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United States Government Accountability Office:
GAO:
Testimony:
Before the Subcommittee on Federal Financial Management, Government
Information, Federal Services, and International Security, Committee
on Homeland Security and Governmental Affairs, U.S. Senate:
For Release on Delivery:
Expected at 10:30 a.m. EST:
Thursday, December 1, 2011:
Foster Children:
HHS Guidance Could Help States Improve Oversight of Psychotropic
Prescriptions:
Statement of Gregory D. Kutz, Director:
Forensic Audits and Investigative Service:
GAO-12-270T:
GAO Highlights:
Highlights of GAO-12-270T, a testimony before the Subcommittee on
Federal Financial Management, Government Information, Federal
Services, and International Security; Committee on Homeland Security
and Governmental Affairs; U.S. Senate.
Why GAO Did This Study:
Why GAO Did This Study
Foster children have often been removed from abusive or neglectful
homes and tend to have more mental health conditions than other
children. Treatment may include psychotropic drugs but their risks to
children are not well understood. Medicaid, administered by states and
overseen by the Department of Health and Human Services (HHS),
provides prescription drug coverage to foster children.
This testimony examines (1) rates of psychotropic prescriptions for
foster and nonfoster children in 2008 and (2) state oversight of
psychotropic prescriptions for foster children through October 2011.
GAO selected Florida, Maryland, Massachusetts, Michigan, Oregon, and
Texas primarily based on their geographic diversity and size of the
foster care population. Results cannot be generalized to other states.
In addition, GAO analyzed Medicaid fee-for-service and foster care
data from selected states for 2008, the most recent year of
prescription data available at the start of the audit. Maryland’s 2008
foster care data was unreliable. GAO also used expert child
psychiatrists to provide a clinical perspective on its methodology and
analysis, reviewed regulations and state policies, and interviewed
federal and state officials.
What GAO Found:
Foster children in the five states GAO analyzed were prescribed
psychotropic drugs at higher rates than nonfoster children in Medicaid
during 2008, which according to research, experts consulted, and
certain federal and state officials, could be due in part to foster
children’s greater mental health needs, greater exposure to traumatic
experiences and the challenges of coordinating their medical care.
However, prescriptions to foster children in these states were also
more likely to have indicators of potential health risks. According to
GAO’s experts, no evidence supports the concomitant use of five or
more psychotropic drugs in adults or children, yet hundreds of both
foster and nonfoster children in the five states had such a drug
regimen. Similarly, thousands of foster and nonfoster children were
prescribed doses higher than the maximum levels cited in guidelines
developed by Texas based on FDA-approved labels, which GAO’s experts
said increases the risk of adverse side effects and does not typically
increase the efficacy of the drugs to any significant extent. Further,
foster and nonfoster children under 1 year old were prescribed
psychotropic drugs, which GAO’s experts said have no established use
for mental health conditions in infants; providing them these drugs
could result in serious adverse effects.
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]
Selected states’ monitoring programs for psychotropic drugs provided
to foster children fall short of best principle guidelines published
by the American Academy of Child and Adolescent Psychiatry (AACAP).
The guidelines, which states are not required to follow, cover four
categories.
* 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:
In our draft report, GAO recommended that HHS consider endorsing
guidance for states on best practices for overseeing psychotropic
prescriptions for foster children. HHS agreed with our recommendation.
Agency comments will be incorporated and addressed in a written report
that will be issued in December 2011.
View [hyperlink, http://www.gao.gov/products/GAO-12-270T] or key
components. For more information, contact Gregory D. Kutz at (202) 512-
6722 or kutzg@gao.gov.
[End of section]
Chairman Carper, Ranking Member Brown, and Members of the Subcommittee:
Thank you for the opportunity to discuss psychotropic drug
prescriptions provided to foster children under state care. 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]
This testimony discusses, for selected states, (1) rates of
psychotropic drug prescriptions for foster children compared with
nonfoster children covered by Medicaid in 2008, including indicators
of health risks, and (2) federal and state oversight policies as of
October 2011 for psychotropic drugs prescribed to foster children. We
have received comments on a draft of the report this testimony is
based on from the Department of Health and Human Services (HHS) and
relevant state agencies. We plan to incorporate their comments into
the report that we will issue in December 2011. We contracted with two
child psychiatrists with clinical and research expertise in the use of
psychotropic drugs in children to provide a clinical perspective on
our methodology and data analysis. To compare rates of psychotropic
drug prescriptions, we reviewed calendar year 2008 fee-for-service
prescription claims and foster care data for Florida, Maryland,
Massachusetts, Michigan, Oregon, and Texas.[Footnote 3],[Footnote 4]
At the start of our audit, 2008 data were the most recent calendar
year prescription claims data available from the Centers for Medicare
& Medicaid Services (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 their foster care data.[Footnote 5] To identify
potential health risk indicators, we consulted with our experts,
performed literature searches, and reviewed state guidelines. 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 based on Food and Drug Administration (FDA)
approved labels, 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.
