Classifications of Psychotropic Medications
- Antianxiety medications
- Mood stabilizers
Sources: California State Auditor’s review of websites for organizations such as the National Institute of Mental Health, the National Alliance on Mental Illness, and the Stanford University School of Medicine.
In the last decade, both public and private entities have expressed concerns about the higher prescription rates for psychotropic medications for children in foster care (foster children) than for nonfoster children.2 In the context of foster care, state law defines psychotropic medications as those medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. Such illnesses may include anxiety disorders, attention‑deficit/hyperactivity disorder, bipolar disorder, post‑traumatic stress disorder, as well as others. As the text box shows, psychotropic medications can fall into several categories, depending on the types of afflictions they treat.3 Although some circumstances warrant the use of psychotropic medications, these medications can have serious side effects, including weight gain or loss, depression, movement disorders, pain, and sleep disturbance. Also, journal articles have linked antipsychotics to the increased risk of sudden cardiac death.
Studies have shown that foster children are prescribed psychotropic medications more frequently than nonfoster children, raising questions about whether foster children are receiving these medications appropriately. For example, in a 2010 multistate study on psychotropic medication oversight in foster care, the Tufts Clinical and Translational Science Institute cited research showing that the use of psychotropic medication in the general child population was only 4 percent while the use of psychotropic medication for foster children ranged from 13 percent to 52 percent. Additionally, a 2011 Government Accountability Office report found that 21 percent to 39 percent of foster children received prescriptions for psychotropic medications in 2008, compared with only 5 percent to 10 percent of nonfoster children. According to the American Psychological Association, studies since the 1970s have found that children in foster care often have greater need for mental health treatment than children in the general population. However, given the potential risks associated with psychotropic medications, the higher rates at which they are prescribed to foster children is a cause for concern.
The Prescription of Psychotropic Medications to Children in California’s Foster Care System
Questions regarding the prescription of psychotropic medications to foster children are of particular importance to California, which has the largest population of foster children in the country. To determine how many of the State’s 79,000 foster children were prescribed psychotropic medications, we used statewide data (state data) from the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services), two key state agencies that work with foster children. As we discuss in Chapter 2, we have concerns about the accuracy and comprehensiveness of the state data; nonetheless, they represent the best information available regarding the number of foster children statewide who were prescribed these medications. As shown in Figure 1, the state data show that nearly 12 percent of California’s foster children had nearly 96,000 prescriptions for psychotropic medications paid by Medi‑Cal in fiscal year 2014–15, or an average of about 10 prescriptions per child per year.4
The state data show the number of foster children prescribed psychotropic medications paid through Medi‑Cal decreased by more than 7 percent from fiscal year 2012–13 to fiscal year 2014–15. At the same time, the number of paid prescriptions for psychotropic medications for these children decreased by nearly 13 percent. Further, our analysis of the state data shows that older foster children were more likely to have paid prescriptions for psychotropic medications than younger ones. Nearly three quarters (74 percent) of the foster children with paid prescriptions for psychotropic medications in fiscal year 2014–15 were aged 12 to 17, compared to less than 2.5 percent aged 5 years or less.
Despite the decrease in the overall number of foster children receiving psychotropic medications, state data show that nearly half of these foster children had paid antipsychotic medication prescriptions in fiscal year 2014–15. Antipsychotics pose a particular risk for children because they have a high risk of severe side effects. Nevertheless, the state data show that antipsychotics made up nearly 35 percent of all paid prescriptions for psychotropic medications for foster children, as Figure 1 shows.
We provide summary data about foster children prescribed psychotropic medications in the Appendix.
Statewide Number and Proportion of Children in Foster Care With Prescriptions for Psychotropic Medications
Paid for by Medi‑Cal During Fiscal Year 2014–15
Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi‑Cal pharmacy data.
