Mental Health and Foster Care

Health Human Services

Up to 80 percent of children in foster care have significant mental health issues, compared to approximately 18-22 percent of the general population.

As a result of these increased mental health issues, foster youth are prescribed psychotropic medications at a much higher rate than non-foster youth, costing the state, through fee-for-service programs such as Medicaid, millions of dollars a year.

The American Academy of Pediatrics, Healthy Foster Care American Initiative, identifies mental and behavioral health as the “greatest unmet heath need for children and teens in foster care.”

Factors contributing to the mental and behavioral health of children and youth in foster care includes the history of complex trauma, frequently changing situations and transitions, broken family relationships, inconsistent and inadequate access to mental health services and the over-prescription of psychotropic medications.

A Foster Care Alumni Study, performed by Casey Family Programs in 2003 found significant disparities in mental health between foster care alumni and the general population. The report, Assessing the Effects of Foster Care: Mental Health Outcomes from the Casey National Alumni Study, 2004 compared 1087 former foster youth and 3547 adults from the general population, matched for age, gender, and race/ethnicity and found the following.

Mental Health Disparities
Mental Illness	% of Foster Care Alumni	% of General Adult Population
Post-Traumatic Stress Disorder	21.5	4.5
Major Depressive Episode	15.3	10.6
Modified Social Phobia	11.9	8.9
Panic Disorder	11.4	3.6
Generalized Anxiety Disorder	9.4	5.1
Alcohol Dependence	3.7	2.0
Drug Dependence	3.6	0.5
Bulimia	2.9	0.4

Of particular note, considering the high level of complex trauma faced by foster children and youth, is that foster care alumni experienced post-traumatic stress disorder at a rate nearly 5 times higher than the general adult population.

Legislation

NCSL’s Child Welfare Project tracks legislation related to the mental health and foster youth in the Child Welfare Legislative Enactments Database. Below are examples of what states have done to address the mental health needs of foster children and youth since 2011.

To see legislation addressing the well-being of children and youth in foster care, check out NCSL’s 50-State Wellbeing Legislation 2008-2014.

