Foster care psychotropic prescribing regulations are complex and insufficient

Abstract

Introduction

Federal and state policymakers, accreditation organizations, and mental health agencies developed standards for evidence-based use of psychotropic medications among youth in foster care. Despite these efforts, foster youth are vulnerable to psychotropic polypharmacy, high dosing, and low rates of monitoring. This manuscript aimed to (1) analyze state-specific psychotropic oversight programs, and (2) examine specific state approaches and outcomes.

Methods

State guidelines, including all 50 United States and Washington, DC, were identified via Google search and a Center for Health Care Strategies, Inc., 2018 technical assistance tool. For each state, authors documented whether guidelines were specific to foster care and whether they included thresholds related to polypharmacy, metabolic monitoring, age-based prescribing, maximum dosages, and any distinctive characteristics.

Results

Most states (61%) have published a foster care psychotropic guideline; 9 states (18%) do not have a one, and the authors were unable to locate guidelines for the remaining 11 states (22%). More than one-third of foster care youth (38%) live in states with no psychotropic monitoring requirements. Sixty-three percent (n = 32) of states require a prior authorization (PA) or drug utilization review (DUR) for youth prescribed more than 1 psychotropic. Forty-seven states have age-based prescribing support in place, with PA (n = 28) and DUR (n = 9) being the most common oversight processes.

Conclusions

States have a wide range of age restrictions, approaches to PA and DUR, and prioritization of monitoring. Some states lack guidelines entirely. Variability in state psychotropic oversight programs, reporting methods, and data collection contributes to barriers to successful optimization of psychotropic prescribing among youth in foster care.

Introduction

Approximately 390 000 youth are enrolled in foster care in the United States, with neglect and caregiver substance use among the most common reasons for foster care entry.^1-6 Youth in foster care are consistently prescribed psychotropics at higher rates relative to their same-aged peers.^1-6 Although the reasons for this are complex, high rates of early childhood trauma or neglect, a lack of a consistent caregiver or guardian, inconsistent medical providers, and gaps in transitions of care are likely key contributors.^1,5,7-9 Population-based studies have shown that the demographics of foster care youth is not characteristic of the general population; race, ethnicity, socioeconomic status, and other social determinants of health also play a role in higher healthcare usage and poorer health outcomes.^10,11 In addition to higher rates of psychotropic use, foster care youth experience higher rates of psychotropic polypharmacy, off-label medication use, supratherapeutic medication dosing, and low rates of evidence-based medication monitoring.^1,2,6,12,13

In response to these concerns, federal and state policymakers, accreditation organizations, and mental health agencies have increased efforts to develop standards for evidence-based use of psychotropic medications among youth in foster care.^12,14,15 The Fostering Connections to Success and Increasing Adoptions Act and the Child and Family Services Improvement and Innovation Act are key pieces of legislation that mandate oversight of psychotropic prescribing by child welfare agencies and state Medicaid programs.^1,12,14-16 Regulatory standards, including the Healthcare Effectiveness Data and Information Set (HEDIS) and professional practice guidelines, are additional supports for evidence-based prescribing and monitoring in foster care youth.¹⁷

In accordance with these national efforts, there has been substantial growth in state-wide interventions. Specialized managed care models, psychotropic medication use guidelines, educational strategies, health home models, and collegial peer review have been described as promising strategies for improving safe and judicious use of psychotropic medications among youth in foster care.^9,12,18,19

Despite these efforts, many states have been identified as noncompliant with regulatory standards.²⁰ Class-action lawsuits and related settlements involving more than 18 000 youth in state custody not only highlight ongoing concerns for “too much, too many, too young” but also influence changes to regulatory standards. As many states update their policies in response to these class-action lawsuits, reactive changes to regulatory standards are all too common. This manuscript aimed to (1) analyze state-specific psychotropic oversight programs and (2) examine specific state approaches and outcomes.

Methods

The authors sought to identify guidelines related to psychotropic prescribing for foster youth. For each state, authors documented whether guidelines were specific to foster care (ie, versus for all youth), and whether the best guidelines identified included thresholds related to polypharmacy, metabolic monitoring, age-based prescribing, maximum dosages, and notes regarding unique characteristics of the state’s guidelines. Based on foster care guideline definitions, psychotropic medications were all inclusive (ie, antiseizure medications).