Foster Children and Health Care
Foster care is a social welfare program funded and administered by federal, state, and county governments. Children enter foster care through one of two channels: the child welfare system or the probation system. Within the child welfare system, state law authorizes a juvenile court to declare a child to be a dependent of the court for certain specified reasons that generally involve the parents’ or caregivers’ unwillingness or inability to provide adequate care, including protecting children from physical or sexual abuse. Within the probation system, state law authorizes the juvenile court to declare a child to be a ward of the court because the child is beyond the control of his or her parent, guardian, or custodian; fails to comply with curfews or attend school; or has committed a crime. State data show that from fiscal years 2012–13 through 2014–15 about 80 percent of California’s foster children with paid prescriptions for psychotropic medications were in the child welfare system, compared to about 20 percent in the probation system.
The federal Social Security Act requires that, in order to be eligible for federal payment, a state must have a plan for child welfare services that provides foster children with health care, including mental health care services. In addition, Medicaid requires—and helps pay for—the provision of necessary health services, including psychosocial services, to children covered by Medicaid, which includes foster children up to age 21. In response to these requirements, the State provides basic health care to foster children that includes health screenings within 30 days of the children entering foster care; periodic screenings and mental health assessments thereafter; and services, treatments, and medications, as needed.
Medicaid funding covers part of the health care costs of foster children, including those related to mental health care services. Its reimbursement levels vary depending upon the type of cost. For example, Medicaid will reimburse 50 percent for the costs of health care services provided to foster children. It will also reimburse 75 percent of the costs for skilled professional medical personnel—such as public health nurses—and their support staff who provide services to the foster care program.
The State and counties generally provide or acquire the remainder of the necessary funding for foster children’s health care. State funding for psychosocial services for foster children can come from a variety of sources, including state public safety realignment funding from sales taxes, vehicle taxes, and fees. In addition, the Mental Health Services Act imposes a 1 percent tax on income in excess of $1 million to expand mental health services. Counties also provide their own funding and may acquire additional funding through grants.
Counties are responsible for ensuring the provision of health care services to foster children. Specifically, state law enacted in 2012 moved programmatic responsibility for child welfare services, including the support and care of foster children, from the State to the counties (child welfare services realignment). However, Social Services—which under state law is jointly responsible with the counties for establishing and supporting the child welfare services system—is still responsible for providing oversight and technical assistance to the counties. Under child welfare services realignment, the counties provide psychosocial services through different types of health care systems, as shown in Figure 2.
A Child in Foster Care’s Path to Mental Health Services in California
Sources: California laws, state and county agency documents, and the California State Auditor’s review of other information.
Oversight of the Provision of Psychotropic Medications to Foster Children
Different levels and branches of government are responsible for overseeing the provision of psychotropic medications to foster children in California. As shown in Table 1, executive branch entities at the federal, state, and county levels oversee foster children who receive psychotropic medications. Further, the judicial branch at the state and county levels also has an oversight role for these foster children.
The federal government provides oversight of the prescription of psychotropic medications through the U.S. Department of Health and Human Services (Health and Human Services). Before 2011, Health and Human Services provided general guidance to states regarding psychotropic medications and Medicaid beneficiaries but did not require the states to take any specific actions. However, in response to a change in federal law in September 2011, Health and Human Services established certain requirements with which states must now comply. For example, states must now include an outline of their protocols for ensuring the appropriate use and monitoring of psychotropic medications in their Child and Family Services Plans, which set forth the states’ strategic plans for strengthening their overall child welfare systems. Health and Human Services requires states to submit these plans every five years and to submit annual progress and services reports related to their plans in the interim. Health and Human Services then uses information from the Child and Family Services Plans as well as the states’ annual reports as part of the statewide assessment component of the federal child and family services review (federal review), which assesses each state’s child welfare system.
