; 
Percentage: 7.6; 
Nonfoster children: 
Number: 588; 
Percentage: 0.8; 
Ratio of foster to nonfoster children: 9.0. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 176; 
Percentage: 3.6; 
Nonfoster children: 
Number: 258; 
Percentage: 0.4; 
Ratio of foster to nonfoster children: 9.8. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 76; 
Percentage: 1.6; 
Nonfoster children: 
Number: 84; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 13.0. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: 19; 
Percentage: 0.4; 
Nonfoster children: 
Number: 22; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 12.4. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 9.0. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 1,112; 
Percentage: 23.0; 
Nonfoster children: 
Number: more than 2,055; 
Percentage: 3.0; 
Ratio of foster to nonfoster children: 7.8. 

Children 6-12: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 228; 
Percentage: 9.3; 
Nonfoster children: 
Number: 1,413; 
Percentage: 1.6; 
Ratio of foster to nonfoster children: 5.7. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 184; 
Percentage: 7.5; 
Nonfoster children: 
Number: 563; 
Percentage: 0.7; 
Ratio of foster to nonfoster children: 11.5. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 73; 
Percentage: 3.0; 
Nonfoster children: 
Number: 170; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 15.1. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 21; 
Percentage: 0.9; 
Nonfoster children: 
Number: 34; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 21.8. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.3; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 27.4. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 506; 
Percentage: 21.0; 
Nonfoster children: 
Number: more than 2,180; 
Percentage: 2.5; 
Ratio of foster to nonfoster children: 8.3. 

Children 0-5: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 10; 
Percentage: 0.4; 
Nonfoster children: 
Number: 70; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 3.5. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: less than 10; 
Percentage: 0.2; 
Nonfoster children: 
Number: 20; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 7.4. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 10; 
Percentage: 0.7; 
Nonfoster children: 
Number: more than 90; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 4.3. 

Source: GAO analysis of Massachusetts Medicaid and foster care data. 

Note: Percentages are rounded to the nearest tenth. 

[End of table] 

Table 17: Rates of Concomitant Psychotropic Prescriptions in Michigan 
during 2008 by Number of Drugs: 

Children 0-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 620; 
Percentage: 3.0; 
Nonfoster children: 
Number: 5,659; 
Percentage: 0.6; 
Ratio of foster to nonfoster children: 5.0. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 332; 
Percentage: 1.6; 
Nonfoster children: 
Number: 1,951; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 7.7. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 134; 
Percentage: 0.6; 
Nonfoster children: 
Number: 608; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 10.0. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 50; 
Percentage: 0.2; 
Nonfoster children: 
Number: 152; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 14.9. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 34; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 13.3. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.5. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 1,146; 
Percentage: 5.5; 
Nonfoster children: 
Number: more than 8,414; 
Percentage: 0.9; 
Ratio of foster to nonfoster children: 6.2. 

Children 13-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 367; 
Percentage: 5.8; 
Nonfoster children:
Number: 2,435; 
Percentage: 1.1; 
Ratio of foster to nonfoster children: 5.5. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 234; 
Percentage: 3.7; 
Nonfoster children: 
Number: 1,045; 
Percentage: 0.5; 
Ratio of foster to nonfoster children: 8.1. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 97; 
Percentage: 1.5; 
Nonfoster children: 
Number: 378; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 9.3. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 38; 
Percentage: 0.6; 
Nonfoster children: 
Number: 95; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 14.5. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: 25; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 13.1. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 6.1. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 736; 
Percentage: 11.8; 
Nonfoster children: 
Number: more than 3,978; 
Percentage: 1.7; 
Ratio of foster to nonfoster children: 6.8. 

Children 6-12: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 236; 
Percentage: 3.5; 
Nonfoster children: 
Number: 3,044; 
Percentage: 0.9; 
Ratio of foster to nonfoster children: 4.0. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 95; 
Percentage: 1.4; 
Nonfoster children: 
Number: 877; 
Percentage: 0.3; 
Ratio of foster to nonfoster children: 5.6. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 37; 
Percentage: 0.5; 
Nonfoster children: 
Number: 228; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 8.3. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 12; 
Percentage: 0.2; 
Nonfoster children: 
Number: 57; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 10.8. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 5.7. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 380; 
Percentage: 5.6; 
Nonfoster children: 
Number: more than 4,206; 
Percentage: 1.2; 
Ratio of foster to nonfoster children: 4.6. 

Children 0-5: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 17; 
Percentage: 0.2; 
Nonfoster children: 
Number: 180; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.5. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: 29; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.9. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 17; 
Percentage: 0.3; 
Nonfoster children: 
Number: more than 209; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 4.5. 

[End of table] 

Source: GAO analysis of Michigan Medicaid and foster care data. 

Note: Percentages are rounded to the nearest tenth. 

[End of table] 

Table 18: Rates of Concomitant Psychotropic Prescriptions in Oregon 
during 2008 by Number of Drugs: 

Children 0-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children:
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 330; 
Percentage: 3.1; 
Nonfoster children: 
Number: 980; 
Percentage: 0.4; 
Ratio of foster to nonfoster children: 7.6. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 131; 
Percentage: 1.2; 
Nonfoster children: 
Number: 317; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 9.4. 

Medications prescribed concomitantly: 4; 
Foster children: Number: 31; 
Foster children: Percentage: 0.3; 
Nonfoster children: Number: 91; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 7.7. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: 11; 
Percentage: 0.1; 
Nonfoster children: 
Number: 19; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 13.1. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.5. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 503; 
Percentage: 4.7; 
Nonfoster children: 
Number: more than 1,407; 
Percentage: 0.6; 
Ratio of foster to nonfoster children: 8.1. 

Children 13-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 214; 
Percentage: 7.9; 
Nonfoster children: 
Number: 488; 
Percentage: 1.0; 
Ratio of foster to nonfoster children: 8.0. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 90; 
Percentage: 3.3; 
Nonfoster children: 
Number: 172; 
Percentage: 0.3; 
Ratio of foster to nonfoster children: 9.6. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: 24; 
Percentage: 0.9; 
Nonfoster children: 
Number: 58; 
Percentage: 0.1; 
Ratio of foster to nonfoster children: 7.6. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: less than 10; 
Percentage: 0.3; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 20.9. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children:
Number: more than 328; 
Percentage: 12.4; 
Nonfoster children:
Number: more than 718; 
Percentage: 1.5; 
Ratio of foster to nonfoster children: 8.5. 

Children 6-12: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children:
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: 109; 
Percentage: 3.1; 
Nonfoster children: 
Number: 473; 
Percentage: 0.6; 
Ratio of foster to nonfoster children: 5.3. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: 40; 
Percentage: 1.1; 
Nonfoster children: 
Number: 137; 
Percentage: 0.2; 
Ratio of foster to nonfoster children: 6.7. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: less than 10; 
Percentage: 0.2; 
Nonfoster children: 
Number: 33; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 4.9. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: less than 10; 
Percentage: 0.1; 
Nonfoster children: 
Number: 12; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 5.8. 

Medications prescribed concomitantly: 6; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 7.7. 

Medications prescribed concomitantly: 7; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 8; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 9; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 149; 
Percentage: 4.5; 
Nonfoster children: 
Number: more than 655; 
Percentage: 0.8; 
Ratio of foster to nonfoster children: 5.6. 

Children 0-5: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: 
Number: less than 10; 
Percentage: 0.2; 
Nonfoster children: 
Number: 19; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 9.3. 

Medications prescribed concomitantly: 3; 
Foster children: 
Number: less than 10; 
Percentage: 0.0; 
Nonfoster children: 
Number: less than 10; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 3.1. 

Medications prescribed concomitantly: 4; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 5; 
Foster children: 
Number: [Empty]; 
Percentage: 0.0; 
Nonfoster children: 
Number: [Empty]; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: 
Number: more than 0; 
Percentage: 0.2; 
Nonfoster children: 
Number: more than 19; 
Percentage: 0.0; 
Ratio of foster to nonfoster children: 7.4. 

Source: GAO analysis of Oregon Medicaid and foster care data. 

Note: Percentages are rounded to the nearest tenth. 

[End of table] 

Table 19: Rates of Concomitant Psychotropic Prescriptions in Texas 
during 2008 by Number of Drugs: 

Children 0-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: 14; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 5.1. 

Medications prescribed concomitantly: 2; 
Foster children: Number: 2,483; 
Foster children: Percentage: 6.8; 
Nonfoster children: Number: 11,002; 
Nonfoster children: Percentage: 0.4; 
Ratio of foster to nonfoster children: 16.2. 

Medications prescribed concomitantly: 3; 
Foster children: Number: 1,672; 
Foster children: Percentage: 4.6; 
Nonfoster children: Number: 4,518; 
Nonfoster children: Percentage: 0.2; 
Ratio of foster to nonfoster children: 26.5. 

Medications prescribed concomitantly: 4; 
Foster children: Number: 839; 
Foster children: Percentage: 2.3; 
Nonfoster children: Number: 1,549; 
Nonfoster children: Percentage: 0.1; 
Ratio of foster to nonfoster children: 38.8. 

Medications prescribed concomitantly: 5; 
Foster children: Number: 301; 
Foster children: Percentage: 0.8; 
Nonfoster children: Number: 415; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 52.0. 

Medications prescribed concomitantly: 6; 
Foster children: Number: 60; 
Foster children: Percentage: 0.2; 
Nonfoster children: Number: 126; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 34.1. 

Medications prescribed concomitantly: 7; 
Foster children: Number: 18; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: 21; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 61.4. 

Medications prescribed concomitantly: 8; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 14.3. 

Medications prescribed concomitantly: 9; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: [Empty]; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: Number: more than 5,373; 
Foster children: Percentage: 14.8; 
Nonfoster children: Number: more than 17,655; 
Nonfoster children: Percentage: 0.7; 
Ratio of foster to nonfoster children: 21.8. 

Children 13-17: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: 13; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: Number: 1,044; 
Foster children: Percentage: 12.8; 
Nonfoster children: Number: 3,652; 
Nonfoster children: Percentage: 0.8; 
Ratio of foster to nonfoster children: 16.4. 

Medications prescribed concomitantly: 3; 
Foster children: Number: 758; 
Foster children: Percentage: 9.3; 
Nonfoster children: Number: 1,792; 
Nonfoster children: Percentage: 0.4; 
Ratio of foster to nonfoster children: 24.3. 

Medications prescribed concomitantly: 4; 
Foster children: Number: 422; 
Foster children: Percentage: 5.2; 
Nonfoster children: Number: 692; 
Nonfoster children: Percentage: 0.1; 
Ratio of foster to nonfoster children: 35.0. 

Medications prescribed concomitantly: 5; 
Foster children: Number: 128; 
Foster children: Percentage: 1.6; 
Nonfoster children: Number: 206; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 35.7. 

Medications prescribed concomitantly: 6; 
Foster children: Number: 38; 
Foster children: Percentage: 0.5; 
Nonfoster children: Number: 78; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 28.0. 

Medications prescribed concomitantly: 7; 
Foster children: Number: 14; 
Foster children: Percentage: 0.2; 
Nonfoster children: Number: 15; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 53.6. 

Medications prescribed concomitantly: 8; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 11.5. 

Medications prescribed concomitantly: 9; 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: [Empty]; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: Number: more than 2,404; 
Foster children: Percentage: 29.5; 
Nonfoster children: Number: more than 6,448; 
Nonfoster children: Percentage: 1.4; 
Ratio of foster to nonfoster children: 21.4. 

Children 6-12: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 73.3. 

Medications prescribed concomitantly: 2; 
Foster children: Number: 1,245; 
Foster children: Percentage: 10.4; 
Nonfoster children: Number: 6,504; 
Nonfoster children: Percentage: 0.7; 
Ratio of foster to nonfoster children: 14.0. 

Medications prescribed concomitantly: 3; 
Foster children: Number: 820; 
Foster children: Percentage: 6.8; 
Nonfoster children: Number: 2,552; 
Nonfoster children: Percentage: 0.3; 
Ratio of foster to nonfoster children: 23.6. 

Medications prescribed concomitantly: 4; 
Foster children: Number: 403; 
Foster children: Percentage: 3.4; 
Nonfoster children: Number: 822; 
Nonfoster children: Percentage: 0.1; 
Ratio of foster to nonfoster children: 36.0. 

Medications prescribed concomitantly: 5; 
Foster children: Number: 171; 
Foster children: Percentage: 1.4; 
Nonfoster children: Number: 206; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 60.9. 

Medications prescribed concomitantly: 6; 
Foster children: Number: 22; 
Foster children: Percentage: 0.2; 
Nonfoster children: Number: 48; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 33.6. 

Medications prescribed concomitantly: 7; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 48.9. 

Medications prescribed concomitantly: 8; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 14.7. 

Medications prescribed concomitantly: 9; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: [Empty]; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 10; 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: Total; 
Foster children: Number: more than 2,661; 
Foster children: Percentage: 22.3; 
Nonfoster children: Number: more than 10,132; 
Nonfoster children: Percentage: 1.2; 
Ratio of foster to nonfoster children: 19.3. 

Children 0-5: 

Medications prescribed concomitantly: 1 (combination drug); 
Foster children: Number: [Empty]; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: [Empty]; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: [Empty]. 

Medications prescribed concomitantly: 2; 
Foster children: Number: 194; 
Foster children: Percentage: 1.2; 
Nonfoster children: Number: 846; 
Nonfoster children: Percentage: 0.1; 
Ratio of foster to nonfoster children: 17.8. 

Medications prescribed concomitantly: 3; 
Foster children: Number: 94; 
Foster children: Percentage: 0.6; 
Nonfoster children: Number: 174; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 41.9. 

Medications prescribed concomitantly: 4; 
Foster children: Number: 14; 
Foster children: Percentage: 0.1; 
Nonfoster children: Number: 35; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 31.0. 

Medications prescribed concomitantly: 5; 
Foster children: Number: less than 10; 
Foster children: Percentage: 0.0; 
Nonfoster children: Number: less than 10; 
Nonfoster children: Percentage: 0.0; 
Ratio of foster to nonfoster children: 51.7. 

Medications prescribed concomitantly: Total; 
Foster children: Number: more than 302; 
Foster children: Percentage: 1.9; 
Nonfoster children: Number: more than 1,055; 
Nonfoster children: Percentage: 0.1; 
Ratio of foster to nonfoster children: 22.3. 

Source: GAO analysis of Texas Medicaid and foster care data. 

Note: Percentages are rounded to the nearest tenth. 

[End of table] 

[End of section] 

Appendix VII: Additional Data on Psychotropic Drug Prescriptions 
Exceeding Maximum Recommended Doses: 

This appendix presents detailed information on rates of psychotropic 
drugs prescribed for foster and nonfoster children that exceeded the 
maximum dose for the child's age cited in the Texas Utilization 
Parameters, which includes doses based on information in the FDA-
approved drug label and published in medical literature for the 
child's age. Based on these parameters, we also analyzed prescriptions 
where there was no FDA-approved dose or published dose in medical 
literature for the child's age. Finally, for those prescriptions that 
had no FDA-approved doses for the child's age, we determined whether 
the prescription dosage exceeded the next most relevant standard: 
dosages published in medical literature for the same age group, 
dosages published in medical literature for an older age group, or the 
FDA-approved dose for an older age group or similar version of the 
same drug. These dosages were drawn from the Texas Utilization 
Parameters or, in limited cases, FDA-approved drug labels. 

In the tables below, rates for foster and nonfoster children can be 
compared within the same state and the ratio of prescriptions to 
foster children to prescriptions to nonfoster children can be compared 
across states. However, prescription rates cannot be compared across 
states. Percentages and ratios are rounded to the nearest tenth, and 
therefore the reported ratio may be slightly different than the ratio 
of the rounded percentages. 

Table 20: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Florida 
during 2008: 

Category: Prescription exceeding FDA maximum dose for age group; 
Foster: Number: 292; 
Foster: Percentage: 1.5; 
Nonfoster: Number: 3,005; 
Nonfoster: Percentage: 0.4; 
Ratio of foster to nonfoster children: 3.4. 

Category: Prescription exceeding maximum dose published in medical 
literature for age group; 
Foster: Number: 423; 
Foster: Percentage: 2.2; 
Nonfoster: Number: 3,566; 
Nonfoster: Percentage: 0.5; 
Ratio of foster to nonfoster children: 4.2. 