For all 50 states and Washington, DC, Google searches were performed using the phrases “[state name] foster youth guidelines for psychotropic medications,” “[state name] state foster psychiatric medication,” “[state name] Medicaid psychiatric prior authorization,” “[state name] foster care medication,” “[state name] Medicaid psychiatric medication,” “[state name] antipsychotic prior authorization,” “[state name] antipsychotic Medicaid prior authorization,” “[state name] HEDIS antipsychotic medication children,” “[state name] psychotropic advisory committee,” “[state name] foster care system,” “[state name] Medicaid formulary,” “[state name] foster care guidelines,” “[state name] foster youth guidelines.”

The Google searches were supplemented with a Center for Health Care Strategies, Inc., 2018 technical assistance tool, which reported psychotropic medication PA requirements from 15 select states. Confirmatory searches between October 16, 2025, and October 21, 2025, ensured the most current information was reported. One author independently collected all data, and a second author independently assessed for accuracy. Any discrepancies (eg, confirming that the most current and comprehensive psychotropic oversight requirements were found) were discussed and resolved between the 2 authors.

Results

Psychotropic Guideline

Most states (61%) have published a foster care guideline to support psychotropic prescribing and monitoring; 9 states (18%) explicitly lack a psychotropic guideline, and the authors were unable to locate guidelines for the remaining 11 states (22%). States without a foster care guideline had fewer than 9000 foster youth each, except for Ohio (N = 15 196). Overall, 13% of foster youth live in states with no foster care-specific guidelines (Table).

TABLE.