Since Health and Human Services’ implementation of the federal review in 1997, it has twice reviewed all the states and is currently reviewing them for the third time. Although California’s past federal reviews have included little discussion of foster children who received psychotropic medications, its third review is likely to more directly address this issue. Specifically, California’s most recent federal review, for which Health and Human Services published a report in 2008, included just two references to psychotropic medications: it acknowledged that stakeholders had expressed concerns that foster children had been prescribed psychotropic medications rather than being given adequate psychosocial services, and it mentioned the role of public health nurses in monitoring psychotropic medications. However, California’s upcoming 2016 federal review will include information from its 2015–2019 Child and Family Services Plan, which describes California’s protocols for the appropriate use and monitoring of psychotropic medications. In particular, the protocols address five key components specified by Health and Human Services’ guidance: screening, assessment, and treatment plans; informed and shared decision making; medication monitoring; mental health expertise and consultation; and mechanisms for sharing accurate and up‑to‑date information.
We discuss the State’s and counties’ oversight mechanisms in more detail in Chapter 2 of our report.
|PUBLIC ENTITY||OVERSIGHT ROLE FOR FOSTER CHILDREN PRESCRIBED PSYCHOTROPIC MEDICATIONS|
|U.S. Department of Health and Human Services—Administration for Children and Families & Centers for Medicare and Medicaid Service||Provides guidance and instructions to states regarding foster children and psychotropic medications.|
|Judicial Council||Provides guidance and instruction—through court rules, template forms, trainings, and some technical support—to county superior courts related to approving psychotropic medications for foster children.|
|California Department of Social Services (Social Services)||Oversees and administers programs serving California’s most vulnerable residents.|
|Child and Family Services Division||Provides assistance in adoptions, foster care, children’s programs, and child welfare services. In collaboration with the Department of Health Care Services (Health Care Services), Social Services maintains the Health Care Program for Children in Foster Care, a public health nursing program administered by local public health departments to provide public health nursing expertise to ensure the health care needs of children in out‑of‑home placement or foster care.|
|Community Care Licensing Division||Administers the Children’s Residential Licensing Program, which issues licenses to homes and facilities that house foster children.|
|Health Care Services||Administers the fee‑for‑service Medi‑Cal program and provides direction and guidance to Medi‑Cal managed care programs and county Medi‑Cal mental health plans.|
|Clinical Assurance and Administrative Support Division||Reviews and adjudicates treatment authorization requests for medications under the Medi‑Cal fee‑for‑service program.|
|Mental Health Services Division||Administers, oversees, and monitors community mental health program service delivery and compliance for the Medi‑Cal Specialty Mental Health Services program and the Mental Health Services Act.|
|Managed Care Quality and Monitoring Division||Monitors and oversees California’s Medi‑Cal managed care health plans and Medi‑Cal managed care policy development.|
|Pharmacy Benefits Division||Administers Health Care Services’ Medi‑Cal fee‑for‑service drug program and responsible for the management of the Medi‑Cal managed care pharmacy program.|
|Provider Enrollment Division||Reviews applications for providers seeking to participate directly or indirectly in the fee‑for‑service Medi‑Cal program.|
|Medical Board of California||Licenses and oversees medical doctors, with the authority to investigate and discipline any physicians alleged to have committed acts of wrongdoing. It is currently in the process of acquiring Medi‑Cal pharmacy claims data related to foster children and psychotropic medications to review and identify physicians who may have inappropriately prescribed psychotropic medications to foster children.|
|Superior Court||Administers the court authorization review process, which adjudicates requests to administer psychotropic medications to foster children.|
|Child Welfare Department/Divisions||Oversees dependents of the court and administers the counties’ foster care programs.|
|Probation Department||Oversees wards of the court, including those who are placed into foster care.|
|Mental Health/Behavioral Health Department/Divisions||Administers county Medi‑Cal mental health plans that provide mental health services, including case management, psychosocial therapies, and psychiatric medication support to Medi‑Cal beneficiaries, including foster children and wards of the court.|
|Department of Public Health||Protects and promotes community health and well‑being.|
Sources: California State Auditor’s review of federal and state laws and various agency documents.
Guidelines for the Safe and Appropriate Use of Psychotropic Medications in the Treatment of Foster Children
Select Recommendations From the American Academy of Child and Adolescent Psychiatry
- Health providers should follow up within at least a month of a child starting a psychotropic medication.