To determine federal and state oversight policies, we interviewed
officials from CMS, the Administration for Children and Families
(ACF), and the six selected states' Medicaid and foster care agencies.
We also reviewed policies 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 the American
Academy of Child and Adolescent Psychiatry's (AACAP) guidelines as a
basis for assessing the extent to which selected states were
implementing recommended practices.[Footnote 6]
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. Our full scope
and detailed methodology will be provided in our report that will be
issued in December 2011.
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 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. 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. 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 7]
States are responsible for administering their Medicaid and foster
care programs; the programs are overseen at the federal level by HHS
through CMS and 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 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. More recently, Congress
passed 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 8]
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 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 9] 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 10]
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.
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 (SSRI) 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 11] These states spent over $375
million for prescriptions provided through fee-for-service programs to
foster and nonfoster children.[Footnote 12] 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 13] However, psychotropic drug claims for foster
children were also more likely to show the indicators of potential
health risks that we established with our experts. According to our
experts, no evidence supports the concomitant use of five or more
psychotropic drugs in adults or children, yet hundreds of both foster
and nonfoster children were prescribed such a medication regimen.
Similarly, thousands of foster and nonfoster children were prescribed
doses exceeding maximum levels cited in guidelines based on FDA-
approved drug labels, which our experts said increases the potential
for adverse side effects, and does not typically increase the efficacy
of the drugs to any significant extent.[Footnote 14] 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 15] 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 16] Figure 1 shows prescription
rates for children in each state for various age ranges.
Figure 1: Psychotropic drug prescription rates for 5 selected states:
[Refer to PDF for image: interactive graphic]
Data available in Appendix I.
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 the 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 17] 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 18] 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 19]
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 20]
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 21] Several studies
of the utilization 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 22] 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 oversee
psychotropic drug prescriptions in the next section of this testimony
that discusses federal and state oversight over 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 23]
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 24] doses exceeding maximum levels in FDA-
approved drug labels, and prescriptions for infants.[Footnote 25]
Figure 2 provides more information on these indicators by state.
Figure 2: Psychotropic drug potential health risk indicators for 5
selected states:
[Refer to PDF for image: interactive graphic]
Data available in Appendix I.
Source: GAO analysis of state Medicaid and foster care data.
[End of figure]
Concomitant psychotropic drug prescriptions.[Footnote 26] 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 27]
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 28]. 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 29]e.:
Psychotropic prescriptions for infants. The rate of children age 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 30] 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 ten 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
31] 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,
these cases raise significant concerns because infants are at a stage
in their development where they are potentially more vulnerable to the
effect of psychotropic drugs. See table 2 for more information.
Table 2: Children age 0-1 year old prescribed psychotropic drugs in
five selected states[A]:
Drug category (subclass): Anti-anxiety (antihistamines)[B];
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.
[A] Note: A total of 76 foster children and 3,765 nonfoster children,
or 3,841 children age 0-1, 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.
[B] 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
non-mental 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 the caretaker's failure to
fill prescriptions on behalf of a child in a timely manner or a lack
of consistent access to care.[Footnote 32] 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 33] and the sudden discontinuation of SSRIs[Footnote
34] such as paroxetine can cause a variety of problems, including
dizziness, headaches, fatigue, and nausea.[Footnote 35] 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 36] 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 provides 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 5 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:
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:
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:
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:
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:
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 had developed monitoring programs that satisfied some of
AACAP's best principles guidelines to varying degrees. Such variation
is not surprising given that states set their own oversight guidelines
and have only recently been required, as a condition of receiving
certain federal child welfare grants, to establish protocols for the
appropriate use and monitoring of psychotropic drugs prescribed to
foster children.[Footnote 37]
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 (CFSR) 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 38] These reviews include 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 39] 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.