Current state-based psychotropic prescribing initiatives

State	Foster Youth (2023)20	Foster Care Guidelines	Polypharmacy	Metabolic Monitoring	Age-Based Prescribing	Above Labeled Max	Notes and Additional Criteria
AK21,22	3315	✓	PA/DUR	PA	PA/DUR	PA	Polypharmacy: >1 AP Age-based: ∘ DUR: <6 yr ∘ PA: AP <5 yr
AL23,24	5788	No	–	PA	PA	–	Documented diagnosis or CAP prescriber required for psychotropic use Age-based: AP <6 yr
AR25	3982	No	–	PA	PA	–	Age-based and metabolic: AP <10 yr
AZ26,27	11,375	✓	DUR	–	PA/DUR	–	Age-based: ∘ FGA <12 yr ∘ SGA <6 yr ∘ Clozapine, LAI <18 yr
CA28,29	43,278	✓	PA/DUR	DUR	PA/DUR	DUR	Authorization form for all medications Polypharmacy: ∘ >1 medication <6 yr ∘ >2 medications 6-11 yr ∘ >4 medications 12-17 yr Age-based: ∘ <6 yr prescribed stimulant, atomoxetine, guanfacine, clonidine, or aripiprazole/risperidone (ASD only)
CO30,31	4351	✓	PA/DUR	DUR	PA/DUR	DUR	AP without diagnosis of psychosis, bipolar disorder, schizophrenia, or ASD Polypharmacy: ∘ >1 psychotropic in same class ∘ >2 psychotropics within 60 days Age-based: ∘ PA: specific per agent ∘ DUR: AP <5 yr
CT32	3069	✓	PA/DUR	PA/DUR	PA/DUR	PA/DUR	Patient assent>8 yr Psychotropics must be prescribed in collaboration with other treatment providers and primary care physician
DE33,34	595	✓	PA/DUR	DUR	PA/DUR	–	Only 1 medication change at a time Age-based: AP <6 yr
FL35,36	20,687	✓	PA/DUR	PA/DUR	PA/DUR	PA	Signed medical report required for all psychotropics
GA37,38	11,474	✓	DUR	–	PA/DUR	PA	Physician must complete authorization form for all psychotropics Voluntary use of MedConsult Line service (board-certified CAP consultation)
HI39-41	1062	✓	–	–	PA	–	Adopted Illinois guideline Age-based: AP <18 yr prescribed by non-psychiatrist 2022 law protects access to AP, AD, and anxiolytics Foster guideline mandates managed care enrollment
IA42	5069	?	DUR	–	DUR	DUR	DHHS reviews quarterly reports of “red flag” prescribing practices Age-based: psychotropic <6 yr
ID43,44	1473	?	PA/DUR	–	PA	PA/DUR	Polypharmacy: >4 psychotropics Age-based: ∘ FGA <18 yr ∘ SGA <12 yr DUR: ∘ No DSM-5-TR diagnosis or treatment plan ∘ Medication side effects that impair a child’s ability to perform ADLs and/or benefit from education
IL41,45,46	19,855	✓	–	–	PA	–	Age-based: ∘ Psychotropic <6 yr ∘ ADHD medication <7 yr ∘ AP <8 yr
IN47,48	8697	✓	PA	PA	–	PA
KS49,50	6159	✓	PA	PA	PA	PA	Age-based: <6 yr
KY51	8585	No	PA	–	PA	–	Polypharmacy: >2 AP Age-based: >2 AP <18 yr
LA52	3968	?	–	PA	PA	–	Age-based: AP <7 yr
MA53,54	8725	✓	PA/DUR	–	PA/DUR	–	Foster guideline requires social work/NP review Age-based: Psychotropics (except for stimulants and alpha agonists) <6 yr PA/DUR: ∘ Psychotropics <3 yr ∘ AP <10 yr
ME55	2485	?	PA	PA	PA	–	Polypharmacy: >1 AP Age-based: AP <5 yr
MD46	4340	?	–	–	PA	–	Age-based: AP <18 yr
MI56,57	9176	✓	DUR	–	DUR	DUR	1939 law stated no PA for certain drug classes including AP; last amendment 2022 Foster guideline requires second physician to complete DUR Polypharmacy: >1 psychotropic Age-based: psychotropic <6 yr
MN58	6214	?	–	–	PA	PA	PA is necessary for specific SGA Not covered: ∘ SGA <6 yr ∘ ADHD medication <4 yr
MO59,60	12,972	?	PA	PA	PA	–	Polypharmacy: ∘ >4 psychotropics>6 yr ∘ >2 psychotropics <6 yr Age-based: ∘ AP <9 yr ∘ ADHD medications <6 yr
MS61,62	3708	?	PA	–	PA	–	Polypharmacy: >1 AP Age-based: per psychotropic
MT63	2530	No	–	PA	PA	–	Age-based and metabolic monitoring: AP <9 yr
NC64,65	10,243	✓	–	–	PA	–	Age-based: off-label use of AP <18 yr
ND66,67	1410	✓	PA	DUR	–	–	Foster guideline offers nothing medication-specific
NE68	3501	✓	DUR	DUR	DUR	–	Adopted Texas guideline in 2018
NH69	1142	✓	DUR	DUR	DUR	DUR	Age-based: ∘ AD, AP <6 yr ∘ Stimulant <5 yr Additional DUR: • Lack of DSM-5-TR diagnosis • Frequent changes in psychotropics without clear rationale
NJ70	3043	no	–	–	PA	–	Almost every age has quantity limit – LAIs and PRNs are exception
NM71	1752	No	–	–	PA	–	Age and quantity limit specific to individual antipsychotic
NV72	3985	No	PA	PA	PA	–
NY73	15,293	✓	PA	DUR	PA	–	Age-based PA per medication Magellan Health Services, NY, behavioral health carve out plan, manages PA for children statewide Need metabolic testing but does not require PA
OH74,75	15,196	no	–	DUR	PA	–	No PA for AP under approved indications
OK76	6873	✓	–	–	PA	–	Age-based: psychotropic <5 yr
OR77,78	2508	✓	DUR	DUR	DUR	DUR	AP without diagnosis of psychosis, schizophrenia, bipolar disorder, ASD, aggression Age-based: psychotropic <6 yr
PA79,80	12,930 (2022)	✓	–	PA	PA	PA	Age-based: ∘ Stimulants and related agents <4 yr ∘ Benzodiazepines <21 yr
RI46	2339	✓	DUR	–	DUR	–	Quoted to be working on foster guidelines in 2018 Age-based: psychotropic <6 yr
SC81,82	3837	✓	DUR	–	PA/DUR	–	Age-based: ∘ Psychotropic <7 yr ∘ AP <18 yr
SD83	1584	✓	DUR	–	DUR	DUR	AP not included on PDL Age-based: psychotropic <6 yr
TN84	8389	✓	DUR	DUR	DUR	DUR	Foster guideline requires: ∘ Documented diagnosis ∘ Psychotropic consistent with diagnosis or target symptoms ∘ Psychiatrist, neurologist or developmental behavioral pediatrician must prescribe psychotropic ∘ Monitoring form for every medication evaluation appointment Age-based: psychotropic <6 yr
TX85,86	18,344	✓	DUR	PA	PA	–	DHHS Commission modifies pharmacy claims system to implement the requirements Health Passport available Psychotropic>60 days Age-based: ∘ AP <3 yr ∘ >2 AP <18 yr
UT87-89	1932	✓	PA/DUR	PA	DUR	PA	Documented diagnosis Psychosocial interventions tried first Tried and failed first-line medication Side effect (cardio-metabolic) monitoring Discussion of risk/benefit with guardian Polypharmacy: >1 AP for >45 days Age-based: ∘ Psychotropic <7 yr ∘ >1 psychotropic>6 yr
VT46,90	1327	?	PA	PA	PA	–	Foster guideline offers no specifics on psychotropics; more logistical (eg, psychiatrist consultation for PCP) Age-based: ∘ AP <18 yr ∘ Stimulants <4 or <6 yr, per agent Polypharmacy: concurrent amphetamine and methylphenidate; >3 stimulants
VA91,92	4973	✓	–	PA	PA	–	Age-based: AP <18 yr Monitoring: monthly for <6 yr with newly prescribed SGA
WA93	7691	?	PA	–	–	–	Foster guideline offers no specific recommendations regarding psychotropics
Washington, DC94	611	No	–	–	–	–	PDL offers no age limits on preferred AP
WI95	6458	✓	–	–	PA	–	Foster guideline offers no mandated psychotropic review Age-based: ∘ AP <7 yr ∘ Non-preferred or brand name AP>6 yr
WV96,97	6696	✓	–	DUR	PA	–	Age-based: ∘ Psychotropic <6 yr ∘ AP <18 yr
WY98	922	?	–	–	PA	PA	Foster guideline includes broad monitoring with no specific criteria or guidance Age-based: AP <6 yr