- Generally, a child should receive nonpharmaceutical mental health services before starting a psychotropic medication.
- A child should receive nonpharmaceutical mental health services when receiving a psychotropic medication.
Sources: California State Auditor’s review of the American Academy of Child and Adolescent Psychiatry’s 2009 Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents, and its 2012 Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents.
A number of different entities have developed or established guidelines that can help to ensure the appropriate use of psychotropic medications in the treatment of foster children. For example, in 2009 the American Academy of Child and Adolescent Psychiatry (Academy) developed a document titled Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents. The purpose of the document was to promote the appropriate and safe use of psychotropic medications in children and adolescents with psychiatric disorders by emphasizing best practice principles that underlie medication prescribing. Further, in 2012 the Academy developed another document titled A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents. The purpose of this document was to provide entities that serve children, including child welfare and juvenile justice agencies, with information regarding the role of psychotropic medications in treatment plans for children. Throughout our report, we refer to these two documents collectively as academy guidelines. We summarize the academy guidelines in the text box and discuss them in more detail in applicable sections of our report.
The State also recently developed its own guidelines for the safe administration of psychotropic medications to foster children. In 2012, Social Services and Health Care Services initiated a statewide quality improvement project to improve techniques for monitoring psychotropic medication use among children in foster care. This project included the creation of a clinical workgroup to develop statewide guidelines for the ongoing oversight and coordination of health care services for children in foster care, including protocols and strategies to improve the appropriate use and monitoring of psychotropic medication for these children.
Key Standards Within the State’s Guidelines for Prescribing Psychotropic Medications to Foster Children
- A foster child should generally not take multiple psychotropic medications within the same class concurrently.
- A foster child should generally be limited to taking a total number of psychotropic medications, regardless of class, that is appropriate for his or her age:
- A foster child should generally only take psychotropic medications within recommended dosage parameters, as outlined in the Los Angeles County Department of Mental Health’s Parameters 3.8: For Use of Psychotropic Medication in Children and Adolescents.
|For Children Aged:||No More Than:|
|one psychotropic medication|
|two psychotropic medications|
|three psychotropic medications|
Source: California State Auditor’s review of California’s Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care.
In March 2015, as part of this quality improvement project, Social Services and Health Care Services jointly released a document titled California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (state guidelines), which they consider to be a summary of the best practices for the treatment of children who are placed in foster care. The state guidelines represent the first comprehensive effort at the state level to address the use of psychotropic medication by children in out‑of‑home care who are being served by the child welfare and/or probation system. In developing these guidelines, Social Services and Health Care Services reviewed the Academy’s publications, the American Academy of Pediatrics’ policies, California county child welfare and behavioral health policies and practices, and the policies of child welfare and mental health agencies in other states.
The state guidelines include prescribing standards that counties can, but are not required to, use when reviewing applications to courts for authorization to prescribe psychotropic medications to foster children. According to Social Services and Health Care Services, these prescribing standards represent the current best practices and incorporate evidence‑based support. The departments do not intend these prescribing standards to stifle independent treatment or care by providers but rather to form a foundation for review, with the goal to ensure that children receive the minimum number of psychotropic medications necessary in the lowest therapeutic doses that are appropriate for their ages.
As shown in the text box, these prescribing standards recommend limiting the number of concurrent psychotropic medications by class that foster children should take. They also recommend limiting psychotropic medications by dosage and by a child's age. According to the prescribing standards, counties should identify prescriptions that exceed these limitations and ask prescribers to submit additional information to justify or explain the prescriptions.
Scope and Methodology
The Joint Legislative Audit Committee (audit committee) directed the California State Auditor to examine state and county agencies’ monitoring and oversight of foster children who have been prescribed psychotropic medications. It also directed us to review the availability and adequacy of other supportive services for foster children, such as mental health and substance abuse counseling. Table 2 lists the audit committee’s objectives and the methods we used to address them.
