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Sunday 10 June 2012

FOSTER CARE : Guidance : letter to state directors of health.

November 23, 2011- Washington, D.C. 20201

Dear State Director:
The Department of Health and Human Services (HHS) has become increasingly concerned about the safe, appropriate, and effective use of psychotropic medications among children in foster care. In the coming months, the Administration for Children and Families (ACF), the Centers for Medicare and Medicaid Services (CMS), and the Substance Abuse and Mental Health Services Administration (SAMHSA) will offer expanded opportunities to States and territories (hereafter States) to strengthen their systems of prescribing and monitoring psychotropic medication use among children in foster care. Included in these opportunities will be a convening of directors of State child welfare, Medicaid, and mental health authorities to develop action plans for addressing this issue.
State child welfare systems are moving children from foster care to permanency faster and in greater numbers than ever. At the same time, we recognize that these systems struggle to achieve positive outcomes for the children in their care who have complex social-emotional, behavioral, and mental health problems. Children in foster care represent only three percent of children covered by Medicaid,1 yet, based on a study of pharmacy claims in 16 States, foster children enrolled in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of other children receiving Medicaid.2 While medications can be an important component of treatment, strengthened oversight of psychotropic medication use is necessary in order to responsibly and effectively attend to the clinical needs of children who have experienced maltreatment.
Enhanced efforts to properly prescribe and monitor psychotropic medication among children in out-of-home care are necessary, appropriate, and urgent. The Fostering Connections to Success and Increasing Adoptions Act of 2008 requires States to strengthen medical oversight and expand access to medical homes for children in the child welfare system. The purpose of these requirements is to ensure that children in foster care receive high-quality, coordinated medical services, including appropriate medication, even as their placements change. The law’s provisions offer States the opportunity to address some of the pressing issues related to psychotropic prescription oversight for children in foster care.
In addition, the Child and Family Services Improvement and Innovation Act of 2011 (Public Law 112-34) includes new language concerning the social-emotional and mental health of children who have experienced maltreatment. State Child and Family Services Plans (five-year strategic plans that set forth the vision and the goals to be accomplished to strengthen the States’1 Crystal, S; Olfson, M; Huang, C; Pincus, H; & Gerhard, T. (2009). Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges. Health Affairs. 28(5):770. (http://content.healthaffairs.org/content/28/5/w770.full.html)child welfare system) must now include details about how emotional trauma associated with maltreatment and removal is addressed, as well as a description of how the use of psychotropic medications is monitored. Read ACF’s recent Information Memorandum (ACYF-CB-IM-11-06) on the new law here:
State Medicaid/CHIP agencies and mental health authorities play a significant role in providing continuous access to and receipt of quality mental health services for children in out-of-home care. Therefore, it is essential that State child welfare, Medicaid, and mental health authorities collaborate in any efforts to improve health, including medication use and prescription monitoring structures in particular.
This letter outlines steps that ACF, CMS, and SAMHSA are taking to support effective management of prescription medications for children in foster care. You will also find background information on the use of psychotropic medication among children in foster care and resources to help your agency and your partners take action to strengthen psychotropic prescription oversight. We encourage you to coordinate with the many partners in your State working with vulnerable children to make use of these and other resources and to fortify controls for psychotropic medication use among children in foster care.