AD = antidepressant; ADHD = attention-deficit hyperactivity disorder; ADLs = activities of daily living; AP = antipsychotic; ASD = autism spectrum disorder; CAP = child and adolescent psychiatrist; DHHS = Department of Health and Human Services; DSM-5-TR = Diagnostic and Statistical Manual, 5^th ed, Text Revision; DUR = drug utilization review; FGA = first-generation antipsychotic; LAI = long-acting injectable; NP = nurse practitioner; PA = prior authorization; PCP = primary care provider; PDL = preferred drug list; PRNs = pro re nata; SGA = second-generation antipsychotic.

Polypharmacy defined as>1 AP or>3 psychotropics unless otherwise specified.

✓: Refers to foster care guideline.

?: Refers to unknown.

Monitoring Oversight

In review of psychotropic monitoring oversight, more than one-third of foster care youth (38%) live in states with no psychotropic monitoring requirements (Table). Twenty-eight states, representing 62% of foster youth, require metabolic monitoring; with 11 states that use drug utilization review (DUR) (29% of foster youth), 15 (27% of foster youth) that use prior authorizations (PA), and 2 (7% of foster youth) that use both. Only 18% of states require a PA or DUR oversight to ensure rational prescribing based on the documented mental health diagnosis.

Sixty-three percent (n = 32) of states require a PA or DUR or other oversight for youth prescribed more than 1 psychotropic medication; a total of more than 4 concurrent psychotropics or more than 2 psychotropics within the same class are common oversight definitions. As a class, atypical antipsychotics are most frequently associated with polypharmacy oversight, followed by stimulants. Fifty-six percent (n = 19) of states require a PA, DUR, or other oversight for youth prescribed psychotropics at doses that exceed the maximum recommended dose.

Age-Based Requirements

Forty-seven states have age-based prescribing supports in place, with PA (n = 28), DUR (n = 9), and a combination of both (n = 10) as the most common oversight processes (Table). Antipsychotics were the most frequent class (22 of 47 states) of psychotropic medication identified in age-based oversight requirements; 46% for youth younger than 18 years of age and 21% younger than 10 years.

Among youth younger than 6 years of age, 13 states require a PA or DUR for any psychotropic prescription. Of those with age-based requirements, 16 states stop them before age 6, while 23 states maintain them until they leave foster care.

Prescribing Rates

Foster youth are evenly distributed across the US by census region as follows: Midwest (27.1%), Northeast (14.1%), South (34.6%), and West (24.2%) (Table). The median state-based prescription rate for foster care youth was 24.8% for the 10 largest states, representing more than half of foster youth.⁹⁹ Among the remaining 40 states, the median prescription rate was 30.9%. Of the 22 states (50% of foster youth) with a prescription rate of 30% or less in 2019, 14 (64%) have guidelines, and 9 (41%) require metabolic monitoring. Of the 23 states (41% of foster youth) with a prescription rate higher than 30% in 2019, 12 (52%) have guidelines, and 15 (65%) require metabolic monitoring.

