Study Calls for HHS Guidance on Oversight of Psychotropic Prescriptions

The Government Accountability Office (GAO) testimony for yesterday’s hearing on the impacts and costs of medicating foster children recommends that the Department of Health and Human Services (HHS) provide best practice guidance to states on overseeing psychotropic medication for children in care. The recommendation is developed in response to the GAO’s study of 2008 Medicaid prescription rates for children in foster care and children not in foster care in the five states of Florida, Massachusetts, Michigan, Oregon, and Texas. In addition, the study explores best practices in psychotropic medication and the selected states’ oversight of prescriptions for children in care. The sources consulted include Medicaid fee-for-service data, foster care data, literature reviews, and practice guidelines, as well as clinical psychiatric experts and federal and state officials.

In all five states, children in foster care were prescribed psychotropic medications at higher rates than children on Medicaid, but not in care. Factors cited to explain this difference include the greater mental health needs of children in care and altered prescription patterns due to caregiver changes and varying state oversight. However, it was found that prescriptions for all children in the study do not adhere to healthy practice as defined by the evidence base and FDA guidelines, including exceeding five medications at a time, doses that are too high, prescriptions to children under age one, and gaps in prescribed regimens. Furthermore, the medication claims for children in foster care were more likely to include these high-risk practices.

The second half of the study found that the selected states’ monitoring programs for psychotropic drugs provided to children in care do not meet all of the American Academy of Child and Adolescent Psychiatry (AACAP) guidelines. Guidelines are proposed as a way to help states identify the high risk practices and give caregivers necessary information to weigh risks and benefits of medication. AACAP guidelines were selected as ideal based on the literature review and discussions with HHS officials.

Finally, the recently passed Child and Family Services Improvement and Innovation Act (P.L. 112-34) is mentioned as an opportunity to improve medication practices for children in care. That legislation includes a provision that adds to the child welfare agency state plan (under IV-B, Part I of the Social Security Act) requirement for ongoing oversight and coordination of health care services a new requirement to include protocols for the appropriate use and monitoring of psychotropic medications in the oversight of prescription medications. HHS agreed with the recommendation for a federal endorsement of best practice guidelines for states on overseeing psychotropic medication for children in care.

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