Category: Prescription with no FDA-approved dose for child's age, 
exceeding dosages for the next most relevant standard; 
Foster: Number: 101; 
Foster: Percentage: 0.5; 
Nonfoster: Number: 586; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 6.1. 

Category: Prescription for medication with no FDA-approved dose for 
age group; 
Foster: Number: 1,628; 
Foster: Percentage: 8.4; 
Nonfoster: Number: 15,282; 
Nonfoster: Percentage: 2.2; 
Ratio of foster to nonfoster children: 3.8. 

Category: Prescription for medication with no published dose in 
medical literature for age group; 
Foster: Number: 71; 
Foster: Percentage: 0.4; 
Nonfoster: Number: 828; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 3.0. 

Source: GAO analysis of Florida Medicaid and foster care data. 

Note: The data contained for each category in this table are not 
mutually exclusive. 

[End of table] 

Table 21: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in 
Massachusetts during 2008: 

Category: Prescription exceeding FDA maximum dose for age group; 
Foster: Number: 216; 
Foster: Percentage: 2.2; 
Nonfoster: Number: 1,214; 
Nonfoster: Percentage: 0.6;
Ratio of foster to nonfoster children: 3.9. 

Category: Prescription exceeding maximum dose published in medical 
literature for age group; 
Foster: Number: 367; 
Foster: Percentage: 3.8; 
Nonfoster: Number: 1,590; 
Nonfoster: Percentage: 0.7; 
Ratio of foster to nonfoster children: 5.1. 

Category: Prescription with no FDA-approved dose for child's age, 
exceeding dosages for the next most relevant standard; 
Foster: Number: 116; 
Foster: Percentage: 1.2; 
Nonfoster: Number: 336; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 7.7. 

Category: Prescription for medication with no FDA-approved dose for 
age group; 
Foster: Number: 2,199; 
Foster: Percentage: 22.5; 
Nonfoster: Number: 8,287; 
Nonfoster: Percentage: 3.8; 
Ratio of foster to nonfoster children: 5.9. 

Category: Prescription for medication with no published dose in 
medical literature for age group; 
Foster: Number: 88; 
Foster: Percentage: 0.9; 
Nonfoster: Number: 433; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 4.5. 

Source: GAO analysis of Massachusetts Medicaid and foster care data. 

Note: The data contained for each category in this table are not 
mutually exclusive. 

[End of table] 

Table 22: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in 
Michigan during 2008: 

Category: Prescription exceeding FDA maximum dose for age group; 
Foster: Number: 346; 
Foster: Percentage: 1.7; 
Nonfoster: Number: 4,592; 
Nonfoster: Percentage: 0.5; 
Ratio of foster to nonfoster children: 3.4. 

Category: Prescription exceeding maximum dose published in medical 
literature for age group; 
Foster: Number: 412; 
Foster: Percentage: 2.0; 
Nonfoster: Number: 4,660; 
Nonfoster: Percentage: 0.5; 
Ratio of foster to nonfoster children: 4.0. 

Category: Prescription with no FDA-approved dose for child's age, 
exceeding dosages for the next most relevant standard; 
Foster: Number: 70; 
Foster: Percentage: 0.3; 
Nonfoster: Number: 492; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 6.4. 

Category: Prescription for medication with no FDA-approved dose for 
age group; 
Foster: Number: 1,411; 
Foster: Percentage: 6.8; 
Nonfoster: Number: 14,026; 
Nonfoster: Percentage: 1.5; 
Ratio of foster to nonfoster children: 4.6. 

Category: Prescription for medication with no published dose in 
medical literature for age group; 
Foster: Number: 186; 
Foster: Percentage: 0.9; 
Nonfoster: Number: 1,750; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 4.8. 

Source: GAO analysis of Michigan Medicaid and foster care data. 

Note: The data contained for each category in this table are not 
mutually exclusive. 

[End of table] 

Table 23: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Oregon 
during 2008: 

Category: Prescription exceeding FDA maximum dose for age group; 
Foster: Number: 121; 
Foster: Percentage: 1.1; 
Nonfoster: Number: 399; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 6.9. 

Category: Prescription exceeding maximum dose published in medical 
literature for age group; 
Foster: Number: 180; 
Foster: Percentage: 1.7; 
Nonfoster: Number: 539; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 7.6. 

Category: Prescription with no FDA-approved dose for child's age, 
exceeding dosages for the next most relevant standard; 
Foster: Number: 43; 
Foster: Percentage: 0.4; 
Nonfoster: Number: 115; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 8.5. 

Category: Prescription for medication with no FDA-approved dose for 
age group; 
Foster: Number: 726; 
Foster: Percentage: 6.8; 
Nonfoster: Number: 3,063; 
Nonfoster: Percentage: 1.3; 
Ratio of foster to nonfoster children: 5.4. 

Category: Prescription for medication with no published dose in 
medical literature for age group; 
Foster: Number: 61; 
Foster: Percentage: 0.6; 
Nonfoster: Number: 334; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 4.1. 

Source: GAO analysis of Oregon Medicaid and foster care data. 

Note: The data contained for each category in this table are not 
mutually exclusive. 

[End of table] 

Table 24: Rates of Children Prescribed Psychotropic Drugs Outside FDA-
Approved Doses or Standards Published in Medical Literature in Texas 
during 2008: 

Category: Prescription exceeding FDA maximum dose for age group; 
Foster: Number: 1,190; 
Foster: Percentage: 3.3; 
Nonfoster: Number: 9,590; 
Nonfoster: Percentage: 0.4; 
Ratio of foster to nonfoster children: 8.9. 

Category: Prescription exceeding maximum dose published in medical 
literature for age group; 
Foster: Number: 1,773; 
Foster: Percentage: 4.9; 
Nonfoster: Number: 11,033; 
Nonfoster: Percentage: 0.4; 
Ratio of foster to nonfoster children: 11.5. 

Category: Prescription with no FDA-approved dose for child's age, 
exceeding dosages for the next most relevant standard; 
Foster: Number: 554; 
Foster: Percentage: 1.5; 
Nonfoster: Number: 1,849; 
Nonfoster: Percentage: 0.1; 
Ratio of foster to nonfoster children: 21.5. 

Category: Prescription for medication with no FDA-approved dose for 
age group; 
Foster: Number: 6,060; 
Foster: Percentage: 16.7; 
Nonfoster: Number: 42,328; 
Nonfoster: Percentage: 1.6; 
Ratio of foster to nonfoster children: 10.3. 

Category: Prescription for medication with no published dose in 
medical literature for age group; 
Foster: Number: 861; 
Foster: Percentage: 2.4; 
Nonfoster: Number: 4,232; 
Nonfoster: Percentage: 0.2; 
Ratio of foster to nonfoster children: 14.6. 

Source: GAO analysis of Texas Medicaid and foster care data. 

Note: The data contained for each category in this table are not 
mutually exclusive. 

[End of table] 

[End of section] 

Appendix VIII: Additional Data on Psychotropic Prescriptions to 
Children Under 1 Year Old: 

This appendix presents detailed information on psychotropic 
prescriptions to children under 1 year old in five selected states. 

Table 25: Prescriptions of Psychotropic Drugs to Foster and Nonfoster 
Children Age 0-1 in Five Selected States: 

Category: ADHD Drugs; 

Ingredient: Clonidine; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 17; 
Nonfoster children: Children: 22; 
Nonfoster children: Prescriptions: 46. 

Ingredient: Guanfacine hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Amphetamine aspartate, amphetamine sulfate, 
dextroamphetamine saccharate, dextroamphetamine sulfate; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Lisdexamfetamine dimesylate; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Methylphenidate hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: 12. 

Ingredient: Subtotal; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 17; 
Nonfoster children: Children: 40; 
Nonfoster children: Prescriptions: 76. 

Category: Anti-anxiety; 

Ingredient: Diphenhydramine hydrochloride (antihistamine); 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: 49; 
Nonfoster children: Prescriptions: 54. 

Ingredient: Hydroxyzine (antihistamine); 
Foster children: Children: 52; 
Foster children: Prescriptions: 70; 
Nonfoster children: Children: 3,408; 
Nonfoster children: Prescriptions: 4,240. 

Ingredient: Alprazolam (benzodiazepine); 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: 14; 
Nonfoster children: Prescriptions: 32. 

Ingredient: Clonazepam (benzodiazepine); 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 18; 
Nonfoster children: Children: 69; 
Nonfoster children: Prescriptions: 219. 

Ingredient: Clorazepate dipotassium (benzodiazepine); 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 14; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Diazepam (benzodiazepine); 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 22; 
Nonfoster children: Children: 95; 
Nonfoster children: Prescriptions: 220. 

Ingredient: Lorazepam (benzodiazepine); 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 15; 
Nonfoster children: Children: 91; 
Nonfoster children: Prescriptions: 127. 

Ingredient: Buspirone hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Subtotal; 
Foster children: Children: 74; 
Foster children: Prescriptions: 142; 
Nonfoster children: Children: 3,730; 
Nonfoster children: Prescriptions: 4,899. 

Category: Antidepressants; 

Ingredient: Bupropion hydrochloride; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Trazodone hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: 16. 

Ingredient: Venlafaxine; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Citalopram hydrobromide; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: 12. 

Ingredient: Escitalopram oxalate; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: 11; 
Nonfoster children: Prescriptions: 24. 

Ingredient: Fluoxetine hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Paroxetine; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Sertraline hydrochloride; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: 12; 
Nonfoster children: Prescriptions: 16. 

Ingredient: Amitriptyline hydrochloride; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: 0; 
Nonfoster children: Prescriptions: 0. 

Ingredient: Doxepin hydrochloride; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: 0; 
Nonfoster children: Prescriptions: 0. 

Ingredient: Subtotal; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: 18; 
Nonfoster children: Children: 49; 
Nonfoster children: Prescriptions: 87. 

Category: Antipsychotics; 

Ingredient: Aripiprazole; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Olanzapine; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Quetiapine fumarate; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Risperidone; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Ziprasidone; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Subtotal ; 
Foster children: Children: less than 10; 
Foster children: Prescriptions: less than 10; 
Nonfoster children: Children: 12; 
Nonfoster children: Prescriptions: 15. 

Category: Hypnotic; 

Ingredient: Triazolam; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Zolpidem tartrate; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Ingredient: Subtotal ; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Category: Mood stabilizer; 
Ingredient: Lithium; 
Foster children: Children: 0; 
Foster children: Prescriptions: 0; 
Nonfoster children: Children: less than 10; 
Nonfoster children: Prescriptions: less than 10. 

Category: Total[A]; 
Foster children: Children: 85; 
Foster children: Prescriptions: 182; 
Nonfoster children: Children: 3,836; 
Nonfoster children: Prescriptions: 5,083. 

Source: GAO analysis of state Medicaid and foster care data. 

[A] Note: These subtotals and total differ from those in table 2 
because children prescribed multiple ingredients from the same 
category of drug are listed once for each ingredient in the table 
above, and therefore may be counted multiple times per category. In 
table 2, children are counted only once per category of drug. 

[End of table] 

[End of section] 

Appendix IX: Additional Data on Psychotropic Drugs with Gaps in 
Prescriptions of 7 to 29 Days: 

This appendix presents detailed information on psychotropic drugs 
prescribed for foster and nonfoster children with gaps in 
prescriptions of 7-29 days. While children in foster care had a higher 
rate of three or more gaps in prescriptions for a single active 
ingredient in all states, other differences between gaps in 
prescriptions for foster and nonfoster children varied by state. 

In the tables below, rates for foster and nonfoster children can be 
compared within the same state. However, prescription rates cannot be 
compared across states. Since we used both primary and secondary lists 
in our gaps analysis, the number of foster and nonfoster children 
prescribed a psychotropic drug is slightly higher than reported in our 
overall prescription rates, which were based on primary drugs only. 

Table 26: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Florida 
during 2008: 

Age: 0-17; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 355; 
Nonfoster children: 7,381; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 1.8; 
Nonfoster children: 1.1; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.8; 
Nonfoster children: 12.1. 

Age: 13-17; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 159; 
Nonfoster children: 2,379; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 2.8; 
Nonfoster children: 1.6; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.2; 
Nonfoster children: 12.6. 

Age: 6-12; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 167; 
Nonfoster children: 4,489; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 3.0; 
Nonfoster children: 1.9; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 9.1; 
Nonfoster children: 14.5. 

Age: 0-5; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 29; 
Nonfoster children: 513; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 0.4; 
Nonfoster children: 0.2; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 5.9; 
Nonfoster children: 4.6. 

Source: GAO analysis of Florida Medicaid and foster care data. 

[End of table] 

Table 27: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Florida during 2008: 

Age: 0-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.09; 
Nonfoster: 1.18; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.59; 
Nonfoster: 1.85. 

Age: 0-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 9.64; 
Nonfoster: 9.63; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 13.98; 
Nonfoster: 15.01. 

Age: 13-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.15; 
Nonfoster: 1.33; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.57; 
Nonfoster: 1.82. 

Age: 13-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 10.35; 
Nonfoster: 11.03; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.05; 
Nonfoster: 15.04. 

Age: 6-12; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.13; 
Nonfoster: 1.35; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.60; 
Nonfoster: 1.88. 

Age: 6-12; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 9.82; 
Nonfoster: 10.72; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 13.89; 
Nonfoster: 14.94. 

Age: 0-5; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.68; 
Nonfoster: 0.48; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.65; 
Nonfoster: 1.74. 

Age: 0-5; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 5.75; 
Nonfoster: 4.24; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.01; 
Nonfoster: 15.28. 

Source: GAO analysis of Florida Medicaid and foster care data. 

[End of table] 

Table 28: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in 
Massachusetts during 2008: 

Age: 0-17; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 330; 
Nonfoster children: 3,825; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 3.4; 
Nonfoster children: 1.8; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 8.4; 
Nonfoster children: 16.4. 

Age: 13-17; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 210; 
Nonfoster children: 1,769; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 4.3; 
Nonfoster children: 2.5; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.8; 
Nonfoster children: 16.4. 

Age: 6-12; 
Number of children who had three or more gaps in drug claims: 
Foster Children: 112; 
Nonfoster children: 1,954; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 4.6; 
Nonfoster children: 2.3; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 9.9; 
Nonfoster children: 17.6. 

Age: 0-5; 
Number of children who had three or more gaps in drug claims: 
Foster Children: less than 10; 
Nonfoster children: 102; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 0.3; 
Nonfoster children: 0.2; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 6.2; 
Nonfoster children: 6.9. 

Source: GAO analysis of Massachusetts Medicaid and foster care data. 

[End of table] 

Table 29: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Massachusetts during 2008: 

Age: 0-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.14; 
Nonfoster: 1.55; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.56; 
Nonfoster: 1.94. 

Age: 0-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 10.57; 
Nonfoster: 11.90; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.37; 
Nonfoster: 14.87. 

Age: 13-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.14; 
Nonfoster: 1.62; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.54; 
Nonfoster: 1.94. 

Age: 13-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 10.65; 
Nonfoster: 12.43; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.42; 
Nonfoster: 14.88. 

Age: 6-12; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.22; 
Nonfoster: 1.60; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.58; 
Nonfoster: 1.95. 

Age: 6-12; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 11.00; 
Nonfoster: 12.14; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.27; 
Nonfoster: 14.84. 

Age: 0-5; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.55; 
Nonfoster: 0.74; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.50; 
Nonfoster: 1.79. 

Age: 0-5; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 5.14; 
Nonfoster: 6.30; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 13.93; 
Nonfoster: 15.18. 

Source: GAO analysis of Massachusetts Medicaid and foster care data. 

[End of table] 

Table 30: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Michigan 
during 2008: 

Age: 0-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 360; 
Nonfoster children: 8,903; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 1.7; 
Nonfoster children: 0.9; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.9; 
Nonfoster children: 11.3. 

Age: 13-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 165; 
Nonfoster children: 3,459; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 2.6; 
Nonfoster children: 1.5; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.2; 
Nonfoster children: 10.8. 

Age: 6-12; 
Number of children who had three or more gaps in drug claims: 
Foster children: 174; 
Nonfoster children: 5,122; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 2.6; 
Nonfoster children: 1.5; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 9.3; 
Nonfoster children: 12.2. 

Age: 0-5; 
Number of children who had three or more gaps in drug claims: 
Foster children: 21; 
Nonfoster children: 322; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 0.3; 
Nonfoster children: 0.1; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 5.6; 
Nonfoster children: 6.4. 