Also, rather than publishing this audit report in June 2016 as originally intended, we had to delay publication by two months to allow us time to obtain and analyze additional data from Health Care Services and to revise the report’s text and graphics accordingly. In November 2015, our office began analyzing data originally provided by Health Care Services in response to our request for all Medi‑Cal data related to the provision of psychotropic medications and related psychosocial services to foster children. These data provided the basis for the audit report we intended to publish in June 2016. However, about one week before we were to originally publish our audit report, Health Care Services confirmed that it had not provided all medical services data that we originally requested. Although it had provided us data for medications, treatment authorizations, and services provided by specialty mental health plans, it had not given us services data for managed care plans or fee‑for‑service providers.5 Our review showed that the additional June 22, 2016, data consisted of approximately 617 million medical service records. The related text and graphics in our audit report reflect a consolidation of the original more than 46 million medical service records provided by Health Care Services in November 2015 and the additional 617 million medical service records it subsequently provided on June 22, 2016, for a total of more than 663 million claims for medical services. Because the results from the consolidated data did not substantively affect the conclusions we reached originally or the recommendations we made, we did not ask the auditees to resubmit their written responses to our June 2016 draft report.
|1||Review and evaluate the laws, rules, and regulations significant to the audit objectives.||
|2||Identify the respective roles in overseeing the mental health care of foster children of the California Department of Social Services (Social Services), the Department of Health Care Services (Health Care Services), county child welfare service agencies and probation agencies, as well as the county mental or behavioral health departments that oversee the specialty mental health services that foster children receive. Specifically identify which agencies are responsible for ensuring that foster children eligible for Medi‑Cal are receiving the mental and behavioral health services to which they are entitled under federal and state laws.||
|3||Examine the adequacy and accuracy of data tracked by these agencies on whether foster children who are being prescribed psychotropic medications also receive other appropriate nonpharmacological supportive services, such as counseling. In particular, evaluate whether these data are sufficient to determine the extent to which foster children are receiving mental health, psychosocial, behavioral health, and substance abuse services.
a. Evaluate how the above data are tracked and used, how their accuracy is ensured, and whether opportunities exist to better gather and use this information. To the extent that barriers exist to effective data collection and use, identify potential solutions.
b. For a selection of foster children at the four counties visited, determine how well the entities listed in Objective 2 have carried out their applicable responsibilities. Using these results, if applicable, identify ways in which oversight of these practices could be improved.
|4||Determine whether any structural deficiencies, network inadequacies, or adverse incentives exist within the county child welfare services, behavioral health, or Medi‑Cal systems that may be leading to the overuse of psychotropic medications among foster children. Specifically, evaluate whether viable alternatives to these medications are being underutilized because of funding deficiencies, disincentives, or other identifiable reasons.||Using results from our case file review described under Objective 3, we identified deficiencies in the oversight process. To identify the causes for these deficiencies, we examined relevant documents and interviewed state and county staff.|
|5||Examine the existing level of oversight of doctors prescribing psychotropic medications to foster children, evaluate whether this oversight is sufficient to identify and remedy noncompliance with accepted standards of practice, and if appropriate, identify opportunities to strengthen this oversight.||To determine the extent of their involvement in the oversight of prescribing physicians, we interviewed staff at the Medical Board of California and staff in ombudsman offices within Social Services and Health Care Services and examined relevant documents.|
|6||Evaluate existing processes used by the courts, the county child welfare services system, and mental health plans and providers to ensure that ongoing use of psychotropic medication by foster children is monitored for negative reactions, side effects, or overdoses.||We included the work associated with this objective—examining prescriber follow up—as part of Objective 3.|
|7||Identify whether county child welfare services agencies are ensuring that necessary health documentation is being transmitted to caregivers, prescribers, and other stakeholders when foster children receiving psychotropic medication change placement.||We included the work associated with this objective—examining Health and Education Passports—as part of Objective 3.|
|8||Determine whether any other states have implemented innovations or oversight systems that have successfully reduced the use of psychotropic medications in foster children or improved their access to nonpharmacological supports, and evaluate whether California could benefit from some of these policies or practices.||
|9||Review and assess any other issues that are significant to the audit.||We did not identify any other significant issues.|
Source: California State Auditor’s analysis of state law, federal law, planning documents, and information and documentation identified in the table column titled Method.