Examples of Legislation related to the mental health and foster youth
State	Citation	Behavioral and Mental Health Legislative Enactments
Arizona	2013 Ariz. Sess. Laws, Chap. 220 2013 Senate Bill 1375	Requires the Arizona Department of Economic Security (DES), in collaboration with the Arizona Department of Health Services and the Arizona Health Care Cost Containment System to determine the most efficient and effective way to provide comprehensive medical, dental and behavioral health services for children who are in a foster home, in the custody of DES or in the custody of a probation department; relates to child protective services.
California	2014 Cal. Stats., Chap. 766 2014 Assembly Bill 1790	Requires the State Department of Social Services to convene a stakeholder group to identify barriers to the provision of mental health services by mental health professionals with specialized clinical training in adoption or permanency issues to children receiving those medically necessary specialty mental health services. Requires the stakeholder group to make specific recommendations by Jan. 31, 2016, for voluntary measures to address those barriers, but would provide that those recommendations are not binding on any state or local government agency or private entity. Requires the stakeholder group to coordinate with, and endeavor not to duplicate, existing local, state, or national initiatives.
Connecticut	2013 Conn. Acts, P.A. 178 2013 Senate Bill 972	Requires the development of a plan for meeting children’s mental, emotional and behavioral health needs; requires the inclusion of certain strategies, including school and community-based mental health services integration and early intervention enhancement; provides for collaboration with emergency mobile psychiatric service providers, training of school resource officers, mental health providers, pediatricians and child care providers, home visitation, and a study on nutrition and psychotropic drugs.
Florida	2014 Fla. Laws, Chap. 2014-227 2014 House Bill 561	Finds that though there are organizations that provide representation to children in dependency proceedings, a child with certain special needs in this system has a particular need for legal services. Requires the court to appoint an attorney for a dependent child who: resides in, or is being considered for placement in, a skilled nursing facility, is prescribed a psychotropic medication and declines it, has a developmental disability, is being placed in, or is considered for placement in, a residential treatment center, or is a victim of human trafficking. Requires the court to ask the Statewide Guardian Ad Litem Office to recommend an attorney willing to work without additional compensation prior to the court appointing an attorney on a compensated basis. Details the requirements of the attorney appointed. Clarifies who will contract with the appointed attorney, the compensation for the appointed attorney and requires the Department of Children and Families to identify and request attorney representation for qualifying children and make rules to administer the bill.
Florida	2014 Fla. Laws, Chap. 2014-224 2014 Senate Bill 1666	Requires physician involvement when evaluating medical neglect of a medically complex child. Revises advertising requirements for adoption services. Provides for the Child Abuse Death Review Committee. Revises standards for Medicaid managed care plan accountability, establishes the criminal offense of unlawful desertion of a child.
Idaho	2014, Idaho Sess. Laws, Chap. 295 2014 Senate Bill 1401	Clarifies responsibility for education of children in state care for child protection or mental health issues.
Illinois	2014 Ill. Laws, P.A. 808 2014 House Bill 5598	Establishes the Custody Relinquishment Prevention Act which creates a pathway for families on the verge of seeking services for their child's serious mental illness or serious emotional disturbance through relinquishment of parental custody to the Department of Children and Family Services, despite the absence of abuse or neglect, to receive services through the appropriate State child-serving agency.
Kansas	2014, Kan. Sess. Laws, Chap. 115 2014 House Bill 2515	Relates to powers, duties and functions transferred to the Kansas department for aging and disability services from the Kansas department for children and families and the department of health and environment, includes medical assistance recovery, community mental health and Medicaid fraud.
Michigan	2014 Mich. Pub. Acts, Act 274 2014 House Bill 4694	Authorizes circuit and district courts, and the family division of the circuit court to adopt and institute a juvenile mental health court, provides the conditions under which such courts shall obtain a memorandum of understanding from specified entities, provides the courts may contract with licensed or accredited treatment providers, provides each court shall determine the eligibility for admittance into each court system.
Michigan	2014 Mich. Pub. Acts, Act 276 2014 House Bill 4696	Relates to the mental health court programs for adults and juveniles, provides the eligibility conditions to be met by adults and juveniles for admittance in a mental health court and the requirements to be maintained once an individual is accepted into the program, provides the services available under the program including substance abuse programs and vocational opportunities, provides that an exit evaluation should be performed to determine the continuing need for specified services.
Michigan	2011 Mich. Pub. Acts, Act 63 2011 House Bill 4526	Sec. 578: Directs the Department of Human Services and child-placing agencies to use a standardized assessment tool to ensure greater cooperation between the department and the Department of Community Health and to measure the mental health treatment needs of every child supervised by the department.
Minnesota	2014 Minn. Laws, Chap. 291 2014 House Bill 2402	Sec. 9: Juvenile treatment screening team. Amends § 260C.157, subd. 3. Requires screenings to be conducted within 10 working days when the screening is requested for placement in mental health residential treatment and the child is enrolled in Minnesota’s Pre-Paid Medical Assistance Program.
Minnesota	2011 Minn. Laws, Chap. 86 2011 Senate Bill 1285	The County Board must arrange for or provide a children’s mental health screening for a child receiving child protective services; a child in out-of-home placement; a child for whom parental rights have been terminated; a child found to be delinquent; or a child found to have committed a juvenile petty offense for the third or subsequent time. Provides that a children’s mental health screening is not required when an assessment has been performed within the previous 180 days or the child currently is under the care of a mental health professional. When a child is receiving protective services or is in out-of-home placement, the court or county agency must notify a parent or guardian whose parental rights have not been terminated of the potential mental health screening and the option to prevent the screening by notifying the court or county agency in writing.