Source: GAO analysis of Michigan Medicaid and foster care data. 

[End of table] 

Table 31: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Michigan during 2008: 

Age: 0-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.10; 
Nonfoster: 1.14; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.60; 
Nonfoster: 1.76. 

Age: 0-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 10.03; 
Nonfoster: 9.61; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.55; 
Nonfoster: 14.85. 

Age: 13-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.14; 
Nonfoster: 1.18; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.55; 
Nonfoster: 1.74. 

Age: 13-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 10.67; 
Nonfoster: 10.16; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.47; 
Nonfoster: 14.96. 

Age: 6-12; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.15; 
Nonfoster: 1.17; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.67; 
Nonfoster: 1.79. 

Age: 6-12; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 9.99; 
Nonfoster: 9.67; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.53; 
Nonfoster: 14.76. 

Age: 0-5; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.67; 
Nonfoster: 0.65; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.64; 
Nonfoster: 1.71. 

Age: 0-5; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 6.34; 
Nonfoster: 5.68; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 15.61; 
Nonfoster: 14.97. 

Source: GAO analysis of Michigan Medicaid and foster care data. 

[End of table] 

Table 32: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Oregon 
during 2008: 

Age: 0-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 167; 
Nonfoster children: 1,174; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 1.6; 
Nonfoster children: 0.5; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.7; 
Nonfoster children: 9.5. 

Age: 13-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 97; 
Nonfoster children: 576; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 3.6; 
Nonfoster children: 1.2; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 8.1; 
Nonfoster children: 9.3. 

Age: 6-12; 
Number of children who had three or more gaps in drug claims: 
Foster children: 61; 
Nonfoster children: 559; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 1.7; 
Nonfoster children: 0.7; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.2; 
Nonfoster children: 10.5. 

Age: 0-5; 
Number of children who had three or more gaps in drug claims: 
Foster children: less than 10; 
Nonfoster children: 39; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 0.2; 
Nonfoster children: 0.0; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.1; 
Nonfoster children: 4.7. 

Source: GAO analysis of Oregon Medicaid and foster care data. 

[End of table] 

Table 33: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Oregon during 2008: 

Age: 0-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.96; 
Nonfoster: 0.95; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.63; 
Nonfoster: 1.79. 

Age: 0-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 8.31; 
Nonfoster: 7.70; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.15; 
Nonfoster: 14.53. 

Age: 13-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.06; 
Nonfoster: 0.95;
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.62; 
Nonfoster: 1.77. 

Age: 13-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 9.06; 
Nonfoster: 7.75; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 13.88; 
Nonfoster: 14.46. 

Age: 6-12; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.88; 
Nonfoster: 1.01; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.64; 
Nonfoster: 1.81. 

Age: 6-12; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 7.75; 
Nonfoster: 8.12; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.51; 
Nonfoster: 14.55. 

Age: 0-5; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.57; 
Nonfoster: 0.52; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.71; 
Nonfoster: 1.72. 

Age: 0-5; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 5.08; 
Nonfoster: 4.63; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 15.37; 
Nonfoster: 15.15. 

Source: GAO analysis of Oregon Medicaid and foster care data. 

[End of table] 

Table 34: Rates of Psychotropic Drugs with Three or More Gaps of 7-29 
Days in Prescriptions to Foster and Nonfoster Children in Texas during 
2008: 

Age: 0-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 798; 
Nonfoster children: 17,512; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 2.2; 
Nonfoster children: 0.7; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 6.6; 
Nonfoster children: 8.6. 

Age: 13-17; 
Number of children who had three or more gaps in drug claims: 
Foster children: 336; 
Nonfoster children: 5,185; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 4.1; 
Nonfoster children: 1.1; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 7.0; 
Nonfoster children: 9.1. 

Age: 6-12; 
Number of children who had three or more gaps in drug claims: 
Foster children: 373; 
Nonfoster children: 10,935; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 3.1; 
Nonfoster children: 1.2; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 6.6; 
Nonfoster children: 10.8. 

Age: 0-5; 
Number of children who had three or more gaps in drug claims: 
Foster children: 89; 
Nonfoster children: 1,392; 
Percentage of foster or nonfoster children who had three or more gaps 
in drug claims: 
Foster children: 0.5; 
Nonfoster children: 0.1; 
Percentage of foster or nonfoster children prescribed a psychotropic 
drug who had three or more gaps in drug claims: 
Foster children: 5.6; 
Nonfoster children: 3.2. 

Source: GAO analysis of Texas Medicaid and foster care data. 

[End of table] 

Table 35: Average Gaps of 7-29 Days in Psychotropic Drug Prescriptions 
to Foster and Nonfoster Children in Texas during 2008: 

Age: 0-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.23; 
Nonfoster: 0.94; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.44; 
Nonfoster: 1.73. 

Age: 0-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 11.97; 
Nonfoster: 8.37; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.00; 
Nonfoster: 15.32. 

Age: 13-17; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.38; 
Nonfoster: 1.08; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.42; 
Nonfoster: 1.71. 

Age: 13-17; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 13.75; 
Nonfoster: 9.72; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.13; 
Nonfoster: 15.38. 

Age: 6-12; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 1.25; 
Nonfoster: 1.12; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.45; 
Nonfoster: 1.76. 

Age: 6-12; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 11.92; 
Nonfoster: 9.73; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 13.85; 
Nonfoster: 15.26. 

Age: 0-5; 
Category: Average number of gaps per child; 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 0.74; 
Nonfoster: 0.36; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 1.54; 
Nonfoster: 1.62. 

Age: 0-5; 
Category: Average length of gaps per child (days); 
Children in Medicaid with a psychotropic prescription (including those 
with or without a gap in prescriptions): 
Foster: 6.77; 
Nonfoster: 3.44; 
Children in Medicaid with at least one gap in psychotropic drug 
prescriptions: 
Foster: 14.09; 
Nonfoster: 15.52. 

Source: GAO analysis of Texas Medicaid and foster care data. 

[End of table] 

[End of section] 

Appendix X: Selected States' Implementation of AACAP's Best Principles 
Guidelines: 

This appendix compares in detail selected states' oversight of 
psychotropic drug prescriptions for foster children with the American 
Academy of Child and Adolescent Psychiatry (AACAP) Best Principles 
Guidelines. The processes were in place as of October 2011 unless 
otherwise noted. The tables are based on interviews and documentation 
provided by state Medicaid and foster care officials. With the 
exception of table 39, the information below was not tested to ensure 
these principles are implemented effectively. 

Table 36: State Consent Laws and Policies Compared with AACAP Best 
Principle Guidelines: 

AACAP guideline: 
Identify the parties empowered to consent for psychotropic drug 
treatment for youth in state custody in a timely fashion [minimal]. 

State: Florida; 
Extent: Full;
Description: The parent or legal guardian can consent for psychotropic 
drug treatment, or the foster care agency may seek court authorization. 

State: Maryland; 
Extent: Full; 
Description: The parent, legal guardian, court-authorized foster care 
agency, or local social services director or designee can consent for 
psychotropic drug treatment. 

State: Massachusetts; 
Extent: Full; 
Description: For children in the care of the Massachusetts Department 
of Children and Families (DCF) through a voluntary placement 
agreement, only parents may consent to the use of antipsychotic drugs. 
For children in the custody of the Massachusetts DCF through a court 
order or through adoption surrender, court approval is required for 
the use of antipsychotic drugs in all nonemergency cases. According to 
agency officials, parents whose rights have not been terminated, 
caseworkers, or foster parents can provide consent for all other 
psychotropic medications. 

State: Michigan; 
Extent: Full; 
Description: For children in the care of the Michigan Department of 
Human Services (DHS) through a voluntary placement, or children who 
are temporary wards of the court, only parents or legal guardians may 
consent to the use of psychotropic drugs. For children who are 
permanent wards of the court, only the court may consent to the use of 
psychotropic drugs. For children who are permanent wards of the state, 
only the Michigan DHS may consent to the use of psychotropic drugs. 

State: Oregon; 
Extent: Full; 
Description: For children in the care of the Oregon Department of 
Human Services (DHS) through a voluntary placement or custody 
agreement, parents or legal guardians must consent to the use of 
psychotropic drugs. However, if the parents have signed a release 
agreement, then the department may consent. For children placed in 
legal custody of the Oregon DHS, or where the department is the legal 
guardian, then child welfare agency officials may consent to the use 
of psychotropic drugs. In any case, children 14 years or older may 
also consent themselves. 

State: Texas; 
Extent: Full; 
Description: Any individual or state department designated by name in 
a court order (which may include parent, relative, foster parent, or 
others) can give consent for psychotropic drug treatment. If the 
Department of Family and Protective Services (DFPS) is named, the 
department designates both a primary medical consenter and a back-up 
medical consenter (typically emergency shelter employees, live-in 
caregivers, relatives, or caseworkers). Children at least 16 years old 
may also consent themselves, if the court determines the child has the 
capacity to consent. 

AACAP guideline: 
Establish a mechanism to obtain assent for psychotropic medication 
management from minors when possible [minimal].[A] 

State: Florida; 
Extent: Full; 
Description: Since 2010, prescribers are required to determine if 
minor can give assent and records decision in child's medical report. 

State: Maryland; 
Extent: Full; 
Description: If a child is prescribed psychotropic medication and is 
developmentally able to understand the usage and effects of the 
medication, the child should be a part of the process and able to 
exercise their right to take the medication. If the child is not of 
age he or she can refuse medication--the assent or dissent to take 
medication is documented in the child's case record. 

State: Massachusetts; 
Extent: No. 

State: Michigan; 
Extent: No. 

State: Oregon; 
Extent: No. 

State: Texas; 
Extent: Full; 
Description: DFPS policy requires all children's medical consenters to 
discuss their medical care with them in a developmentally appropriate 
way and obtain their input. 

State: AACAP guideline: 
Obtain simply written psycho-educational materials and medication 
information sheets to facilitate the consent process [recommended]. 

State: Florida; 
Extent: Full; 
Description: Florida has an online guide to children's mental health 
services and support which can facilitate the consent process. In 
addition, the child's medical report contains drug information and is 
used during the consent process. The Florida Dependency Court Judges 
Bench-book includes a section on psychotropic drugs to help judges 
when reviewing cases during court hearings. 

State: Maryland; 
Extent: Partial; 
Description: The caseworker must provide information, including reason 
prescribed and side effects, but no standard form is used. 

State: Massachusetts; 
Extent: Full; 
Description: There are two documents staff can use to assist in 
collecting information to make informed consent decisions. One form is 
specific to antipsychotic medications and the other form is for all 
other medications. The prescriber is asked to complete the form and 
give it to the social worker, who can then ask for a member of the 
Massachusetts DCF Health and Medical Services Team to assist in 
interpreting the information and if necessary, obtain additional 
information from the prescriber. An information form stating the risks 
and benefits of medications is available to caseworkers upon request. 

State: Michigan; 
Extent: No; 
Description: Although there are no psycho-educational materials and 
medication information sheets to facilitate the consent process, 
Michigan policy requires that the caseworker maintain a copy of the 
consent form used by the prescriber. 

State: Oregon; 
Extent: Full; 
Description: Since June 2010, the consent form allows prescribers to 
describe target symptoms, potential side effects, and alternative 
treatments. The Oregon DHS website also has a link to a medical chart 
that includes psychotropic drug benefits and side effects. 

State: Texas; 
Extent: Full; 
Description: Since February 2005, psycho-educational materials are 
available to consent-givers online through the Texas DFPS website. 

State: AACAP guideline: 
Establish training requirements for child welfare, court personnel 
and/or foster parents to help them become more effective advocates for 
children in their custody [ideal]. 

State: Florida; 
Extent: Partial; 
Description: Florida DCF's partnership with the University of South 
Florida provides online training, research articles, and child welfare 
resources to foster parents and caseworkers. Guidelines are also 
compiled specifically for court personnel. Content related to 
psychotropic drugs is included in each module of the three tiers of 
required caseworker training. However, the names and indications for 
use of commonly prescribed psychotropic medications are not included 
as part of the required training. 

State: Maryland; 
Extent: Partial; 
Description: As part of the foster parent training, some local 
departments of social services have begun offering training on 
psychotropic drugs and the behaviors associated with taking the 
medication. However, there is no statewide training. 

State: Massachusetts; 
Extent: Partial; 
Description: Caseworkers and attorneys who represent parents and 
children are trained on the court process for obtaining authorization 
for antipsychotic medication and general information on the use and 
effect of psychotropic medications. However agency officials did not 
confirm whether each of the elements listed in AACAP's guidelines for 
training is included. 

State: Michigan; 
Extent: No; 
Description: Michigan has optional children's mental health training 
for child welfare agency staff. There are plans to develop training, 
but the particulars of the trainings had not been completed as of 
September 2011. 

State: Oregon; 
Extent: Partial; 
Description: Oregon required training as a one-time initiative in July 
2010 for Child Welfare Supervisors that covered all of the AACAP best 
principle guidelines for training. The training was optional for 
nonsupervisory staff and a modified version of this course was 
provided at an annual conference for foster parents, Citizen Review 
Board, and other community partners. A webcast training has also been 
offered for foster parents and other child welfare staff and an 
updated version of the training is in the early development stages and 
will be provided as an ongoing training course once completed. 

State: Texas; 
Extent: Full; 
Description: Since 2005, all consent-givers, except parents, must take 
training for informed consent and the provision of medical care which 
includes each of the training requirements listed in the AACAP best 
principle guidelines. The Minimum Standards for Residential Child Care 
Licensing requires that training for foster parents and other 
residential providers include these elements as well. DFPS has no 
authority to require court personnel to complete psychotropic 
medication training. However, DFPS is in the process of developing 
online training to include all of the training requirements noted in 
the AACAP guidelines and will be made available to children's 
caregivers, staff, court personnel, and others in the child welfare 
system through an external website. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and foster care officials, and the AACAP's best principles guidelines. 

[A] According to AACAP, consent is given by the person who has legal 
authority to make medical decisions, whereas assent is for the patient 
themselves if they are not legally able to make their own decisions. 

[B] AACAP Best Principles Guidelines state this training should 
include the names and indications for use of commonly prescribed 
psychotropic medications, monitoring for medication effectiveness and 
side effects, and maintaining medication logs. Materials for this 
training should include a written "Guide to Psychotropic Medications" 
that includes many of the basic guidelines reviewed in the 
psychotropic medication training curriculum. 

[End of table] 

Table 37: State Oversight Laws and Policies Compared with AACAP's Best 
Principle Guidelines: 

AACAP guideline: 
Establish guidelines for the use of psychotropic medications for 
children in state custody [minimal]. 

State: Florida; 
Extent: Partial; 
Description: Evidence-based Medication Drug Guidelines for Children 
were developed by the Florida Mental Health Institute with input from 
physician researchers and are updated biennially. However, these 
guidelines are not specifically targeted towards children in state 
custody. Since 2008, the prior authorization review process requires a 
clinical review or second medical opinion by a child and adolescent 
psychiatrist for children less than 6 years of age prescribed an 
antipsychotic medication, in order to be reimbursed by Medicaid. Since 
2010 prior authorization reviews are conducted for any antipsychotic 
lacking an FDA indication or acceptable evidence-base for safety and 
efficacy for children less than 18 years of age, and any high dose of 
antipsychotic medication. 

State: Maryland; 
Extent: Partial; 
Description: Beginning October 2011, the Maryland Medicaid Pharmacy 
Program (MMPP) implemented a peer-review authorization process to 
ensure the safe and effective use of antipsychotic medications in 
children. Claims for antipsychotic medications for children younger 
than the FDA approved age require a prior authorization based on the 
peer-review assessment. The MMPP's board-certified child psychiatrist 
oversees the peer-review project. 

State: Massachusetts; 
Extent: Partial; 
Description: Massachusetts guidelines are specific only to 
antipsychotic drugs. However, the majority of children in state 
custody are members of MassHealth and are subjected to the 
requirements and clinical management principles of the MassHealth Drug 
List, but these principles are not specific to foster children. 

State: Michigan; 
Extent: Full; 
Description: As of April 2010 Michigan adopted the guidelines 
established by Texas for the use of psychotropic medication for 
children in state custody. 