Assessment of Data Reliability
In performing this audit, we obtained electronic data files extracted from the information systems listed in Table 3. The U.S. Government Accountability Office, whose standards we are statutorily required to follow, requires us to assess the sufficiency and appropriateness of computer‑processed information that we use to support findings, conclusions, or recommendations. Table 3 describes the analyses we conducted using data from these information systems, our methods for testing, and the results of our assessments. Although these determinations may affect the precision of the numbers we present, there is sufficient evidence in total to support our audit findings, conclusions, and recommendations.
|INFORMATION SYSTEM||PURPOSE||METHOD AND RESULT||CONCLUSION|
Health Care Services (Health Care Services)
Paid Claims and Encounters System (PCES), as of November 2015
|To identify psychosocial and medication services for children in foster care (foster children) who had paid psychotropic medication prescriptions filled during fiscal year 2013–14.||We performed data-set verification procedures and electronic testing of key data elements and did not identify significant issues.
We did not perform accuracy or completeness testing on these data because the source documentation is located at various locations throughout the State, making such testing cost‑prohibitive.
In our review of more than 663 million claims for Medi‑Cal services, we found that more than 2.7 million of these claims—or less than half a percent—did not have sufficient identifying information for us to determine if the claim was for a child in foster care. We determined that none of these more than 2.7 million claims were for psychosocial services for children and only 6,155 were for follow‑up medication services provided to children between July 1, 2013, and July 31, 2014. Because these claims did not have sufficient identifying information, such as a social security number, we were not able to determine whether the claim was for a child in foster care. Therefore, we excluded them from our analyses.
|Undetermined reliability for these audit purposes. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our audit findings, conclusions, and recommendations.|
|Health Care Services
California Medicaid Management Information System (CA‑MMIS), as of November 2015
|To identify foster children who had multiple psychotropic medication prescriptions filled in the same medication class, or who had more psychotropic medication prescriptions filled than recommended by the State’s guidelines during fiscal year 2014–15.|
|Health Care Services
Service Utilization Review, Guidance, and Evaluation (SURGE) system, as of March 2016
|To identify whether a selection of 80 foster children’s psychotropic medication prescriptions had approved Treatment Authorization Requests from July 2013 through December 2015.||We performed data‑set verification procedures and electronic testing of key data elements and did not identify significant issues.
We did not perform accuracy and completeness testing on these data because the SURGE system is a mostly paperless system. Alternatively, we could have reviewed the adequacy of selected application controls, but we determined that this level of review was cost‑prohibitive.
|California Department of Social Services (Social Services)
Child Welfare Services/
Case Management System (CWS/CMS), as of November 2015, and matched Medi‑Cal pharmacy data, as of December 2015
||We performed data‑set verification procedures and electronic testing of key data elements and did not identify significant issues.
We reviewed existing information to determine what is already known about the data and found that prior audit results indicate there are pervasive weaknesses in Social Services’ general controls over its information systems. Further, as discussed in Chapter 2, we observed inaccurate and incomplete medical information in CWS/CMS.
|Not sufficiently reliable. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our audit findings, conclusions, and recommendations.|
Sources: California State Auditor’s analysis of various documents, interviews, and data from Health Care Services and Social Services.
2 Throughout this report, we use the term foster children to refer to children ages zero to 17 in the foster care system. Go back to text
3 Examples of psychotropic medications include the following brand names: Abilify, Ativan, Cymbalta, Haldol, Prozac, Ritalin, Seroquel, Wellbutrin, Xanax, and Zoloft. Go back to text
4 The average number of paid prescriptions per foster child may reflect that some foster children received more than one type of psychotropic medication. Alternatively, it may indicate that some foster children had paid prescriptions of a single medication filled a number of times during the year (perhaps on a monthly or bimonthly basis). Go back to text