Montana	2015 Mont. Laws, Chap. 265 2015 House Bill 422	Creates a pilot project to improve outcomes for youth in the children's mental health system, requires an interim study of evidence-based outcomes, provides for public participation in development of evidence-based outcomes models, requires collection and analysis of data, provides for development of options for performance-based reimbursement, provides an appropriation.
Montana	2011 Mont. Laws, Chap. 377 2011 House Bill 565	Requires the Department of Public Health and Human Services (DPHHS) to consider placement options in in-state treatment facilities for high-risk children with mental health needs who have multiagency service needs before the department places children out of state. The DPHHS will create rules to ensure that out-of-state placement is a last resort. The rules will establish a procedure for in-state facilities to offer a treatment plan for high-risk children with mental health needs that will be considered by DPHHS before children are placed out of state.
Nevada	2011 Nev. Stats., Chap. 444 2011 Senate Bill 371	Requires appointment of a person who is legally responsible for the psychiatric care of each child who is in the custody of an agency that provides child welfare services. The person appointed is to be responsible for making all decisions concerning services and treatment provided to such children. The law allows the court to appoint the person nominated by the agency or to appoint any other person the court determines is qualified to carry out such duties and responsibilities. To the extent that a parent or legal guardian of the child is able and willing to serve as the person legally responsible for the child’s psychiatric care, the parent or guardian must be nominated and appointed pursuant to this law. It also requires the person who is legally responsible for the child’s psychiatric care to provide written consent or denial of consent for each appointment or for a course of routine treatment for the child’s psychiatric care; to maintain current information concerning the child’s medical history and emotional, behavioral and educational needs.
Oklahoma	2014 Okla. Sess. Laws, Chap. 238 2014 House Bill 1384	Creates the Parents' Bill of Rights, prohibits the state from infringing upon parental rights, directs the board of education of a school district to develop a policy listing parental rights related to education, includes sex education, prohibits a surgical procedure on a minor without parental consent, excluding abortion, prohibits a mental health evaluation of a minor without parental consent, provides exceptions, relates to immunizations, provides criminal penalties, requires identity verification.
Oregon	2014 Or. Laws, Chap. 99 2014 House Bill 4124	Establishes a Youth Suicide Intervention and Prevention Coordinator within the State Health Authority, sets forth responsibilities of the coordinator, requires the periodic updating of the Youth Suicide Intervention and Prevention Plan, reestablishes the Youth Suicide Intervention and Prevention Coordinator with that part of the Authority that works with mental health and addiction issues, includes school student data.
Oregon	2013 Or. Laws, Chap. 515 2013 Senate Bill 123	Requires the Department of Human Services to adopt rules to establish the Oregon Foster Children's Bill of Rights; provides for rights including to obtain health care and mental health care, including services and treatments available without parental consent.
Rhode Island	2015 R.I. Pub. Laws, Chap. 2015-118 2015 Senate Bill 572	Mandates the development of a transition plan by the Department of Children, Youth and Families in collaboration with the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals for all children, under the jurisdiction of the family court, who are developmentally delayed or seriously emotionally disturbed, prior to the child turning a certain age, which addresses housing, placement options, health insurance, education, employment services, mentors and continuing support services.
Rhode Island	2015 R.I. Pub. Laws, Chap. 2015-130 2015 House Bill 6016	Mandates the development of a transition plan by the Department of Children, Youth and Families in collaboration with the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals for all children, under the jurisdiction of the family court, who are developmentally delayed or seriously emotionally disturbed, prior to the child turning a certain age, which addresses housing, placement options, health insurance, education, employment services, mentors and continuing support services.
Tennessee	2015 Tenn. Pub. Acts 199 2015 Senate Bill 75	Relates to the rights of adoptive and foster care families, requires the Department of Children's Services to disclose certain information about children adopted from the department's guardianship to the adoptive family, relates to health, educational, mental and behavioral health information, as well as nationality, ethnic background, race, and religious preference, requires rules to govern the operation of a foster parent advocacy program, provides for investigation of child abuse.
Texas	2013 Tex. Gen. Laws, Chap. 1143 2013 Senate Bill 58	Relates to integrating behavioral health and physical health services provided under the Medicaid program using managed care organizations; relates to delivery of mental health, behavioral health, substance abuse, and certain other services.
Virginia	2011 Va. Acts, Chap. 9 2011 House Bill 1984	Establishes that, in cases where a child cannot be returned to his or her family or cannot be placed for adoption or where kinship care is not in the best interests of the child, the Department of Social Services shall consider other placements and services that afford the best alternative for protecting the child’s welfare. These include family foster care; treatment foster care and residential services; and services such as wraparound, respite, mentoring, adoption support and crisis stabilization that may be in the best interests of the child.
Washington	2015 Wash. Laws, Chap. 283 2015 House Bill 1879	Directs the Health Care Authority to seek proposals to establish an integrated managed health and behavioral health plan for foster children enrolled in Medicaid, requires a second opinion review from a psychiatric expert before approving a prescription for a specified supply of an antipsychotic medication for a person under a specified age who is in foster care.
Washington	2015 Wash. Laws, Chap. 117 2015 Senate Bill 5486	Creates the parents for parents program, relates to the dependency court system, provides that the goal is to increase the permanency and well-being of children in foster care through peer mentoring that increases parental engagement and contributes to family reunification.
Washington	2012 Wash. Laws, Chap. 232 2012 House Bill 2536	Concerns the use of evidence-based practices for the delivery of services to children and juveniles, provides for a baseline assessment of utilization of evidence-based and research-based practices in the areas including child welfare and children's mental health services and recommendations for the reallocation of resources for evidence-based and research-based practices.