State: Oregon; 
Extent: No; 
Description: Since June 2010, annual reviews of psychotropic drugs 
must be conducted for all children under 6, or for any individual 
under 20 who remains in the care and custody of the state and who has 
more than two prescriptions for psychotropic drugs. The review must be 
performed by an individual other than the prescriber who is either a 
licensed medical professional, a qualified mental health professional 
with the authority to prescribe drugs, or a licensed pharmacist with 
the Drug Use Review Program. However, these are retrospective reviews 
that occur on an annual basis and do not take place at the time of 
prescription. 

State: Texas; 
Extent: Full; 
Description: Since 2005, the Psychotropic Medication Utilization 
Parameters for Foster Children have been in place to serve as 
guidelines for the use of psychotropic drugs for children in foster 
care. For a child being prescribed a psychotropic medication, any of 
the following suggests the need for additional review: 
1. Absence of a thorough assessment of child's mental health diagnosis 
in the child's medical record; 
2. Five or more psychotropic medications prescribed concomitantly 
(side-effect medications are not included in this count); 
3. Prescribing of: 
(a) Two or more concomitant antidepressants (if an additional one is 
used, may be reviewed but will be allowed if reasonable for the 
indications); 
(b) Two or more concomitant antipsychotic medications; 
(c) Two or more concomitant stimulant medications; 
(d) Three or more concomitant mood stabilizer medications; 
Note: Polypharmacy is defined here as the use of two or more 
medications for the same indication. The prescription of a long-acting 
stimulant and an immediate release stimulant of the same chemical 
entity does not constitute concomitant prescribing and when switching 
psychotropic drugs, medication overlap and lowering the dose of an old 
drug while increasing the dose of a new drug may be utilized before 
discontinuing the first medication; 
4. The prescribed psychotropic medication is not consistent with 
appropriate care for the patient's diagnosed mental disorder or with 
documented target symptoms usually associated with a therapeutic 
response to the medication prescribed; 
5. Psychotropic polypharmacy for a given mental disorder is prescribed 
before utilizing psychotropic monotherapy; 
6. The psychotropic medication dose exceeds usual recommended doses; 
7. Psychotropic medications are prescribed for children of very young 
age, including children receiving the following medications with an 
age of: 
Antidepressants: Less than four years of age; 
Antipsychotics: Less than four years of age; 
Psychostimulants: Less than three years of age; 
8. Prescribing by a primary care provider who has not documented 
previous specialty training for a diagnosis other than the following 
(unless recommended by a psychiatrist consultant): 
Attention Deficit Hyperactive Disorder (ADHD); 
Uncomplicated anxiety disorders; 
Uncomplicated depression. 

State: AACAP guideline: 
Oversight program includes an advisory committee to oversee a 
medication formulary and provide medication monitoring guidelines to 
practitioners who treat children in the child welfare system 
[ideal][A]. 

State: Florida; 
Extent: Partial; 
Description: The Florida Medicaid Drug Therapy Management Program for 
Behavioral Health (MDTMP for BH) was created in 2004 to improve the 
quality of behavioral health drug prescribing, improve patient 
adherence to therapy, reduce clinical risks, and lower cost while 
providing appropriate therapy. In 2006, an expert panel of 
psychiatrists developed evidence-based best practice guidelines for 
the use of psychotherapeutic drugs in children and adolescents. The 
guidelines were published in October 2006 and are reviewed and updated 
biennially. Members of the panel include a combination of pediatric, 
adolescent, and adult psychiatrists as well as primary care 
physicians, pediatricians, DCF members, Agency for Health Care 
Administration (AHCA) staff and clinical pharmacists. However, the 
advisory committee does not include other mental health providers, 
consulting clinical pharmacists, family advocates or parents, or state 
child advocates. The advisory committee does not oversee a medication 
formulary or provide medication monitoring guidelines specifically for 
practitioners who treat children in the child welfare system. The 
Florida MDTMP for BH does provider outreach and the guidelines are 
also accessible online. 

State: Maryland; 
Extent: Partial; 
Description: The MMPP's board-certified child psychiatrist oversees 
the peer-review project for antipsychotic medications. However, there 
are no medication-monitoring guidelines specific to practitioners who 
treat children in the child welfare system. 

State: Massachusetts; 
Extent: No; 
Description: The Massachusetts Drug Utilization Review program's goal 
is to ensure that prescribed drugs are appropriate, medically 
necessary, and not likely to result in medication-related problems. 
However, Massachusetts does not have an advisory committee that 
oversees a medication formulary and monitoring guidelines specific to 
practitioners who treat children in the child welfare system. 

State: Michigan; 
Extent: Partial; 
Description: Michigan DHS established a Child Welfare Health Advisory 
Board in June 2010 and a subcommittee from that group meets to discuss 
the oversight of psychotropic medication including monitoring 
guidelines. Members of the subcommittee include agency and community 
child and adolescent psychiatrists, pediatricians, other mental health 
providers, and state child advocates. However, the subcommittee does 
not include consulting clinical pharmacists, and family advocates or 
parents. The group met in 2010, and it was determined that the 
pharmacy claims data were needed to move forward and that the group 
would not meet again until they were available. The advisory committee 
planned to meet again in October 2011 after receiving a second set of 
data. There is not a separate formulary for children in state custody. 

State: Oregon; 
Extent: No; 
Description: Oregon accesses the Drug Use Review (DUR) in the Division 
of Medical Assistance Programs. DUR is a program designed to measure 
and assess the proper utilization, quality, therapy, medical 
appropriateness, appropriate selection and cost of prescribed 
medication through evaluation of claims data. However, Oregon does not 
have an advisory committee that oversees a medication formulary and 
monitoring guidelines specific to practitioners who treat children in 
the child welfare system. 

State: Texas; 
Extent: Partial; 
Description: In 2004, an advisory committee convened and issued a 
report recommending that parameters and oversight for psychotropic 
medications for children in foster care be put into place. In 2005 the 
Psychotropic Medication Utilization Parameters for Foster Children 
were released. The most recent update to the parameters was released 
in December 2010. Members of the advisory committee who update the 
parameters on a biennial basis as necessary include agency and 
community child and adolescent psychiatrists, pediatricians, other 
mental health providers, consulting clinical pharmacists, and family 
advocates or parents, but do not include state child advocates. 
However, according to agency officials Texas is initiating a new 
psychotropic medication workgroup that will include state child 
advocates and judges in addition to the current members. The 
Psychotropic Medication Monitoring Group, comprised of various health 
care professionals, reviews ongoing monitoring conducted by consulting 
child psychiatrists. An annual report on psychotropic medication 
utilization is posted online and a panel of experts reviews and 
updates the parameters periodically based on the most current evidence-
based literature available at the time of publication. 

State: AACAP guideline: 
Oversight program monitors the rate and types of psychotropic 
medication usage and the rate of adverse reactions among youth in 
state custody [ideal]. 

State: Florida; 
Extent: Partial; 
Description: Florida DCF has two recurring file exchanges with 
Florida's Agency for Health Care Administration (AHCA). One file is 
used to identify and verify those children who are enrolled in the 
prepaid Mental health program. The second file exchange is a Psych 
Meds Match report that recurs monthly. This report is used to validate 
the recording of psychotropic medications. Florida DCF provides a list 
of all children who are active in in-home or out-of-home care to 
Florida's third party vendor for pharmacy data. The third party 
matches against their pharmacy data and reports back all psychotropic 
medications prescribed for the last 3 months. This information is 
subsequently provided to the local agencies for monitoring. Florida 
DCF also provides a weekly report of all children prescribed 
psychotropic medications (according to the child welfare record) and a 
corresponding list report that includes every child by name so that 
regions and management can address individual cases as needed. 
Supervisors review cases every 30 days and may address issues at that 
time. The report is completed for all psychotropic medications for all 
children 0-17 years of age and supervisory reviews are done on all 
children. The Florida Mental Health Institute at the University of 
South Florida performs retrospective prescription claims reviews for 
AHCA to determine the rate and types of psychotropic drugs used for 
Medicaid eligible children in the child welfare system. However, 
Florida DCF does not monitor the rate and types of psychotropic 
medication in relation to the state guidelines and does not monitor 
and review adverse reactions at the aggregate level. 

State: Maryland; 
Extent: Partial; 
Description: According to an agency official, data on rate and types 
of psychotropic medication usage are gathered for all children in the 
child welfare system in a collaborative effort between the Departments 
of Human Resources (Child Welfare) and Health and Mental Hygiene, and 
the University of Maryland Schools of Pharmacy, Social Work and 
Medicine. However, there is not a uniform system in place among local 
departments of social services to monitor the rate of adverse 
reactions. 

State: Massachusetts; 
Extent: Partial; 
Description: Unstable and medically complex children receive home 
visits from a pediatric nurse practitioner. Also, when a court 
authorizes antipsychotic medication, it appoints a Guardian ad Litem 
to monitor the use of the medication and it sets periodic--usually 
every 6 months--reviews of the usage and impact of the medication, 
including any adverse reactions. 

State: Michigan; 
Extent: Partial; 
Description: Michigan DHS completed an interagency agreement for data 
sharing with the Michigan Department of Community Health (DCH) to 
review foster children's prescription claims data on a quarterly 
basis. However, Michigan DHS was unable to build reliable reports with 
the first data set received April 2011 and there is no process to 
monitor and review adverse reactions. 

State: Oregon; 
Extent: Partial; 
Description: As of June 2010, an annual review of psychotropic 
medications by an individual other than the prescriber is performed 
when: 
(a) a child or young adult has more than two prescriptions for 
psychotropic medications; or; 
(b) a child is under 6 years of age; 
The annual review guidelines have been used as a threshold for review 
or additional review on an individual basis. There is no macro level 
review of foster children's claims data to track prescribing trends 
across the entire foster care population and no aggregate reviews of 
adverse reactions to medications. Prior to 2010 the department enacted 
a number of different informal strategies to better understand and 
inform the process which concluded with the development of the rules 
now in place. 

State: Texas; 
Extent: Partial; 
Description: In June 2006, a report on the use of psychotropic 
medications in Texas foster children was released. This macro level 
analysis reports the rate and types of various psychotropic 
prescribing practices and is updated and reported on an annual basis. 
However, adverse reactions are not tracked and reviewed on a macro 
level. 

State: AACAP guideline: 
Oversight program establishes a process to review non-standard, 
unusual, and/or experimental psychiatric interventions with children 
who are in state custody [ideal]. 

State: Florida; 
Extent: Partial; 
Description: A preconsent review by a consultant child psychiatrist is 
obtained prior to the prescription of a psychotropic medication for 
any child under 11 years of age who is prescribed two or more 
psychotropic medications and who is in the custody of the department 
in out-of-home care. The results of the review by the consultant child 
psychiatrist are provided to the child and to the person who has legal 
authority to provide express and informed consent or the judge who is 
providing the court order for treatment with a psychotropic 
medication. Florida DCF may utilize the department's pre-consent 
review contract with the University of Florida or may contract locally 
with a child psychiatrist. The University of Florida has at least two 
certified child psychiatrists on staff who review the medications 
identified by Florida DCF for additional review. The child 
psychiatrists can contact the prescriber and request more information 
or recommend alternative treatment options as necessary. However, the 
prescribing physician is permitted by law to fill the prescription 
using their own discretion regardless of the child psychiatrists' 
recommendation. 

State: Maryland; 
Extent: Partial; 
Description: A child and adolescent psychiatrist who is on the faculty 
at Johns Hopkins University School of Medicine monitors all 
psychotropic medication use for children entering foster care in 
Baltimore City. However, this practice is not statewide. 

State: Massachusetts; 
Extent: Partial; 
Description: For extraordinary, complex, risky, or novel treatment, 
Massachusetts DCF is required to get the consent of the parents (if 
the child is in the department's care) or receive prior judicial 
approval (if the child is in the department's custody). However, the 
only psychotropic medication regimen that has been defined to meet 
these criteria is antipsychotic medications. 

State: Michigan; 
Extent: Full; 
Description: The Michigan DHS oversight program flags pharmacy claims 
when the prescribing of psychotropic medication falls outside of 
established guidelines. Current reviews are conducted on prescribing 
practices including: four or more psychotropic medications prescribed 
concomitantly; prescribing two or more concomitant antidepressant 
medications, two or more concomitant antipsychotic medications, two or 
more concomitant stimulant medications, or two or more concomitant 
mood stabilizer medications; psychotropic medication dose exceeds 
usually recommended dose; and psychotropic medications prescribed for 
children 5 years and under. In addition, Michigan DHS hired 25 health 
liaison officers to serve as health care advocates for foster children 
and help assist in the review and oversight process of psychotropic 
medications under the direction of the Michigan DHS medical consultant. 

State: Oregon; 
Extent: Partial; 
Description: Oregon's annual review guidelines have been used as a 
threshold for review or additional review on an individual basis. 

State: Texas; 
Extent: Full; 
Description: Since April 2008, State of Texas Access Reform (STAR) 
Health Service Managers perform health assessments on foster children 
to identify those who have medication regimens which appear to be 
outside the Psychotropic Medication Utilization Parameters. 

State: AACAP guideline: 
Oversight program collects and analyzes data and makes quarterly 
reports to the state or county child welfare agency regarding the 
rates and types of psychotropic medication use. These data are made 
available to clinicians in the state to improve the quality of care 
provided [ideal]. 

State: Florida; 
Extent: Partial; 
Description: Florida DCF reports the number of children on 
psychotropic medications, the number of children who received informed 
consent, and the demographics of those cases on a weekly basis to 
management. Florida DCF monitors the number of children prescribed 
psychotropic medications and whether valid express and informed 
consent were obtained or court authorized, but does not monitor and 
report the rates and types of psychotropic medications prescribed. The 
state conducts quarterly quality assurance reviews of all community-
based care agencies. Cases are randomly selected for a comprehensive 
quality assurance review and if the child is on psychotropic 
medications, the reviewer is required to determine if the case 
management organization complied with statute and Florida 
Administrative Code. All quality assurance reports are accessible 
online. Florida DCF also publishes an annual report of findings. 

State: Maryland; 
Extent: Partial; 
Description: The oversight program used in Baltimore City collects and 
analyzes data and makes reports to the state and the Baltimore City 
Child Welfare Department. However, this practice is not statewide. 

State: Massachusetts; 
Extent: Partial; 
Description: Individual cases are reviewed quarterly, but macro-level 
reports are not done regularly. However, episodic reports have been 
issued on the rates and types of psychotropic medication for specific 
drug types and age ranges that include foster children. 

State: Michigan; 
Extent: No; 
Description: There is a plan to look at the claims data systemically, 
but it has not yet been determined how the reports will be developed 
or shared. Those decisions will be made by the Child Welfare Health 
Advisory Board's subcommittee. 

State: Oregon; 
Extent: No; 
Description: Medication logs are reviewed monthly on an individual 
basis by the caseworker, but no macro-level report is available to 
improve the quality of care. 

State: Texas; 
Extent: Full; 
Description: Quarterly reports are reviewed by the Psychotropic 
Medication Monitoring Group, which is chaired by DFPS. These reports 
include the percentile of children in foster care on psychotropic 
medications and the percentile that are outside parameters (receiving 
any psychotropic medications under age 4 years, two of more of the 
same class and/or five or more of the same class). Annually, at the 
end of each state fiscal year, a report specific to foster children is 
generated from Medicaid prescription data and posted on the Texas 
Health and Human Services Commission website for use by clinicians and 
other stakeholders. 

State: AACAP guideline: 
Maintain an ongoing record of diagnoses, height and weight, allergies, 
medical history, ongoing medical problem list, psychotropic 
medications, and adverse medication reactions that are easily 
available to treating clinicians 24 hours a day [ideal]. 

State: Florida; 
Extent: Partial; 
Description: Florida maintains a resource record as the child's 
standardized record that contains copies of all available and 
accessible medical and psychological information-
-including behavioral health information--pertaining to the child. The 
resource record is a hard copy form maintained in the child's foster 
home. However, the states Automated Child Welfare Information System 
includes medical information and most child welfare agencies store 
documents electronically to maintain copies of medical records. The 
electronic systems that store critical information such as 
immunizations and medical history are accessible 24 hours a day. 
However, Florida's policy does not specify whether the record of 
diagnosis, height and weight, allergies, medical history, ongoing 
medical problem list, psychotropic medications, and adverse medication 
reactions are specifically required to be maintained. 