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 40] 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 41] 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 42] 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
43] 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's 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 can
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 44] 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.
Prescriptions for infants are also of concern, due to the potential
for serious adverse effects even when these drugs are used for non-
mental 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 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:
In our draft report, we recommended that the Secretary of HHS evaluate
our findings and consider endorsing guidance to state Medicaid and
child welfare agencies on best practices for monitoring psychotropic
drug prescriptions for foster children, including guidance that
addresses, at minimum, informed consent, oversight, consultation, and
information sharing.
We have received written comments on our draft report from HHS and
relevant agencies in 6 states. In written comments, HHS agreed with
our recommendation and provided technical comments, which we
incorporated as appropriate. In written comments and exit conferences,
staff from state Medicaid and foster care agencies provided comments
on key facts from the report. Agency comments will be incorporated and
addressed in a written report that will be issued in December 2011.
Chairman Carper, Ranking Member Brown, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions that you may have at this time.
GAO Contacts:
For additional information about this testimony, 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 statement.
[End of section]
Appendix I: Print-friendly version of figure 1 and figure 2:
Figure 1 data:
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 Figure 1 data]
Figure 2 data:
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 Figure 2 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.:
February 6, 2009).
[2] Medicaid programs vary from state to state.
[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. 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 these states, since we examined only fee-for-
service data, we were more likely to identify psychotropic
prescriptions to foster children during calendar year 2008 than to
nonfoster children.
[4] In addition, the Medicaid 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.
[5] 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 Redbook. 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.
[6] AACAP guidelines are available at [hyperlink,
http://www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinci
ples_FINAL.pdf].
[7] 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).
[8] Pub. L. No. 112-34, § 101(b)(2), 125 Stat. 369.
[9] National Institute of Mental Health, Treatment of Children with
Mental Illness, NIH Publication No. 09-4702, (Bethesda, MD.: Revised
2009).
[10] 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).
[11] 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.
[12] 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)).
[13] 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)
[14] 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.
[15] 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 ratio of prescriptions to foster children to
prescriptions to nonfoster children is comparable across states.
[16] 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.
[17] 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.
[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 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).
[19] 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.
[20] 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, [hyperlink,
http://www.gao.gov/products/GAO-11-457] (Washington, D.C.: May 2011).
[21] 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).
[22] 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).
[23] Leslie et al, Multi-State Study on Psychotropic Medication
Oversight in Foster Care, Tufts Clinical and Translational Science
Institute (Boston, Mass.: 2010).
[24] According to one of our experts, this may be justified in rare
cases of children with serious, complex mental health issues.
[25] 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.
[26] 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.
[27] For example, see Zito et al, Psychotropic Medication Patterns
Among Youth in Foster Care, Pediatrics 2008; Volume 121; 157-163.
[28] 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).
[29] 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.
[30] 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.
[31] 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.
[32] 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.
[33] G. Chouinard, Issues in the clinical use of benzodiazepines:
potency, withdrawal, and rebound. J Clin Psychiatry. 2004; 65 Suppl
5:7-12.
[34] Selective serotonin reuptake inhibitors (SSRIs) are
antidepressants.
[35] S. Hosenbocus , R. Chahal, SSRIs and SNRIs: A review of the
Discontinuation Syndrome in Children and Adolescents. J Can Acad Child
Adolesc Psychiatry. 2011 Feb; 20(1): 60-7.
[36] National Institute of Mental Health, Mental Health Medications,
U.S. Department of Health and Human Services. (Bethesda, Md.: Revised
2008).
[37] Child and Family Services Improvement and Innovation Act, Pub. L.
No. 112-34, § 101(b)(2), 125 Stat. 369 (2011).
[38] 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.
[39] 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.
[40] 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). 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 states' DUR process included reviews of psychotropic drugs
varied across our states and the DUR process is not focused on the
foster child population specifically.
[41] M. W. Naylor, et al, 2007. Psychotropic Medication Management for
Youth in State Care: Consent, Oversight, and Policy Considerations,
Child Welfare V 86, 5 (2007) p.175-192.
[42] Primary care provider prescriptions were not flagged when
treating ADHD, uncomplicated depression, and uncomplicated anxiety
disorders.
[43] 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 a 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.
[44] 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.
[End of section]
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