Psychotropic Medication

Background

Psychotropic medication is used for the treatment of behavioral and mental health problems of children and youth in foster care. Psychotropic medications generally include mood stabilizers, antipsychotics, anti-anxiety medications and stimulants. Over the past decade, psychotropic medication use in children and youth in foster care has increased dramatically. A multi-state, 2009-2010 study by Tufts Clinical and Translational Science Institute (CTSI) estimates that youth in foster care use psychotropic medications at a much higher rate (ranging from 13-52 percent) than youth in the general population (4 percent).

Recent research has identified major concerns surrounding the administration of psychotropic medications for children and youth in foster care, including the use of multiple psychotropic medications simultaneously, the use of multiple psychotropic medications before the use of a single medication, and the use of such medications in young children between 3-6 years of age. Additionally, research has demonstrated a great deal of variation in rates of medication use for youth in foster care in different geographic communities. Consequently, there is rising concern about the appropriate use of psychotropic medications for youth in foster care.

Federal Legislation

Child and Family Services Improvement Act:

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’ child welfare systems) 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 the Administration for Children, Youth, and Families recent Information Memorandum on the Child and Family Services Improvement Act.

Health Oversight Provisions in the Fostering Connections to Success Act of 2008:

The Fostering Connections to Success and Increasing Adoption Act of 2008 now requires each state to consult with pediatricians and other experts and develop a plan for the oversight and coordination of medical and mental health services, including psychotropic medications, for youth in foster care. Plans for oversight and coordination should:

Promote collaborative efforts between child welfare agencies, Medicaid, pediatricians, and other experts to monitor and track medical and mental health;
Include medical and mental health evaluations, both on entry into foster care and periodically while in foster care; and
Provide continuity of care and oversight of medication use.

State Guidelines

Written policies or guidelines for the use of psychotropic medications for foster care youth vary by state. The CTSI study mentioned above reported that, in 2010, 26 states had written policies regarding psychotropic medication use, while 13 states were developing such a policy, nine states had no policy regarding the use of psychotropic medications, and two states did not participate in the study. In most cases, these written policies or guidelines were housed within the state child welfare agency. Two states reported that their child welfare agency followed the guidelines of other state agencies, specifically the Department of Health and the Medicaid office. A link to the CTSI study is provided below.

California recently released Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care. This three-year project’s recommendations include consideration of non-drug treatments to help children and youth in foster care cope with the trauma they have experienced, a preference for FDA-approved medications for children, a restriction on the number of medications that children in care are prescribed and frequent check-ins to adjust medication or to obtain a second opinion before prescribing anything. The report stresses the need for legislation to ensure the guidelines are implemented and enforced. As such, California’s legislation is considering several bills (SB 238, SB 253, SB 319, SB 484, and AB 1067) to address the administration of psychotropic medications to children in foster care.

In addition to California’s efforts, Connecticut’s Department of Children and Families’ Psychotropic Medication Advisory Committee released its own Guidelines for Psychotropic Medication Use in Children and Adolescents in 2010.

Further, the Center for Health Care Strategies, Inc., with support from The Annie E. Casey Foundation, operates a Psychotropic Medication Quality Improvement Project which includes a webinar series and a resource center focused on the use of psychotropic medications to treat children and youth in foster care.

Legislation

NCSL’s Child Welfare Project tracks legislation related to the psychotropic medications and foster youth in the Child Welfare Legislative Enactments Database. Below is a look at what states have done since 2009 to address the use of psychotropic medications for foster children.

For state legislation from 2008-2014, check out NCSL’s Mental Health and Foster Care brief, which includes legislation on mental and behavioral health, psychotropic medications, dental and vision care, among other health issues affecting children and youth in foster care.