State: Maryland; 
Extent: Full; 
Description: Each child that enters out-of-home placement is given a 
medical passport. This passport serves as a record of the child's 
previous and current medical file. The passport is provided to the 
placement resource (e.g., foster parents or group home) and is carried 
to every medical appointment to be reviewed if necessary by the health 
care provider. Each medical visit, medication, and immunization is 
documented in the passport along with diagnoses, height and weight, 
allergies, medical history, ongoing medical problem list, psychotropic 
medications, and adverse medication reactions. An additional copy of 
the passport is kept in the child's case record and also maintained 
electronically. Since the passport is maintained at the child's 
placement it is available 24 hours a day for emergencies. 

State: Massachusetts; 
Extent: Partial; 
Description: Massachusetts DCF requires the use of a "medical 
passport" for all children in substitute care. The medical passport 
records pertinent and available medical dental/mental health and 
developmental data about the child. Department social workers and 
medical providers complete relevant portions of the passport. The 
passports are held by the substitute care provider and remain with the 
child for the duration of his or her placement. If a child moves to a 
new substitute care placement or returns home, the medical passport 
moves with the child. However, the medical passport does not include 
height and weight, adverse reactions, or an ongoing medical problem 
list. 

State: Michigan; 
Extent: Full; 
Description: Each foster child is provided a medical passport that 
records all of the elements recommended by AACAP. The passport is a 
paper document and is provided to the foster parents to ensure health 
information is updated as necessary. The passport stays with the child 
over time, but it is the responsibility of the foster parents to make 
sure the passport stays updated and is made available to treating 
clinicians. 

State: Oregon; 
Extent: Partial; 
Description: Oregon has medical information and a health care record 
for the child in foster care. However, these records may not be 
inclusive of all the child's health care information--which may be 
with other medical offices--and they are not accessible 24 hours a day 
to health care providers. 

State: Texas; 
Extent: Partial; 
Description: As of April 2008, a web-based electronic health record 
system maintains health information for foster children and is 
available to treating clinicians 24 hours a day. The electronic health 
record system records an ongoing record of diagnoses, medical history, 
and psychotropic medications, but the adverse medication reactions, 
height and weight, and allergies are optional and not all health care 
providers enter this information. An ongoing medical problem list is 
not recorded in the electronic health record system. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and foster care officials, and the AACAP's best principles guidelines. 

[A] AACAP describes advisory committees as composed of agency and 
community child and adolescent psychiatrists, pediatricians, other 
mental health providers, consulting clinical pharmacists, family 
advocates or parents, and state child advocates. 

[End of table] 

Table 38: State Consultation Programs Compared with AACAP's Best 
Principle Guidelines: 

State: AACAP guideline: 
Design a consultation program administered by child and adolescent 
psychiatrists. This program provides consultation by child and 
adolescent psychiatrists to the persons or agency that is responsible 
for consenting for treatment with psychotropic medications 
[recommended][A]. 

State: Florida; 
Extent: Full; 
Description: Starting in 2004, the MedConsult line was made available 
for families, guardians, and the courts to consult with board-
certified child psychiatrists via telephone. The purpose of the 
MedConsult line is to assist decision makers who give express and 
informed consent for psychotropic medication for dependent children or 
children enrolled in the Behavioral Health Network. The MedConsult 
Line is available Monday through Friday 9:00 am until 5:00 pm. The 
court may order additional medical consultation, including 
consultation with the MedConsult line at the University of Florida, if 
available, or require the department to obtain a second opinion within 
a reasonable timeframe as established by the court, not to exceed 21 
calendar days, after such order based upon consideration of the best 
interests of the child. The MedConsult line is not a second opinion 
and participation is voluntary. The kind of information provided 
include indicated uses, usual and customary practices, dose ranges, 
starting dose, FDA Box Warnings, on-or off-label use, any precautions 
such as EKGs, and lab work. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: Partial; 
Description: The Massachusetts Department of Mental Health (DMH) has 
six child psychiatrists who are available to provide consultations on 
a part-time basis. In addition, Massachusetts DCF has a part-time 
child psychiatrist on staff who is available for consultation on 
individual cases and provides consultation to the agency senior 
managers. Pharmacists are also available to consult with consent-
givers if the child is enrolled on MassHealth. A pharmacist is 
available via phone to provide information regarding the child's drug 
history, provide an opinion on proposed medications--including 
interactions between multiple medications--make consent 
recommendations, and/or call the prescriber to ask questions and seek 
additional information. 

State: MI; 
Extent: No; 
Description: According to agency officials, Michigan DHS has set aside 
$1 million to develop a consultation program and is considering a line 
item for future fiscal years to continue the program if successful. 

State: Oregon; 
Extent: Partial; 
Description: As of February 2009, child welfare agency officials give 
consent for children placed in legal custody of Oregon DHS, or where 
the department is the legal guardian, and have access to a consulting 
child and adolescent psychiatrist on a part-time basis. 

State: Texas; 
Extent: Partial; 
Description: The DFPS Medical Director who is a board-certified child 
and adolescent psychiatrist, consults with CPS staff regarding policy, 
procedures, training materials and complex cases. Under the guidance 
of the DFPS Medical Director, the CPS Division Administrator for 
Medical Services and the Regional Nurse Consultants also provide 
guidance and education to staff that consent to a child's treatment 
with psychotropic medications and consult on specific cases when 
necessary or when requested. 

State: AACAP guideline: 
The consultation program provides consultations by child and 
adolescent psychiatrists to, and at the request of, physicians 
treating this difficult patient population [recommended]. 

State: Florida; 
Extent: Full; 
Description: The MedConsult line is available to physicians who seek 
consultations by child and adolescent psychiatrists. 

State: Maryland; 
Extent: Partial; 
Description: A child and adolescent psychiatrist consults with 
prescribers for youth entering Baltimore City Child Welfare. MMPP has 
contracted with the University of Maryland (UMD) Division of Child and 
Adolescent Psychiatry and School of Pharmacy to provide call center 
services. UMD utilizes psychiatrists and pharmacists to answer calls 
from Medicaid prescribers who prescribe antipsychotic medications off-
label to children and provide reviews of patient profiles to determine 
if the program will approve or deny the claim. However, these reviews 
are only for antipsychotic drugs and do not include other psychotropic 
drugs. 

State: Massachusetts; 
Extent: Full; 
Description: As of December 2005, the Massachusetts Child Psychiatry 
Access Project (MCPAP) was put in place, which allows pediatricians to 
have access to consultations with child and adolescent psychiatrists 
by phone on weekdays between 9 a.m. and 5 p.m., within 30 minutes of 
the request. 

State: MI; 
Extent: No. 

State: Oregon; 
Extent: No; 
Description: The Oregon Psychiatric Access Line for Kids project is 
under development which would allow primary care physicians and nurse 
practitioners to consult with child psychiatrists as needed. Agency 
officials told us that future implementation is dependent on finding a 
long-term funding source. Neither the Oregon Foster children program 
nor the state Medicaid agency currently uses this program. 

State: Texas; 
Extent: No; 
Description: Child psychiatrists with Texas STAR health consult with 
prescribing physicians as part of the psychotropic medication 
utilization review process. However, these consultations are not 
conducted at the request of treating physicians as recommended by 
AACAP. 

State: AACAP guideline: 
The consultation program conducts face-to-face evaluations of youth by 
child and adolescent psychiatrists at the request of the child welfare 
agency, the juvenile court, or other state or county agencies 
empowered by law to consent for treatment with psychotropic 
medications when concerns have been raised about the pharmacological 
regimen [recommended]. 

State: Florida; 
Extent: No. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: Full; 
Description: Massachusetts DCF mental health specialists are able to 
arrange consultations or evaluations if needed and the Juvenile Courts 
have access to Juvenile Court Clinics where evaluations can be 
conducted. 

State: MI; 
Extent: No. 

State: Oregon; 
Extent: No. 

State: Texas; 
Extent: Full; 
Description: Since April 2008, the psychotropic medication utilization 
review process is triggered when a child's medication regimens are 
outside the parameters or when certain criteria are met, including at 
the request of CPS nurse consultants, caseworkers, court appointed 
special advocates, foster parents, attorneys, residential child care 
providers, and at the request of the court. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and foster care officials, and the AACAP's best principles guidelines. 

[A] Massachusetts, Oregon, and Texas received a partial categorization 
because the consultation programs do not ensure all possible consent-
givers have access to consultations with a child and adolescent 
psychiatrist. For example, when parent(s) have retained their rights 
to consent for their child's medication and the child enters foster 
care through a voluntary placement agreement. In addition, 
consultations in Massachusetts and Oregon are only available to agency 
officials on a part-time basis. 

[End of table] 

Table 39: State Information-Sharing Laws and Policies Compared with 
AACAP's Best Principle Guidelines: 

AACAP guideline: 
Create a website to provide ready access for clinicians, foster 
parents, and other caregivers to pertinent policies and procedures 
governing psychotropic medication management [ideal]. 

State: Florida; 
Extent: Full; 
Description: Florida DCF has partnered with the University of South 
Florida to implement Florida's Center for the Advancement of Child 
Welfare Practice to provide needed information and support to 
Florida's professional child welfare stakeholders. The website 
includes policies and procedures regulating psychotropic drug 
management. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: Full; 
Description: The official website of the Executive Office of Health 
and Human Services (EOHHS) includes policies and procedures governing 
psychotropic medication management. 

State: Michigan; 
Extent: No. 

State: Oregon; 
Extent: Full; 
Description: Oregon developed a website as a communication tool 
during the implementation of the agency's recent 2010 administrative 
rules, but the website is not an ongoing resource for information. The 
website currently has information on state policies and procedures 
governing the use of psychotropic drugs. 

State: Texas; 
Extent: Full; 
Description: As of September 2005, DFPS posted the Psychotropic 
Medication Utilization Parameters for Foster Children on the agency's 
website. Also, DFPS has incorporated requirements to follow the 
principles underlying the parameters into each residential 
child-care contract. The residential contract is revised each year and 
posted on the website. 

AACAP guideline: 
Website includes psycho-educational 
materials [ideal]. 

State: Florida; 
Extent: Full; 
Description: Florida's Center for the Advancement of Child Welfare 
Practice website includes staff publications and educational 
materials about psychotropic drugs. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: Full; 
Description: The official website of EOHHS includes web links to 
psycho-educational materials and publications. 

State: Michigan; 
Extent: No; 
Description: According to an agency official, Michigan DHS added a 
Health Information and Resource page to its internal website that 
Michigan DHS staff can access. The website is updated by the Health, 
Education, and Youth Unit and was activated in January 2011. However, 
this information is not available to external caregivers such as 
clinicians.[A] 

State: Oregon; 
Extent: Full; 
Description: Oregon's official website links to a medication chart 
that can be used as a psychotropic medication reference tool. 

State: Texas; 
Extent: Full; 
Description: As of February of 2005, DFPS posted the Psychotropic 
Medication Utilization Parameters for Foster Children on their 
website. The parameters describe appropriate practice for prescribers 
and literature references. Since the Summer of 2007, DFPS has posted 
tables addressing medication uses, dosages and possible side effects 
on the agency website. 

AACAP guideline: 
Website includes consent forms [ideal]. 

State: Florida; 
Extent: Full
Description: Florida's Center for the Advancement of Child Welfare 
Practice website includes a consent form. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: No. 

State: Michigan; 
Extent: No. 

State: Oregon; 
Extent: Full; 
Description: Oregon's official website includes a consent form. 

State: Texas; 
Extent: No; 
Description: DFPS does not have a standardized form that all 
prescribing health care providers are required to use. Each health 
care provider documents consent in his or her office-based medical 
record. 

AACAP guideline: 
Website includes adverse effect rating forms [ideal]. 

State: Florida; 
Extent: No. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: No. 

State: Michigan; 
Extent: No. 

State: Oregon; 
Extent: No. 

State: Texas; 
Extent: No. 

AACAP guideline: 
Website includes reports on prescription patterns for psychotropic 
medications [ideal]. 

State: Florida; 
Extent: No;
Description: Although Florida's Center for the Advancement of Child 
Welfare Practice website does not include prescribing patterns, 
Florida's DCF website does post prescription patterns and tracks 
informed consent as of 2009. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: No. 

State: Michigan; 
Extent: No. 

State: Oregon; 
Extent: No. 

State: Texas; 
Extent: Full; 
Description: Annual outcomes regarding prescribing patterns are posted 
on the website. 

AACAP Guideline: 
Website includes links to helpful, accurate, and ethical websites 
about child and adolescent psychiatric diagnoses and psychotropic 
medications [ideal]. 

State: Florida; 
Extent: Full; 
Description: The website includes links to other informative 
publications and news stories related to foster children and 
psychotropic medications. 

State: Maryland; 
Extent: No. 

State: Massachusetts; 
Extent: No. 

State: Michigan; 
Extent: No; 
Description: Agency officials said that Michigan DHS has a draft 
policy to link publications from the National Institute of Mental 
Health to the Michigan DHS website to give workers up-to-date 
information about child and adolescent psychiatric diagnoses and 
psychotropic medications. 

State: Oregon; 
Extent: No. 

State: Texas; 
Extent: Full; 
Description: The website includes links to state and national 
sites that have information on medication guidelines and diagnoses of 
psychotropic medications. 

Source: GAO analysis of information collected through interviews with, 
and various documentation provided by, the selected states' Medicaid 
and foster care officials, and the AACAP's best principles guidelines. 

[A] This information was provided by Michigan state officials and was 
not tested to ensure effective implementation. 

[End of table] 

[End of section] 

Appendix XI: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 21, 2011: 

Gregory  D. Kutz, Director: 
Forensic Audits and Investigative Services: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20458: 

Dear Mr. Kutz: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) draft report entitled, "Foster Children: HHS Guidance Could Help 
States Improve Oversight of Psychotropic Prescriptions" (GAO-12-201). 

The Department appreciates the opportunity to review this report 
before its publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 
         
GENERAL COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled, 
"Foster Children: HHS Guidance Could Help States Improve Oversight Of 
Psychotropic Prescriptions" (GAO-12-201): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

GAO Recommendation: 

To improve the comprehensiveness of oversight of psychotropic drugs 
prescribed to foster children, we recommend that the Secretary of HHS 
evaluate our findings and consider issuing HHS-endorsed 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. 

HHS Response: 

The Department agrees with this recommendation. 

A large number of children in the child welfare system have mental 
health needs -many stemming from trauma they have faced. In 2007, 
12.4% of children in foster care were prescribed psychotropic 
medications, compared to 1.6% of children participating in state 
Medicaid programs. Research has shown that there are wide variations 
in medication rates among children in foster care in different states.
As the understanding about the multidimensional impact of maltreatment 
has increased, the knowledge of effective, evidence-based 
interventions has grown as well. However, these interventions have not 
been widely available in the child welfare system and there has been a 
lack of capacity to fully incorporate this knowledge and consistently 
apply it to improve the lives of children who have been abused or 
neglected. Thus, there is real concern that these children are not 
getting the best, evidence-informed treatments available. And, while 
there are evidence-based practices, there remains much to be learned 
about how to best promote the social and emotional well-being of 
children in foster care. HHS is, therefore, undertaking efforts to 
expand the evidence base for what works in helping children in the 
child welfare system that have trauma and mental health needs. 

To address this issue, the Department is undertaking efforts to work 
with States and others to build the capacity of child welfare and 
health systems to both recognize the social-emotional, mental, and 
behavioral health consequences of maltreatment and deliver a mix of 
services that effectively responds to the complex needs of the 
children they serve. In addition, in June 2011, Congress acted on an 
Administration proposal to provide HHS with additional authority in 
the Child and Family Services Improvement and Innovation Act of 2011 
(Public Law 112-34) to require States to address the trauma needs of 
children and to develop protocols for monitoring the use of 
psychotropics. 

Children in the child welfare system are served by a large number of 
entities and individuals -their families, their foster families, the 
child welfare system, the school system, the Medicaid program, and the 
physical, behavioral, mental and dental health systems. Given this 
reality, it will take a multi-faceted approach to ensure that children 
in the child welfare system with trauma and mental health needs get 
effective support and interventions to reach their full potential and 
live healthy, productive lives. 

To that end, HHS is strongly committed to the appropriate prescribing 
and use of psychotropic therapies for children. The Administration for 
Children and Families (ACF) will issue guidance to States on best 
practices for monitoring psychotropic drug prescriptions for foster 
children. Effective immediately, ACF will disseminate to States the 
current best practices for use in developing their approaches and 
protocols. 