Much of what is known about the use of psychotropic medications among children who have experienced maltreatment comes from research using the National Survey of Child and Adolescent Well-Being (NSCAW), overseen by ACF. This longitudinal, nationally representative study of children who have been the subject of a child protective services report is the most extensive source of information about their experiences, health, and welfare over time. The information below is largely drawn from studies of the NSCAW dataset.
Data from NSCAW indicate that nearly 12 percent of children who have experienced maltreatment are taking a psychotropic drug. Over three years, 22 percent of children in foster care will have taken psychotropic drugs at some point. It is unclear the extent to which these rates of psychotropic use are commensurate with need, given high rates of emotional distress among children in foster care.
Research has clearly demonstrated that children known to the child welfare system are diagnosed with mental health disorders at a much higher rate than the general population. Conduct Disorder/Oppositional Defiant Disorder, Depression, Attention Deficit/Hyperactivity Disorder, and Posttraumatic Stress Disorder are their most common diagnoses, as well as the most common diagnoses among children in foster care receiving psychotropic medication.
Several factors have been shown to increase the likelihood that a child in foster care will receive a prescription for psychotropic medication:
• Age: Children in foster care are more likely to be prescribed psychotropic medications as they grow older. The likelihood of receiving multiple psychotropic medications also increases with age.
• Gender: Males in foster care are more likely to be receiving psychotropic medications (19.6 percent) than their female counterparts (7.7 percent).
• Behavioral Concerns: Children with behavioral problems, including internalizing and externalizing issues, are much more likely to be prescribed psychotropic drugs.
• Placement Type: The likelihood that a child will be taking any psychotropic medication tends to increase as placements become more restrictive. Eleven percent of children residing in in-home settings receive psychotropic medications versus nearly 14 percent in foster care homes. In group or residential homes, where the behavioral and mental health needs of children are the most severe, nearly half of the young people are taking at least one psychotropic drug. Additionally, children in more restrictive placement types are more likely to be taking multiple psychotropic medications.
There are also significant geographic variations within and across States in the prevalence of psychotropic use among children in foster care, suggesting that factors other than clinical need may be influencing prescribing practices.
In light of the clinical vulnerability of children who have experienced maltreatment, it is paramount that problematic psychotropic medication use for children in foster care be addressed. Policymakers, providers of care, families, and youth must join together to focus on these issues. Among these specific issues are the following:
• Polypharmacy: A majority of children in foster care receiving psychotropic medications have multiple prescriptions. Although children often present with complex symptoms and co-morbid conditions, there is scant evidence of the effectiveness of treatment with multiple medications. Further, taking multiple medications increases the likelihood of drug interactions and other adverse effects.
• Limited Study in Children: Most psychotropic medications are approved based on clinical trial data from studies of adults. Prescription of psychotropic drugs to children, while often effective for treatment of certain conditions, is frequently done in the absence of population-specific effectiveness research.
Collaborative efforts across HHS agencies addressing the use of psychotropic medication among children in foster care have resulted in the development of a comprehensive Departmental plan. The goal of these efforts is to improve the health, well-being, and future prospects of children who have been impacted by maltreatment. Below is a partial list of activities to be undertaken, organized by agency.
ACF Activities
In the coming months, ACF will be providing several opportunities for State child welfare staff to access information on the use of psychotropic medication among children in foster care, strategies to implement best practices, and recommendations for strengthening oversight. In their June 2012 Annual Progress and Services Report (APSR) submissions, States will be asked to submit comprehensive descriptions of procedures and protocols planned or in place to ensure the safe and appropriate use of psychotropic medications.
• Online Resources: ACF’s Child Welfare Information Gateway has been updated to include an expanded array of resources pertaining to psychotropic medication use among children in foster care. These include recommended guidelines for prescription and monitoring of psychotropic drugs for children in foster care developed by professional associations. Additionally, research articles examining the prevalence of and variation in use, and links to examples of States’ efforts to fortify prescription controls for this population are available. The Child Welfare Information Gateway is located at http://www.childwelfare.gov.
• Webinars: ACF will host a webinar for child welfare personnel in which experts will present material on mental health disorders among children in foster care and issues pertaining to treatment with psychotropic medications. A subsequent webinar will be jointly hosted with CMS and open to State child welfare and Medicaid personnel. Other joint webinars may also be planned.
• Program Instruction: In advance of the June deadline, the Children’s Bureau will publish a Program Instruction detailing the information that will be requested of States in their APSR medical oversight submissions. Key considerations, exemplary practices from around the country, and technical assistance resources will also be provided to guide your State’s work and inform your responses to the enhanced APSR items.
CMS Activities
• Share what is known: CMS is working with partners to disseminate a report summarizing findings from a 16-State consortium of State Medicaid Medical Directors to develop best practices for the use of psychotropic medications among children in Medicaid. This report is available at: http://rci.rutgers.edu/~cseap/MMDLNAPKIDS/Antipsychotic_Use_in_Medicaid_Children_Report_and_Resource_Guide_Final.pdf.
• Quality Measures: CMS, through its Pediatric Quality Measures Program (PQMP), established in collaboration with the Agency for Healthcare Research and Quality (AHRQ), focuses on the refinement and development of children’s health care quality measures covering a range of health care issues, including behavioral health. The measurement development activities conducted through the PQMP build on the initial core set of children’s health care quality measures. This measurement set, released in 2010 for voluntary use by Medicaid and CHIP programs, includes three measures related to behavioral health (Follow-up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder Medication; and Follow-up after Hospitalization for Mental Illness; and Developmental Screening in the First Three Years of Life). States choosing to collect the three measures can use these data in monitoring care and implementing initiatives to improve the quality of care for children with behavioral health conditions.
More information on the initial core set of children’s health care quality measures may be found at