legislation related to psychotropic medications and foster youth
State	Citation	Psychotropic Medication Legislative Enactments
California	2015 Cal. Stats., Chap. 540 2015 Senate Bill 484	Provides group foster homes may use psychotropic medications under specified conditions. Requires the Department of Social Services to compile information on the use of such drugs at group homes and post it on the Department's Internet Website. Requires a methodology to ascertain which homes have a utilization of such drugs that warrants additional review. Requires sharing information learned with specified entities. Requires submission of a plan to address identified risks. Requires plan review.
California	2015 Cal. Stats., Chap. 534 2015 Senate Bill 238	Requires the Judicial Council to amend and adopt rules of court and develop appropriate forms for the implementation of specified provisions. Specifies the contents of such rules of court. Requires a report on the number of such medications authorized. Requires specified related training on aspects of taking and administering such medications. Requires foster care public health nurses to receive this training.
California	2015 Cal. Stats., Chap. 535 2015 Senate Bill 319	Requires a foster care public health nurse, as part of medical care planning and coordination, to monitor and oversee the child's use of psychotropic medications. Authorizes such nurse to assist a nonminor dependent to make informed decisions about health care. Authorizes the disclosure of health care and mental health care information to such nurse.
Colorado	2011 Colo., Sess. Laws, Chap. 102 2011 Senate Bill 120	Establishes certain protections for the rights of youth in foster care, except for those in the custody of the Division of Youth Corrections or a state mental hospital, including freedom from administration of prescription medication unless authorized by a physician among others.
Connecticut	2013 Conn. Acts, P.A. 13-178 2013 Senate Bill 972	Requires the development of a plan for meeting children's mental, emotional and behavioral health needs, requires the inclusion of certain strategies, including school and community-based mental health services integration and early intervention enhancement, provides for collaboration with emergency mobile psychiatric service providers, training of school resource officers, mental health providers, pediatricians and child care providers, home visitation, and a study on nutrition and psychotropic drugs.
Florida	2014 Fla. Laws, Chap. 2014-227 2014 House Bill 561	Finds that though there are organizations that provide representation to children in dependency proceedings, a child with certain special needs in this system has a particular need for legal services. Requires the court to appoint an attorney for a dependent child who: resides in, or is being considered for placement in, a skilled nursing facility, is prescribed a psychotropic medication and declines it, has a developmental disability, is being placed in, or is considered for placement in, a residential treatment center, or is a victim of human trafficking. Requires the court to ask the Statewide Guardian Ad Litem Office to recommend an attorney willing to work without additional compensation prior to the court appointing an attorney on a compensated basis. Details the requirements of the attorney appointed. Clarifies who will contract with the appointed attorney, the compensation for the appointed attorney and requires the Department of Children and Families to identify and request attorney representation for qualifying children and make rules to administer the bill.
Florida	2014 Fla. Laws, Chap. 227 2014 House Bill 461	Finds that though there are organizations that provide representation to children in dependency proceedings, a child with certain special needs in this system has a particular need for legal services. Requires the court to appoint an attorney for a dependent child who, among other things ,is prescribed a psychotropic medication and declines it,
Illinois	2011 Ill. Laws, P.A. 245 2011 House Bill 286	Creates the Administration of Psychotropic Medications to Children Act. Requires the Department of Children and Family Services to promulgate rules establishing and maintaining standards and procedures to govern the administration of psychotropic medications to children and youth in state care. Such rules shall include administration to youth in correctional facilities, residential facilities, group homes and psychiatric hospitals.
Nevada	2011 Nev. Stats., Chap. 259 2011 Senate Bill 246	Requires a medical facility that accepts custody of children pursuant to a court order to adopt a policy concerning administration and management of medication to such children and to ensure that each employee of the medical facility who will administer medication to a child in the facility receives a copy of and understands the policy. The law imposes the same requirement on 1) a public or private institution or agency to which a juvenile court commits a child, 2) a state facility for detention or commitment of children, 3) a specialized foster home or a group foster home, 4) a child care facility that occasionally or regularly has physical custody of children pursuant to the order of a court, and 5) a treatment facility and any other facility of the Division of Child and Family Services into which a child may be committed by a court order.
Nevada	2011 Nev. Stats., Chap. 444 2011 Senate Bill 371	Requires appointment of a person who is legally responsible for the psychiatric care of each child who is in the custody of an agency that provides child welfare services. The person appointed is to be responsible for making all decisions concerning services, treatment and psychotropic medications provided to such children. The law allows the court to appoint the person nominated by the agency or to appoint any other person the court determines is qualified to carry out such duties and responsibilities. To the extent that a parent or legal guardian of the child is able and willing to serve as the person legally responsible for the child’s psychiatric care, the parent or guardian must be nominated and appointed pursuant to this law. It also requires the person who is legally responsible for the child’s psychiatric care to provide written consent or denial of consent for each appointment or for a course of routine treatment for the child’s psychiatric care; to maintain current information concerning the child’s medical history and emotional, behavioral and educational needs; and to approve or deny administration of each psychotropic medication recommended for the child. The law prohibits administration of a psychotropic medication to a child in the custody of an agency without consent from the person who is legally responsible for the child’s psychiatric care.
2011 Nev. Stats., Chap. 443 2011 Senate Bill 370	NCSL staff in Washington, D.C. track and analyze federal legislation and policy and represent state legislatures on child welfare issues before Congress and the Administration. Staff in D.C. can be reached at (202) 624-5400 or message us by clicking on email icon on left.

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Psychotropic Medication

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Federal Legislation

State Guidelines

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