We note the work already being done by various States and others to 
address these concerns, such as providing better oversight of 
prescribing practices, getting second opinions prior to prescribing, 
obtaining informed consent and providing better education to 
caretakers on the risks and benefits of drug treatment. As we finalize 
guidance on this issue, we will continue to evaluate available studies 
and consider effective practices already in place in states. We will 
also explore other avenues to support quality improvements in the care 
delivered to children in foster care, including efforts to improve 
data reporting and quality measures. 

Inter-Agency Workgroup on the Use of Psychotropics with Children in 
Foster Care: 

A workgroup with representatives from across HHS agencies convened in 
summer 2011 with an initial task of gathering information about the 
need for mental and behavioral health services among children in 
foster care, as well as the use of psychotropic medications in this 
population. Peer-reviewed journal articles, research reports, reviews 
of state practices, and conversations with expert researchers and 
clinicians informed this process. The workgroup identified the 
activities already underway within the Department and determined the 
additional steps necessary to ensure appropriate use of psychotropic 
medications with children and youth in foster care. Workgroup members, 
drawn from ACF, Food and Drug Administration, Centers for Medicare and 
Medicaid Services, Substance Abuse and Mental Health Services 
Administration, National Institute of Mental Health, and the 
Administration for Healthcare Research and Quality met weekly between 
July and September to explore the following topics: 1) prevalence of 
psychotropic use and mental health treatment among foster children; 2) 
research on the safety and effectiveness of psycho-pharmacological and 
psychosocial treatments for children and adolescents; 3) guidelines 
and best practice models related to psychotropic management and 
oversight; and 4) actions currently underway and planned to be taken 
to address the use of psychotropic medication with children in foster 
care. 

An important step taken by the workgroup was to convene a meeting in 
mid-September of individual experts to provide information on the 
prevalence of use of psychotropic medication, the geographic variation 
of the use of psychotropic medication in children in foster care (i.e.
what explains the variation across states?), best practices in 
oversight and monitoring, and data needs (i.e. what could be learned 
from better tracking of the use of psychotropic medication in
children in foster care?). This meeting and other activities such as 
research and literature reviews provided important information to 
assist the Department in better understanding the issues and
learning more about the currently available resources and best 
practices. 

As a result of this process, the Department has developed a plan to 1) 
expand the use of evidence-based screening, diagnosis and 
interventions, 2) strengthen the oversight and monitoring of 
psychotropic medications among children in foster care, and 3) expand 
the overall knowledge and evidence base. This work will educate 
Federal, State, and community entities about both the mental health 
and trauma-related needs of children who have been maltreated and the 
evidence-based treatments available. Work is underway to expand the 
evidence base with regard to interventions, both psychosocial and 
pharmacological, for treating children with mental health and trauma-
related needs. 

We expect the cumulative result of these efforts to be: 

1) State child welfare agencies will have a more thorough 
understanding of the extent to which psychotropic medications are 
being used with children in foster care and the effectiveness of 
psychopharmaceutical treatment. 

2) States will develop more comprehensive approaches to the monitoring 
and oversight of psychotropic medication use in child welfare. 

3) Child welfare, Medicaid, and mental health entities at the State 
level will develop more collaborative working relationships with one 
another. 

4) Data collection will be established or enhanced in the States to 
better capture the mental health diagnoses and psychotropic medication 
use among children in foster care. 

5) To the extent possible, States will be able to provide a wider 
array of supports to children with mental and behavioral health 
problems and their families who are served by the child welfare system. 

6) A clear understanding of research needs will be developed at the 
Federal level. 

[End of section] 

Appendix XII: Comments from the Florida Agency for Health Care 
Administration: 

GAO comments supplementing those in the report text appear at the end 
of this appendix. 

Florida Medicaid: 
A Division of the Agency for Health Care Administration: 
Rick Scott, Governor: 
Elizabeth Dudek, 
Secretary: 
2727 Mahan Drive, MS#8: 
Tallahassee, Florida 32308: 
Visit AHCA online at AHCA.MyFlorida.com: 

"Better Health Care for all Floridians" 

Date: November 22, 2011: 

To: Justin M. Senior: 
Deputy Secretary for Medicaid: 

From: Phil Williams: 
Assistant Deputy Secretary for Medicaid Finance: 

Subject: Delegation of Authority: 

I will be out of the office tomorrow, November 23, 2011. For 
administrative purposes, Karen Chang will serve as Assistant Deputy 
Secretary for Medicaid Finance. 

Should you have any questions or need assistance please contact Karen 
at 412-4075, or my assistant, Christianna Gaudio at 412-4011. 

Thank you. 

[End of letter] 

Florida Medicaid: 
A Division of the Agency for Health Care Administration: 
Rick Scott, Governor: 
Elizabeth Dudek, 
Secretary: 
2727 Mahan Drive, MS#8: 
Tallahassee, Florida 32308: 
Visit AHCA online at AHCA.MyFlorida.com: 

Memorandum: 

Date: November 21, 2011: 

TO: Matt Valenta, Assistant Director, Government Accountability Office: 

From: Phil Williams, Assistant Deputy Secretary of Medicaid Finance, 
AHCA: 

SUBJECT: Medicaid Review of the GAO draft report entitled, "Foster 
Children: HHS Guidance Could Help States Improve Oversight of 
Psychotropic Prescriptions." 

On behalf of the Florida Agency for Health Care Administration, 
Division of Medicaid, we would like to thank you for the opportunity 
to review and comment on the Government Accountability Office (GAO) 
draft report entitled, "Foster Children: HHS Guidance Could Help 
States Improve Oversight of Psychotropic Prescriptions." 

Provided below are Florida Medicaid's comments and recommendations. We 
look forward to seeing the recommendations made by our Bureau of 
Pharmacy used to replace existing information in the report, as noted 
in our comments. The additional information provided by our Bureau of 
Medicaid Services should be added as an addendum to the existing 
document. 

Florida Medicaid's Review of the GAO Draft Report Entitled Foster 
Children: HHS Guidance Could Help States Improve Oversight of 
Psychotropic Prescriptions: 

Bureau of Pharmacy Services: 

Correction/clarification for Table 37 (page 87) requiring states to 
establish guidelines for the use of psychotropic medication for 
children in state custody: The paragraph below should replace the 
paragraph in the table. 

In 2006, the Florida Mental Health Institute at USF convened a grOup 
of experts to develop the Florida Best Practice Medication Guidelines 
for the use of psychotropic medication in children and adolescents. 
The medical experts included academic psychiatrists, Florida 
practicing psychiatrists and national experts. The guidelines are 
updated biennially and reflect the state of knowledge, current at the 
time of publication, on effective and appropriate care, as well as 
clinical consensus judgment when research findings are lacking. The 
application of the guidelines is relevant to children in state 
custody, as well as any child prescribed a behavioral health 
medication. Previously in 2008 the Agency convened an Ad Hoc committee 
(composed of family physicians, psychiatrists and clinical 
pharmacists) which held a meeting to invite public comment from 
parents, guardians, advocacy groups, and other concerned citizens. The 
consensus of the committee was to rely upon qualified clinical 
professionals to oversee a prior authorization process for 
antipsychotics prescribed in children and adolescents. State agencies 
represented in this committee included Department of Children and 
Family Services, Department of Health, and the Agency for Health Care 
Administration. The prior authorization review process requires a 
clinical review or second medical opinion by a child or adolescent 
psychiatrist for children less than 6 years of age prescribed an 
antipsychotic medication prior to reimbursement consideration by 
Medicaid. [See comment 1] Since 2010, prior authorization reviews are 
conducted for any antipsychotic medication lacking an FDA indication 
or acceptable evidence-base for safety and efficacy for children less 
than 18 years of age. All other antipsychotics require prior 
authorization at high dose. 

Correction/clarification for Table 37 (page 89) requiring that the 
state's oversight program includes an advisory committee to oversee a 
medication formulary and provide medication monitoring guidelines to 
practitioners who treat children in the child welfare system: The 
paragraph below should replace the paragraph in the table. 

The Florida Medicaid Drug Therapy Management Program for Behavioral 
Health (MDTMP for BH) was created in 2004 to improve the quality of 
behavioral health drug prescribing, improve patient adherence to 
therapy, reduce clinical risks, and lower costs while providing 
appropriate therapy. In 2006, an expert panel of psychiatrists 
developed evidence-based best practice guidelines for the use of 
psychotherapeutic drugs in children and adolescents. The guidelines 
were published in October 2006 and are reviewed and updated 
biennially. Members of the panel include a combination of pediatric, 
adolescent and adult psychiatrists, as well as primary care 
physicians, pediatricians, DCF members, AHCA staff and clinical 
pharmacists. However, the advisory committee does not include other 
mental health care providers, consulting clinical pharmacists, family 
advocates or parents, or state child advocates. Advocacy groups were 
involved in the 2008 Ad Hoc committee meeting which supported the 
oversight of the prior authorization process by only qualified 
healthcare clinicians. The panel or advisory committee does not 
oversee a medication formulary. However, the panel provides guidelines 
to practitioners who treat any Medicaid children on mental health 
medication, including those in the child welfare system. The Florida 
MDTMP for BH does provider outreach and the guidelines are also 
accessible online. [See comment 2] 

The statement below should be added as the last sentence in the 
paragraph in the table on page 90 which requires that the oversight 
program monitors the rate and types of psychotropic medication usage 
and the rate of adverse reactions among youth in state custody: 

However, the Florida Mental Health Institute at USF performs 
retrospective prescription claims reviews for AHCA to determine the 
rate and types of psychotherapeutic medications used. This includes 
review of claims for Medicaid eligible children in the child welfare 
system. [See comment 2] 

Bureau of Medicaid Services: 

It is recommended that the following information be added to this 
report, as the report does not take into account some specific 
activities undertaken by Medicaid managed care plans to improve 
oversight of psychotropic medications: [See comment 3] 

Florida Prepaid Mental Health Plans (PMHPs) are comprehensive managed 
mental health care services plans that are available to a defined 
population of enrolled Medicaid recipients. Many PMHPs use a pharmacy 
report which they give to their providers for all enrollees receiving 
multiple medications. This report includes any drug prescribed for an 
enrollee, so a prescribing physician will have this information prior 
to changing or adding to an enrollee's regimen. This information is 
helpful for medically complex enrollees and is being used as part of 
the provider peer review process. 

The Child Welfare Prepaid Mental Health Plan is a specialized plan 
developed to address the needs of Medicaid-eligible children who are 
receiving specific child welfare services, including foster care 
children from the Florida Department of Children and Families. This 
Plan offers additional mental health services to address the needs of 
children in Florida's child welfare system. 

The Child Welfare Prepaid Mental Health Plan is expected to 
demonstrate through its policies, procedures and plan implementation 
how services related to psychotropic medication management are being 
delivered in a manner consistent with other necessary mental health 
services. This expectation includes: how the plan will ensure family 
participation, obtain informed consent (general and medication 
specific), promote enrollee compliance/adherence through enrollee and 
family education, and ensure enrollees are connected to a willing 
prescribing provider upon discharge from the child welfare system. 

In addition, the Child Welfare Prepaid Mental Health Plan must comply 
with all pharmacy management protocols adopted by the Agency. As an 
example, the plan must submit quarterly outreach reports that include 
information about a program designed to assist MediPass and HMO 
primary care physicians in identification and management of clinical 
depression including alternative strategies to ensure the appropriate 
use of psychotropic medications for. children served. 

The following are GAO's comments on the Florida Agency for Health Care 
Administration letter dated November 21, 2011: 

1. We revised the report to reflect the prior authorization for 
children under 18. 

2. We believe that the report accurately summarizes Florida's 
oversight program. 

3. Some states' prescription drugs are covered by Medicaid managed 
care plans in which drug payments are included in the capitated 
payments that plans receive from states. The scope of our review was 
fee-for-service. As such, we did not evaluate managed care 
organizations' controls related to the prescribing of psychotropic 
drugs to foster children. 

[End of section] 

Appendix XIII: Comments from the Massachusetts Executive Office of 
Health and Human Services: 

Note: GAO comments supplementing those in the report text appear at 
the end of this appendix. 

The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
One Ashburton Place
Boston, MA 02108: 

Deval L. Patrick, Governor: 
Timothy P. Murray, Lieutenant Governor: 
Judyann Bjgby, M.D., Secretary: 
Julian J. Harris. M.D., Medicaid Director: 

November 18, 2011: 

Matt Valenta, Assistant Director: 
Forensic Audits & Investigative Service: 
U.S. Government Accountability Office (GAO): 
1999 Bryan Street, Suite 2200: 
Dallas, TX 75201-6848: 

Re: Report GAO-12-201L 

Dear Mr. Valenta: 

Thank you for the opportunity to review and comment on the draft 
report How HHS Could Help States Improve Oversight of Psychotropic 
Prescriptions for Foster Children. 

The Office of Medicaid, the Office of Clinical Affairs (MassHealth) 
and the Department of Children and Families (DCF) appreciate the 
opportunity to participate in your review. We agree that discussion 
and investigation of this topic is timely and important to improve the 
health and welfare of children in foster care. 

Following our discussions in September 2010, we provided a significant 
amount of program information and documentation, pharmacy initiatives 
and reports, and claims data to support your efforts. We also 
responded to a lengthy statement of facts to confirm, clarify or 
correct critical facts and key information used to formulate the GAO's 
analyses in August and September 2011. Specifically, we commented on a 
comparison of Massachusetts' medication management practices for 
foster children with the American Academy of Child and Adolescent 
Psychiatry (AACAP) 2005 best principle guidelines. 

On November 16, 2011, we provided additional comments that would 
further enhance the report and highlight the complexities of providing 
services to children in foster care in Massachusetts. We also offered 
one comment about the accuracy of the number of infants who may appear 
to have received behavioral health prescriptions (i.e., the 
prescription may not have been intended for or consumed by the child). 
The potential for coding errors is a recognized factor. 

EOHHS endorses the GAO's recommendation that HHS guidance on best 
practices could improve oversight on psychotropic prescriptions to 
children in foster care. 

Sincerely, 

Signed by: 

Julian J. Harris, M.D. 
Medicaid Director: 

cc: Scott Clayton, CFE, GAO: 
Analyst, Forensic Audits & Investigative Service: 

Liz Skinner-Reilly, Federal Liaison, DCF: 

Dr. Paul Jeffrey, Director of Pharmacy, MassHealth: 

The following are GAO's comments on the Massachusetts Executive Office 
of Health and Human Services letter dated November 18, 2011: 

1. We revised the report to reflect Massachusetts' technical comments 
as appropriate. 

[End of section] 

Appendix XIV: Comments from the Oregon Health Authority: 

GAO comments supplementing those in the report text appear at the end 
of this appendix. 

Office of the Director: Oregon Health Authority: 
John A. Kitzhaber, MD, Governor: 
500 Summer Street NE E-20: 
Salem, OR 97301: 
Voice: 503-947-2340: 
Fax: 503-947-2341: 
Website: www.Oregon.Gov/OHA: 

November 18, 2011: 

Mr. Matthew Valenta: 
Assistant Director Forensic Audits and Special Investigations: 
US Government Accountability Office: 

Dear Mr. Valenta: 

Thank you for the opportunity to comment on your draft report entitled 
"Foster Children: HHS Guidance Could Help States Improve Oversight of 
Psychotropic Prescriptions"  (GA0-12-201). The work done by your team 
produced an excellent report that clearly outlines the issues 
surrounding this subject. 

We support the overall findings of this report and the recommendations 
are a step forward in helping states with the treatment of foster 
children. 

As referenced in numerous places in the report, the Oregon data is 
limited. In December  of 2008 Oregon's MMIS system was replaced. Prior 
to that date the data fields necessary to identify prescribers were 
not required to be valid. Thus prescriber identification prior to  
2008 has a high occurrence of inaccurate prescriber data. For claims 
post December 2008 this data is accurate. [See comment 1] 
    
We also shared with your staff that the prescriber data, the data for 
drugs prescribed to foster children who received their health care 
through one of the states 15 fully capitated health plans, was not 
captured by the state. With eighty percent of the total Medicaid  
population served by fully capitated health plans the State was unable 
to provide accurate pharmacy data about its clients. [See comment 2] 

We also would like to remind you that the Oregon Legislature addressed 
this issue with the passage of HB 3114 in 2009. This bill directed the 
state agencies which provide care for foster children, the Department 
of Human Services and the Oregon Health Authority, to put in place a 
review panel of all foster kids in our system that were receiving 
psychotropic prescriptions.  