• Continuity of Eligibility and Care: Children who move from one placement to another typically remain eligible for Medicaid but they may nonetheless see gaps in eligibility and disruptions in their care. Working with States, ACF, health care providers, and others, CMS will identify and communicate strategies to States for ensuring continuity of eligibility and care for children moving in and out of foster care.
• Working with States to Enhance Drug Utilization Review (DUR): States may use their Drug Utilization Review (DUR) programs to monitor dispensing at the point of service and influence prescriber behavior. For instance, at the point of service, the DUR programs can use system edits to limit inappropriate dosage and polypharmacy. In addition, States can use their retrospective DUR programs to reach out to providers whose prescribing habits vary significantly from recommended standards of care for children. CMS is developing a process for sharing with States best and innovative practices to enhance the functionality of their pharmacy programs. Additionally, CMS is considering new guidance to assist States in their efforts to monitor the utilization of psychotropic drugs dispensed by pharmacies and will be soliciting State input on what practices would be most helpful to address the special challenges of treating this population with psychotropic medications.
• Health Homes: Section 2703 of the Affordable Care Act, “State Option to Provide Health Homes for Enrollees with Chronic Conditions,” provides a new opportunity and an incentive for States, through temporary enhanced Federal reimbursement, to build a person-centered health care delivery system – caring not just for an individual’s physical condition, but providing linkages to long-term community care services and supports, social services, and family services, which are critical to children in foster care with chronic conditions. Through technical assistance pursuant to an already-published “State Medicaid Director/State Health Official Letter,”3 CMS can support States’ interest in implementing this model, which integrates primary care and behavioral health services. States interested in receiving technical assistance may send an e-mail message to the Health Homes team at healthhomes@cms.hhs.gov or to the Integrated Care Resource Center mailbox, at IntegratedCareResourceCenter@cms.hhs.gov.
• Health Information Technology: Medicaid incentive payments are available in many States to certain providers who adopt, implement, or upgrade certified Electronic Health Records (EHR) technology. Electronic health records could be used to capture clinical quality measures, such as those developed by CMS, AHRQ and SAMHSA for children and behavioral health. More information on health information technology may be found at https://www.cms.gov/ehrincentiveprograms.
3 “State Medicaid Director/State Health Official Letter” available at https://www.cms.gov/smdl/downloads/SMD10024.pdf
SAMHSA Activities
• Defining Best Practices: SAMHSA and the American Academy of Child and Adolescent Psychiatry (AACAP) are finalizing guidelines for the use of psychotropic medications among children and adolescents being served in community-based agencies. These guidelines are for service providers and agency leaders to assist them in developing policy about the role of psychotropic medications in treatment planning for children and youth. These guidelines will be relevant to providers working with youth in foster care and will be disseminated to groups listed below.
• Developing Resources: SAMHSA is working with the AACAP to finalize a Tip Sheet for Child and Adolescent Psychiatrists on how to engage youth, how to give youth a voice in the treatment process, and how to improve communication between youth and their psychiatrists. This document will be disseminated to AACAP State and regional associations, the National Association of State Mental Health Program Directors (NASMHPD) Children’s Directors, and through a number of other related listservs.
• Infusing Clinical Expertise: SAMHSA is sponsoring a Child and Adolescent Psychiatry Fellowship. Beginning in July of 2011, two child and adolescent psychiatrists were selected to spend 20 percent of a fellowship with SAMHSA working on policy issues and providing technical assistance to grantees and the field.
• Health Homes: Over the past year, SAMHSA and CMS have worked closely with States in the development and submission of their State Plan Amendments (SPAs) related to health homes. States that pursue the new health home optional benefit under section 2703 of the Patient Protection and Affordable Care Act of 2010 are required to consult and coordinate with SAMHSA to address the prevention and treatment of mental and substance use disorders among Medicaid eligible individuals with chronic conditions. Given the complex health problems faced by children and youth in the child welfare system, health homes are one vehicle for improving the care they receive.
• Addressing Trauma: As a part of its Strategic Initiative on Trauma and Justice, SAMHSA has identified child welfare as an area of focus for the prevention and treatment of the negative behavioral health consequences of traumatic events. In its portfolio of work on trauma, SAMHSA included a specific emphasis on serving children and youth in the child welfare system in the funding announcements released for the National Child Traumatic Stress Initiative. This work aims to support a balanced array of services for children who are experiencing trauma-related behavioral health problems. This effort includes a strong focus on empirically-validated psychosocial treatments in addition to the appropriate use of psychotropic medication.
Joint Activity
• Facilitating Collaboration: In Summer 2012, ACF, CMS, and SAMHSA will convene State child welfare, Medicaid, and mental health authorities to address the use of psychotropic medications with children in foster care and the mental health needs of children who have experienced maltreatment. Peer learning and technical assistance to States will be made available.
Over the next year, we will add webinars, update online resources, and plan other activities as necessary to accelerate the pace of system improvements to meet the unique and urgent needs of children who have experienced maltreatment.
As we strengthen child welfare systems’ ability to safely and appropriately manage psychotropic medication use, it is necessary to recognize the corresponding need to enhance system capacity to implement effective, non-pharmaceutical interventions to treat the social-emotional, behavioral, and mental health issues common among children who have been maltreated. We remain committed to promoting the use of evidence-based practices throughout child welfare and will continue working to support their widespread dissemination and implementation.
Responding to the unique needs of children who have experienced maltreatment requires a multifaceted yet targeted approach, of which psychotropic medication use is one component. As we work together to construct and refine this approach, we urge you to make use of the available information and establish partnerships with other entities within your State working with children who have experienced maltreatment and to let us know what each of our Federal agencies can do to improve the care provided to children in foster care. Our shared efforts will guide significant improvements in addressing the needs of the children, youth, and families that we serve.

Thank you for your ongoing and committed work to improve the lives of our Nation’s young people.

George H. Sheldon, Acting Assistant Secretary Donald Berwick, Administrator Administration for Children and Families Centers for Medicare and Medicaid Services,
Pamela S. Hyde, J.D., Administrator Substance Abuse and Mental Health Services Administration
cc. State child welfare director State Medicaid director State mental health authority director

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