The result of this review has led to an increased collaboration and 
shared responsibility among the Oregon state agencies for Medicaid 
Services and Child Welfare Services. Some of the early achievements of 
the review panel have been the beginning of a reduction in the overall 
percentage of psychotropic medication use and an increase in the 
awareness of the need for informed consent. 

We look forward to continued improvement in our treatment of our 
foster children population and look forward to the guidance from HHS 
on how to treat these children. 

Sincerely, 

Signed by: 

Thomas A. Burns: 
Director of Pharmacy Programs: 
Oregon Health Authority: 

The following are GAO's comments on the Oregon Health Authority letter 
dated November 18, 2011: 

1. Our evaluation found that the prescriber field was not reliable for 
several states. As such, we did not use that field in our data 
analysis. 

2. Some states' prescription drugs are covered by Medicaid managed 
care plans in which drug payments are included in the capitated 
payments that plans receive from states. Although Oregon states that 
eighty percent of its Medicaid population was served by a fully 
capitated plan, the majority of drugs on our list were covered by a 
fee-for-service carve out of Oregon managed care plans. The data 
included in the fee-for-service carve out were reliable and the scope 
of our review was fee-for-service. As such, we did not evaluate 
managed care organizations' controls related to the prescribing of 
psychotropic drugs to foster children. 

[End of section] 

Appendix XV: Comments from the Texas Health and Human Services 
Commission: 

GAO comments supplementing those in the report text appear at the end 
of this appendix. 

Texas Health And Human Services Commission: 
Thomas M. Suehs: 
Executive Commissioner: 
P.0. Box 13247: 
Austin, Texas 78711: 
4900 North Lamar, Austin, Texas 78751: 
(512) 424-6500: 

Mr. Gregory D. Kutz: 
Director, Forensic Audits and Investigative Service: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

November 18, 2011 

Re: Draft Report GAO-12-201: 

Dear Mr. Kutz:  

The Texas Health and Human Services Commission (HHSC) received a draft 
report entitled "Foster Children — NHS Guidance Could Help States 
Improve Oversight of Psychotropic Prescriptions" from the U.S. 
Government Accountability Office (GAO) on November 4, 2011. HHSC was 
requested to provide written or oral comments on the contents of the 
report.  

HHSC and the Texas Department of Family and Protective Services (DFPS) 
appreciate GAO's efforts to ensure the appropriate prescribing of 
psychotropic medications to children in foster care. The report 
highlights the need for guidance and oversight of the use of 
psychotropic medications in this population.  

We agree there is a need for oversight systems to ensure the 
appropriate use of psychotropic medication in foster care. To address 
this need, Texas has expended significant time and resources. Since 
2004, HHSC and DFPS have implemented a number of strategies to better 
assess issues regarding psychotropic medication use by children in 
foster care and to assist health care providers in prescribing 
psychotropic medications appropriately. Every year, the use of 
psychotropic medications in Texas foster care continues to decrease — 
from 29.9 percent in State Fiscal Year (fiscal year) 2004 to 20.6 
percent in fiscal year 2010 — for children prescribed psychotropic 
medications for 60 days or more. This decrease represents a 31 percent 
reduction in usage. Furthermore, Texas has already fully or partially 
implemented 35 of the 40 oversight procedures recommended by the 
American Academy of Child and Adolescent Psychiatrists (AACAP).  

Following are some of the significant developments in the Texas 
oversight system: 

* Development and implementation of the Psychotropic Medication 
Utilization Review Parameters for Foster Children in 2005, with 
subsequent updates in 2007 and 2010. 

* Hiring of a child and adolescent psychiatrist in 2007 to serve as 
DFPS first medical director. This new position provides DFPS' primary 
medical oversight and expertise related to the use of psychotropic 
medications in foster care. 

* Implementation in April 2008 of the STAR Health program, which 
provides comprehensive health care to children in Texas foster care, 
conducts ongoing Psychotropic Medication Utilization Reviews (PMURs) 
and includes an electronic health information system, the Health 
Passport. 

* Creation of an interagency Psychotropic Medication Monitoring Group 
by the DFPS Medical Director to provide further expertise, 
coordination, and oversight of the PMUR process. The process includes 
quarterly reviews of PMUR outcomes. 

* Ongoing data collection, review, and reporting by HHSC on the use of 
psychotropic medications in Texas foster children from fiscal year 
2002 through present. Annual updates are published on the HHSC website. 

* Effective June 14. 2011, Texas Medicaid began to require a prior 
authorization before an antipsychotic medication may be prescribed to 
a child under age three years for both foster care and non-foster care 
populations. 

Since GAO uses 2008 data, report results do not fully capture the 
continued success in Texas that occurred after the implementation of 
STAR Health and the PMUR process in 2008. 

Additionally, the report focuses on children who have been prescribed 
psychotropic medications for 30 days rather than the broadly accepted 
standard of 60 days, which is currently being used in Texas and in 
other studies outside of Texas, focusing on foster children who 
receive prescriptions for 60 days suggests that the child remained on 
the psychotropic medication beyond the trial period and is actively 
being treated with the medication. 

Texas remains committed to continued improvements of our oversight 
system and ensuring the optimal care for children in foster care. 

If you have any questions or require additional information, please 
contact David M. Griffith, HHSC Internal Audit Director. Mr. Griffith 
may be reached by telephone at (512) 424-6998 or by e-mail at 
David.Griffith@hhssc.state.tx.us. 

Sincerely, 

Signed by: 

Thomas M. Suehs: 

The following are GAO's comments on the Texas Health and Human 
Services Commission letter dated November 18, 2011: 

1. The evaluation of psychotropic rates and potential health risks 
were based on 2008 data. As such, we agree that it would not reflect 
any changes that have been made by the state after this time period. 
However, our review of state controls examined policies in place 
through October 2011. 

2. Our analysis focused on foster and nonfoster Medicaid children who 
were prescribed a psychotropic drug during 2008. Our methodology 
accurately reflects the percentages of those children that received 
such prescriptions during that time period. 

[End of section] 

Appendix XVI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Gregory D. Kutz, 202-512-6722 or kutzg@gao.gov: 

Staff acknowledgments: 

In addition to the contact named above, Matthew Valenta, Assistant 
Director; Erika Axelson, Assistant Director; Gary Bianchi; Assistant 
Director; Luqman Abdullah; Scott Clayton; Matthew Harris; Maria 
Kabiling; Sandra Moore; James Murphy; Robert Rodgers; Barry Shillito; 
April Van Cleef; Timothy Walker; and Monique Williams made significant 
contributions to this report. 

[End of section] 

Appendix XVII: Print-Friendly Version of Figure 1, Psychotropic 
Prescription Rates for Children in Five States: 

State: Florida (FL); 

Medicaid amount paid for psychotropic medications prescribed to foster 
and nonfoster children during 2008: $64,358,968. 

Percentage of children prescribed psychotropic medication age: 0-17 
years old; 
Foster children: 22.0%; 
Nonfoster children: 8.2%; 
Ratio of foster to nonfoster children: 2.7. 

Percentage of children prescribed psychotropic medication age: 13-17 
years old; 
Foster children: 36.8%; 
Nonfoster children: 11.9%; 
Ratio of foster to nonfoster children: 3.1. 

Percentage of children prescribed psychotropic medication age: 6-12 
years old; 
Foster children: 31.2%; 
Nonfoster children: 12.3%; 
Ratio of foster to nonfoster children: 2.5. 

Percentage of children prescribed psychotropic medication age: 0-5 
years old; 
Foster children: 5.3%; 
Nonfoster children: 3.3%; 
Ratio of foster to nonfoster children: 1.6. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states. In 
addition, we excluded children whose prescriptions were not reported 
to CMS because they were covered by an HMO in the two states with both 
fee-for-service and HMO prescription coverage. Percentages and ratios 
are rounded to the nearest tenth, and therefore the reported ratio may 
be slightly different than the ratio of the rounded percentages. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Massachusetts (MA); 

Medicaid amount paid for psychotropic medications prescribed to foster 
and nonfoster children during 2008: $29,584,901. 

Percentage of children prescribed psychotropic medication age: 0-17 
years old; 
Foster children: 39.1%; 
Nonfoster children: 10.2%; 
Ratio of foster to nonfoster children: 3.8. 

Percentage of children prescribed psychotropic medication age: 13-17 
years old; 
Foster children: 53.4%; 
Nonfoster children: 14.7%; 
Ratio of foster to nonfoster children: 3.6. 

Percentage of children prescribed psychotropic medication age: 6-12 
years old; 
Foster children: 44.8%; 
Nonfoster children: 12.1%; 
Ratio of foster to nonfoster children: 3.7. 

Percentage of children prescribed psychotropic medication age: 0-5 
years old; 
Foster children: 4.9%; 
Nonfoster children: 2.2%; 
Ratio of foster to nonfoster children: 2.2. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states. In 
addition, we excluded children whose prescriptions were not reported 
to CMS because they were covered by an HMO in the two states with both 
fee-for-service and HMO prescription coverage. Percentages and ratios 
are rounded to the nearest tenth, and therefore the reported ratio may 
be slightly different than the ratio of the rounded percentages. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Michigan (MI); 

Medicaid amount paid for psychotropic medications prescribed to foster 
and nonfoster children during 2008: $72,749,858. 

Percentage of children prescribed psychotropic medication age: 0-17 
years old; 
Foster children: 21.0%; 
Nonfoster children: 7.9%; 
Ratio of foster to nonfoster children: 2.7. 

Percentage of children prescribed psychotropic medication age: 13-17 
years old; 
Foster children: 35.0%; 
Nonfoster children: 13.1%; 
Ratio of foster to nonfoster children: 2.7. 

Percentage of children prescribed psychotropic medication age: 6-12 
years old; 
Foster children: 26.7%; 
Nonfoster children: 11.5%; 
Ratio of foster to nonfoster children: 2.3. 

Percentage of children prescribed psychotropic medication age: 0-5 
years old; 
Foster children: 4.4%; 
Nonfoster children: 1.1%; 
Ratio of foster to nonfoster children: 3.8. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states. In 
addition, we excluded children whose prescriptions were not reported 
to CMS because they were covered by an HMO in the two states with both 
fee-for-service and HMO prescription coverage. Percentages and ratios 
are rounded to the nearest tenth, and therefore the reported ratio may 
be slightly different than the ratio of the rounded percentages. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Oregon (OR); 

Medicaid amount paid for psychotropic medications prescribed to foster 
and nonfoster children during 2008: $14,326,756. 

Percentage of children prescribed psychotropic medication age: 0-17 
years old; 
Foster children: 19.7%; 
Nonfoster children: 4.8%; 
Ratio of foster to nonfoster children: 4.1. 

Percentage of children prescribed psychotropic medication age: 13-17 
years old; 
Foster children: 43.3%; 
Nonfoster children: 12.0%; 
Ratio of foster to nonfoster children: 3.6. 

Percentage of children prescribed psychotropic medication age: 6-12 
years old; 
Foster children: 23.4%; 
Nonfoster children: 6.2%; 
Ratio of foster to nonfoster children: 3.8. 

Percentage of children prescribed psychotropic medication age: 0-5 
years old; 
Foster children: 2.5%; 
Nonfoster children: 0.6%; 
Ratio of foster to nonfoster children: 3.9. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states. In 
addition, we excluded children whose prescriptions were not reported 
to CMS because they were covered by an HMO in the two states with both 
fee-for-service and HMO prescription coverage. Percentages and ratios 
are rounded to the nearest tenth, and therefore the reported ratio may 
be slightly different than the ratio of the rounded percentages. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Texas (TX); 

Medicaid amount paid for psychotropic medications prescribed to foster 
and nonfoster children during 2008: $194,952,105. 

Percentage of children prescribed psychotropic medication age: 0-17 
years old; 
Foster children: 32.2%; 
Nonfoster children: 7.1%; 
Ratio of foster to nonfoster children: 4.5. 

Percentage of children prescribed psychotropic medication age: 13-17 
years old; 
Foster children: 58.2%; 
Nonfoster children: 11.4%; 
Ratio of foster to nonfoster children: 5.1. 

Percentage of children prescribed psychotropic medication age: 6-12 
years old; 
Foster children: 45.8%; 
Nonfoster children: 10.6%; 
Ratio of foster to nonfoster children: 4.3. 

Percentage of children prescribed psychotropic medication age: 0-5 
years old; 
Foster children: 9.1%; 
Nonfoster children: 3.1%; 
Ratio of foster to nonfoster children: 2.9. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states. In 
addition, we excluded children whose prescriptions were not reported 
to CMS because they were covered by an HMO in the two states with both 
fee-for-service and HMO prescription coverage. Percentages and ratios 
are rounded to the nearest tenth, and therefore the reported ratio may 
be slightly different than the ratio of the rounded percentages. 

Source: GAO analysis of state Medicaid and foster care data. 

[End of section] 

Appendix XVIII: Print-Friendly Version of Figure 2, Psychotropic Drug 
Potential Health Risk Indicators for Five Selected States: 

State: Florida (FL); 

Children age 0-17 prescribed five (5) or more medications 
concomitantly: 
Percentage of foster children: 0.11%; 
Percentage of nonfoster children: 0.03%. 

Children age 0-17 with a dosage exceeding maximum guidelines based on 
FDA-approved labels: 
Percentage of foster children: 1.50%; 
Percentage of nonfoster children: 0.44%. 

Children under 1 year old prescribed a psychotropic drug: 
Percentage of foster children: 2.1%; 
Percentage of nonfoster children: 1.2%. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states.
In addition, we excluded children whose prescriptions were not 
reported to CMS because they were covered by an HMO in the two states 
with both fee-for-service and HMO prescription coverage. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Massachusetts (MA); 

Children age 0-17 prescribed five (5) or more medications 
concomitantly: 
Percentage of foster children: 1.33%; 
Percentage of nonfoster children: 0.07%. 

Children age 0-17 with a dosage exceeding maximum guidelines based on 
FDA-approved labels: 
Percentage of foster children: 2.21%; 
Percentage of nonfoster children: 0.56%. 

Children under 1 year old prescribed a psychotropic drug: 
Percentage of foster children: 0.7%; 
Percentage of nonfoster children: 0.7%. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states.
In addition, we excluded children whose prescriptions were not 
reported to CMS because they were covered by an HMO in the two states 
with both fee-for-service and HMO prescription coverage. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Michigan (MI); 

Children age 0-17 prescribed five (5) or more medications 
concomitantly: 
Percentage of foster children: 0.29%; 
Percentage of nonfoster children: 0.02%. 

Children age 0-17 with a dosage exceeding maximum guidelines based on 
FDA-approved labels: 
Percentage of foster children: 1.67%; 
Percentage of nonfoster children: 0.49%. 

Children under 1 year old prescribed a psychotropic drug: 
Percentage of foster children: 1.5%; 
Percentage of nonfoster children: 0.3%. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states.
In addition, we excluded children whose prescriptions were not 
reported to CMS because they were covered by an HMO in the two states 
with both fee-for-service and HMO prescription coverage. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Oregon (OR); 

Children age 0-17 prescribed five (5) or more medications 
concomitantly: 
Percentage of foster children: 0.13%; 
Percentage of nonfoster children: 0.01%. 

Children age 0-17 with a dosage exceeding maximum guidelines based on 
FDA-approved labels: 
Percentage of foster children: 1.12%; 
Percentage of nonfoster children: 0.16%; 

Children under 1 year old prescribed a psychotropic drug: 
Percentage of foster children: 0.3%; 
Percentage of nonfoster children: 0.1%. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states.
In addition, we excluded children whose prescriptions were not 
reported to CMS because they were covered by an HMO in the two states 
with both fee-for-service and HMO prescription coverage. 

Source: GAO analysis of state Medicaid and foster care data. 

State: Texas (TX); 

Children age 0-17 prescribed five (5) or more medications 
concomitantly: 
Percentage of foster children: 1.05%; 
Percentage of nonfoster children: 0.02%. 

Children age 0-17 with a dosage exceeding maximum guidelines based on 
FDA-approved labels: 
Percentage of foster children: 3.27%; 
Percentage of nonfoster children: 0.37%. 

Children under 1 year old prescribed a psychotropic drug: 
Percentage of foster children: 1.2%; 
Percentage of nonfoster children: 1.0%. 

Note: Rates for foster and nonfoster children are comparable within 
the same state and the ratio of prescriptions to foster children to 
prescriptions to nonfoster children is comparable across states. 
However, prescription rates are not comparable across states because 
certain states covered more psychotropic drugs than other states.
In addition, we excluded children whose prescriptions were not 
reported to CMS because they were covered by an HMO in the two states 
with both fee-for-service and HMO prescription coverage. 

Source: GAO analysis of state Medicaid and foster care data. 

[End of section] 

Footnotes: 

[1] GAO, Foster Care: State Practices for Assessing Health Needs, 
Facilitating Service Delivery, and Monitoring Children's Care, 
[hyperlink, http://www.gao.gov/products/GAO-09-26] (Washington, D.C.: 
Feb. 6, 2009). 

[2] Medicaid programs vary from state to state. 

[3] National Institute of Mental Health, Treatment of Children with 
Mental Illness, NIH Publication No. 09-4702 (Bethesda, Md.: Revised 
2009). 

[4] For example, see Medicaid Medical Directors Learning Network and 
Rutgers Center for Education and Research on Mental Health 
Therapeutics, Antipsychotic Medication Use in Medicaid Children and 
Adolescents: Report and Resource Guide from a 16-State Study MMDLN/ 
Rutgers CERTs, Publication 1 (July 2010). 

[5] AACAP guidelines are available at [hyperlink, 
http://www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinci
ples_FINAL.pdf].  

[6] Pub. L. No. 112-34, § 101(b)(2), 125 Stat. 369. 

[7] Some states' prescription drugs are covered by Medicaid managed 
care plans in which drug payments are included in the capitated 
payments that plans receive from states. For this review, we selected 
states that cover psychotropic medications largely under fee-for-
service programs so that individual drug claims could be analyzed. In 
Michigan, Oregon, and Texas, psychotropic medications were primarily 
paid on a fee-for-service basis. In Florida and Massachusetts, 
psychotropic prescription claims for most foster children were paid on 
a fee-for-service basis, with the remaining children largely covered 
by managed care. In Florida, about 60 percent of foster children and 
45 percent of nonfoster children had their prescriptions covered only 
on a fee-for-service basis during 2008. In Massachusetts, the 
percentages were about 72 percent for foster children and about 42 
percent for nonfoster children. For these two states, our analysis is 
not applicable to the entire state's foster care or Medicaid program. 
In these states, since we examined only fee-for-service data, we were 
more likely to identify psychotropic prescriptions for foster children 
during calendar year 2008 than for nonfoster children. Appendix IV 
shows how rates of psychotropic prescriptions are affected by the 
length of time a child is covered under a Medicaid fee-for-service 
program. 

[8] According to our experts, these medications, such as 
anticonvulsants, are likely being prescribed to treat mental health 
conditions when combined with another psychotropic medication. 

[9] GAO, Foster Care: State Practices for Assessing Health Needs, 
Facilitating Service Delivery, and Monitoring Children's Care, 
[hyperlink, http://www.gao.gov/products/GAO-09-26] (Washington, D.C.: 
Feb. 6, 2009). 

[10] We also examined Maryland, but found that its 2008 data on foster 
children were not sufficiently reliable for this study. State 
officials told us that Maryland's transition to a new records system 
in 2007 resulted in incorrect and missing data for foster children. A 
state audit in 2008 reported duplicate records with different 
identifying numbers for the same child, records showing children who 
had exited foster care as still enrolled in the program, and personal 
information for the mother recorded as that of the child. Our analysis 
of the data Maryland provided to us identified 8,869 children in 
foster care as of September 30, 2008--about 16 percent more than the 
7,613 children that Maryland reported to ACF that year. However, audit 
reports for Maryland indicated that the state had taken some 
corrective actions as of March 2011. 

[11] Based on our analysis of Medicaid fee-for-service claims data, 
these five states spent over $317 million on psychotropic drugs for 
nonfoster children and about $59 million on psychotropic drugs for 
foster children (in care 30 days or more) during 2008. This amount 
paid includes only claims paid for by a fee-for-service program and 
does not include manufacturer rebates or costs such as managed care 
(e.g., health maintenance organization (HMO)). 

[12] For example, see Leslie et al, Multi-State Study on Psychotropic 
Medication Oversight in Foster Care, Tufts Clinical and Translational 
Science Institute (Boston, Mass: 2010). 

[13] According to our experts, medications are approved based on 
therapeutic research and doses above the recommended level have 
generally not been shown to be safe or effective. 

[14] The kinds of drugs included in prescription data reported to CMS 
in 2008 varied by state. Because the claims data we obtained from CMS 
contained fewer types of medications for Michigan and Oregon, we may 
understate the rates of psychotropic prescriptions for both foster and 
nonfoster children in those states. While rates of psychotropic 
prescriptions are not comparable across states, they are comparable 
between foster and nonfoster children within the same state. 
Similarly, the ratios of prescriptions to foster children to 
prescriptions to nonfoster children are comparable across states. 

[15] In Florida, nonfoster children were in fee-for-service Medicaid 
an average of 2 months less than foster children. Therefore, the 
number of nonfoster children with psychotropic prescriptions may be 
understated. 

[16] S. dosReis et al., Mental Health Services for Youths in Foster 
Care and Disabled Youths, Am J Public Health, 2001, 91(7): pp 1094-9. 

[17] Children in states that required CPS to initially contact the 
family before the study's field staff were excluded from the study. 
Those states are not represented. See National Survey of Child and 
Adolescent Well-Being (NSCAW), No. 7: Special Health Care Needs Among 
Children in Child Welfare, Office of Planning, Research and 
Evaluation, Administration for Children and Families (Washington, 
D.C.: 2007). 

[18] Children in states that required CPS to initially contact the 
family before the study's field staff were excluded from the study. 
Those states are not represented. See B.J. Burns et al., Mental Health 
Need and Access to Mental Health Services by Youths Involved with 
Child Welfare: A National Survey, Journal of the American Academy of 
Child and Adolescent Psychiatry, 43 (2004), pp. 960-70. 

[19] As we have previously reported, some steps have been taken to 
address the lack of drug research in the pediatric population. For 
example, as part of the Food and Drug Administration Amendments Act of 
2007, Congress reauthorized two laws, the Pediatric Research Equity 
Act (PREA) and the Best Pharmaceuticals for Children Act (BPCA). The 
PREA requires that sponsors conduct pediatric studies for certain 
products unless the FDA grants a waiver or deferral. See GAO, 
Pediatric Research: Products Studied under Two Related Laws, but 
Improved Tracking Needed by FDA, GAO-11-457 (Washington, D.C.: May 
2011). 

[20] GAO, Foster Care: State Practices for Assessing Health Needs, 
Facilitating Service Delivery, and Monitoring Children's Care, 
[hyperlink, http://www.gao.gov/products/GAO-09-26] (Washington, D.C.: 
Feb. 6, 2009). 

[21] For example, see Leslie et al., Multi-State Study on Psychotropic 
Medication Oversight in Foster Care, Tufts Clinical and Translational 
Science Institute (Boston, Mass.: 2010). 

[22] Leslie et al, Multi-State Study on Psychotropic Medication 
Oversight in Foster Care, Tufts Clinical and Translational Science 
Institute (Boston, Mass.: 2010). 

[23] According to one of our experts, this may be justified in rare 
cases of children with serious, complex mental health issues. 

[24] These indicators are similar to those used by Texas to identify 
cases for further review, and were cited by our experts as indicators 
of potential health risks. 

[25] In our analysis of rates of psychotropic prescriptions, we 
included stimulants (e.g., ADHD drugs), anti-anxiety drugs, 
antidepressants, antipsychotics, hypnotics, mood stabilizers, and 
medications containing combinations of these drug classes. Other 
psychotropic drugs, such as anticonvulsants and alpha agonists, may be 
used to treat both physical and mental health conditions. However, 
because they are more likely to be used for mental health indications 
when combined with another psychotropic drug, we included them in our 
concomitant analyses when combined with a second psychotropic drug. 
See appendix I for more details explaining how the concomitant 
analysis was conducted to eliminate cases in which a patient began 
taking a new drug without finishing the previous supply, thereby 
creating the appearance of concurrent use. 

[26] For example, see Zito et al., Psychotropic Medication Patterns 
Among Youth in Foster Care, Pediatrics 2008; Volume 121; pp.157-163. 

[27] For this analysis, we used dosage guidelines developed by the 
state of Texas based on FDA-approved drug labels, where available, for 
33 drugs. For additional information, see Heiligenstein, Psychotropic 
Medication Utilization Parameters for Foster Children, Office of the 
Commissioner, Texas Department of Family and Protective Services 
(Austin, Tex.: December 2010). 

[28] According to one of our experts, the effect of psychotropic 
medications has not been proven to be safe or effective above the 
maximum recommended dose by an FDA review. At lower dosages, 
psychotropic medications generally show an increase in efficacy with 
an increase in dose, but this dose-response relationship changes as 
the dose increases. At higher dosages, increasing doses of medications 
are often accompanied by an increased risk in adverse effects with 
little or no added benefit. 

[29] While the data we used for this analysis were generally reliable, 
the date-of-birth field was blank for some records. The number of 
foster infants, in particular, captured in the claims data may be 
underreported. It is also possible that a small number of Medicaid and 
foster care records may contain inaccurate personal data or 
prescription information likely resulting from data entry errors. See 
appendix I on our assessment of data reliability. 

[30] Experts also noted that some of these prescriptions may have been 
written with the intention of treating an uninsured parent or sibling. 
It is not possible to determine from the data whether this was the 
case. 

[31] Infrequent gaps may also be caused by a serious illness that 
prevents the patient from taking the medication as prescribed, or 
patients who choose to discontinue a medication because of side 
effects. 

[32] G. Chouinard, Issues in the clinical use of benzodiazepines: 
potency, withdrawal, and rebound, J Clin Psychiatry, 2004; 65 Suppl 5: 
pp. 7-12. 

[33] SSRIs are antidepressants. 

[34] S. Hosenbocus and R. Chahal, SSRIs and SNRIs: A review of the 
Discontinuation Syndrome in Children and Adolescents, J Can Acad Child 
Adolesc Psychiatry (February 2011) 20(1): pp. 60-67. 

[35] National Institute of Mental Health, Mental Health Medications, 
U.S. Department of Health and Human Services (Bethesda, Md.: Revised 
2008). 

[36] Child and Family Services Improvement and Innovation Act, Pub. L. 
No. 112-34, § 101(b)(2), 125 Stat. 369 (2011). 

[37] CFSRs, which occur on a regular and recurring basis in every 
state (generally every 2 to 5 years depending on the results of the 
prior review), are the central and most comprehensive component of 
federal efforts to determine state compliance with federal child 
welfare requirements. ACF also reviews states' progress related to 
areas found not to be in substantial conformity with federal 
requirements based on the last CFSR, generally on an annual basis. 

[38] In order to be eligible for certain federal child welfare grants, 
state child welfare agencies are required to develop a plan for 
ongoing oversight and coordination of health care services for foster 
children, including mental health, in coordination with the state 
Medicaid agency, pediatricians, other health care experts, and child 
welfare experts. See 42 U.S.C. § 622(b)(15). Among other things, the 
state plans must also include the oversight of prescription drugs, and 
how the agency actively consults and involves physicians and other 
professionals in assessing the health and well-being of children in 
foster care in determining appropriate medical treatment for the 
children. 

[39] Each of the six states reviewed performs a drug utilization 
review during the prescription claims process to promote patient 
safety, reduce costs, and prevent fraud and abuse as required by the 
Omnibus Budget Reconciliation Act (OBRA) of 1990 (Pub. L. No. 101-508, 
§ 4401, 104 Stat. 1388, § 1388-143. (1990)). States were encouraged by 
enhanced federal funding to design and install point-of-sale 
electronic claims management systems that interface with their 
Medicaid Management Information Systems (MMIS) operations. The annual 
report requirement is used to assess patient safety, provider 
prescribing habits, and dollars saved by avoidance of problems such as 
drug-drug interactions, drug-disease interactions, therapeutic 
duplication, and overprescribing by providers. However, the extent to 
which a state's DUR process included reviews of psychotropic drugs 
varied across our states and the DUR process is not focused on the 
foster child population specifically. 

[40] M.W. Naylor, et al., Psychotropic Medication Management for Youth 
in State Care: Consent, Oversight, and Policy Considerations, Child 
Welfare V 86, 5 (2007) pp.175-192. 

[41] Primary care provider prescriptions were not flagged when 
treating ADHD, uncomplicated depression, and uncomplicated anxiety 
disorders. 

[42] Beginning October 2011, the Maryland Medicaid Pharmacy Program 
(MMPP) implemented a peer-review authorization process to ensure the 
safe and effective use of antipsychotic medications in children. 
Claims for antipsychotic medications that are for children younger 
than the FDA-approved age require prior authorization (PA) based on 
the peer-review assessment. The MMPP's board-certified child 
psychiatrist oversees the peer-review project. According to a state 
agency official, a child and adolescent psychiatrist who is faculty at 
Johns Hopkins University School of Medicine monitors all psychotropic 
medication use for children entering foster care in Baltimore City. 
However, this practice is not statewide. 

[43] According to the Center's website, its mission is to support and 
facilitate the identification, expansion, and transfer of expert 
knowledge and best practices in child welfare case practice, direct 
services, management, finances, policy, and organizational development 
to child welfare and child protection stakeholders throughout Florida. 

[44] However, we determined through data tests, interviews, and 
reviews of state audit reports that data on children in Maryland 
foster care during 2008 were unreliable. Maryland data were not 
included in the data analysis portion of this report. 

[45] States with fee-for-service carve outs for psychotropic 
medications pay providers directly for these medications, and manage 
the resulting claims in a centralized data set. States without 
prescription carve outs used managed care organizations to oversee and 
pay for prescriptions, resulting in numerous, noncentralized data sets 
that would have inhibited our ability to identify psychotropic drugs 
for this analysis. 

[46] Approved drugs lists were either the state's formulary or 
preferred drug list. 

[47] Although some medications may be prescribed on an "as needed" 
basis, these types of prescriptions are not distinguished in the data. 
In our analysis of doses exceeding levels recommended by the FDA and 
medical literature, we count all medications as though they were taken 
on a daily basis. 

[48] According to one of our experts, these secondary medications are 
likely used to treat physical symptoms when prescribed alone, but when 
paired with another psychotropic medication, they are likely used for 
mental health. 

[49] In Florida, about 60 percent of foster children and 45 percent of 
nonfoster children had their prescriptions covered only on a fee-for-
service basis during 2008. In Massachusetts, the percentages were 
about 72 percent for foster children and about 42 percent for 
nonfoster children. For these two states, our analysis is not 
applicable to the entire state's foster care or Medicaid program. 

[50] Thomson Reuters' Red Book™ is a medical resource for healthcare 
professionals for current information on medications. 

[51] Calculating the number of prescriptions on a monthly rather than 
daily basis may result in an underestimate of concomitant 
prescriptions for individuals with continuous prescriptions that did 
not cover 84 days during 3 calendar months. 

[52] For a comprehensive list of mental health medication categories, 
uses, and side effects, see National Institute of Mental Health, 
Mental Health Medications, U.S. Department of Health and Human 
Services (Bethesda, Md.: Revised 2008). 

[53] For our analysis of concomitant use, we also included several 
drugs from the following categories: certain anti-anxiety drugs, 
anticonvulsants, anti-enuretics, antiparkinson drugs, and sleep aids. 

[54] Combination drugs have two different classes of drugs in a single 
dose. For example, Symbyax contains olanzepine and fluoxetine, an 
antipsychotic and an antidepressant. This medication is used to treat 
depression with bipolar I disorder or depression that does not respond 
to other medicines. These drugs have side effects similar to their 
component medications. 

[55] Some benzodiazepines may be prescribed for insomnia, and 
therefore may also be considered hypnotics. 

[56] Some medications developed to treat depression, such as selective 
serotonin reuptake inhibitors and tricyclic antidepressants may also 
be used to treat anxiety disorders. 

[57] Some anti-anxiety medications may also be considered hypnotics. 
For example, in this report we categorize clonazepam (Klonopin), 
lorazepam (Ativan), and alprazolam (Xanax) as anti-anxiety 
medications, but they may also be used for insomnia. 

[58] For example, Symbyax contains olanzapine and fluoxetine, an 
antipsychotic and an antidepressant, in a single dose. 

[End of section] 

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