Discussion

Despite increased efforts by federal and state policymakers, accreditation organizations, and mental health agencies, this manuscript highlights significant variability of psychotropic oversight among foster care youth. Among the top 10 states with the highest numbers of foster care youth, state-based psychotropic guideline, metabolic monitoring oversight for youth prescribed an antipsychotic, PA requirements to support age-based prescribing, and polypharmacy oversight (eg, PA or DUR) are the most common oversight strategies (Table).

California

With the largest population of youth in foster care in the US (N = 43 278) and the third lowest rate of psychotropic prescribing, California is often viewed as a leader of psychotropic oversight.¹⁰⁰ In addition to judicial oversight/approval of psychotropic prescribing, treatment authorization requests are required as Medi-Cal preauthorization for youth prescribed any psychotropic.²⁹ A 2011 state-wide Quality Improvement Project, co-sponsored by Medi-Cal and the California Department of Social Services, initiated treatment authorization request oversight and monitoring, modified procedures for court-approved prescribing, and data reporting requirements.

In 2018, technical assistance calls were initiated to better support foster youth with complex needs and often complex medication regimens. Technical assistance calls offer an opportunity for interprofessional review of high-risk psychotropic medication regimens for youth enrolled in foster care. Owing to a lack of pharmacologic expertise on the calls (ie,<1% of calls included a child and adolescent psychiatrist), child welfare partnered with USC Mann School of Pharmacy to have Board-Certified Psychiatric Pharmacists (BCPP) participate in technical assistance calls starting in 2023. The inclusion of a BCPP has increased subject matter expertise on the technical assistance calls 10-fold and offers a unique opportunity for psychotropic stewardship^9,101,102

Indiana

Indiana uses a partnership between Medicaid, the Department of Child Services, child psychiatrists, and a BCPP to revise and approve pediatric psychotropic medication use guidelines on a biannual basis.^48,103 Child psychiatrists and a BCPP review medical records of foster care youth identified as outliers in psychotropic medication prescribing using psychotropic polypharmacy, patient age, and off-label prescribing. The BCPP reviews medication regimens and provides feedback for medication change considerations to the psychiatrist, who then meets one-on-one with the prescriber to discuss diagnostic clarity, laboratory monitoring, and medication choice and dose. Follow-up phone calls are initiated if concerns remain after consultation. These reviews led to 88% prescriber agreement for changes in medication prescribing and/or the addition of psychotherapy and an average healthcare expenditure decrease of $10 000 per month postintervention.¹⁰³

Texas

With the fourth largest population of youth in foster care in the US (N = 18 344), Texas is often referenced as a leader in guideline development and metric identification for inappropriate psychotropic use.¹² In 2005, the first psychotropic guideline for youth in foster care was released, with subsequent updates continuing to inform guidelines published in other states, metrics to identify inappropriate prescribing, and other standard development. Of note, a review process is triggered if the prescribed medication falls outside the guideline, and a usage review may be requested by the caseworker, other team members who are involved in the care of the youth, advocates, or judges.¹⁰⁴ Data indicate that rates of metabolic monitoring increased among those prescribed an antipsychotic, and non–FDA-labeled antipsychotic prescribing decreased.¹⁰⁴

Proposed Solutions

Psychotropic oversight programs vary significantly state by state, posing barriers to successful implementation in practice. Although PAs and DURs are among the most common strategies to promote evidence-based use of psychotropics, their criteria, medication targets, and follow-up requirements vary. Additionally, mechanisms to support psychotropic monitoring vary, with many states lacking specific recommendations (Table). Not only does variability exist among states, but also organizational authority or policies can vary within state counties or regions.¹⁰⁵

Data sharing is a known challenge among foster care youth, with a lack of child welfare service integration into health systems and variability in policies regarding confidentiality. Additionally, information transfer resources (eg, medical passports) are dependent on the child welfare service and/or organizational authority of the state, region, or county in which the foster youth currently resides.¹⁰⁵

With this variability, comprehensive oversight is difficult.^105,106 Data limitations, including a focus on a limited number of states, a single class of psychotropic, and variability in reporting methods, interfere with the comprehensive evaluation of psychotropic oversight programs.¹⁰⁵

Proposed solutions to these challenges include the availability of (1) national data for states to use as benchmarks to measure progress toward meeting foster care-specific requirements, (2) successful policy and practice strategies that have been used by other states to meet requirements, (3) enhanced communication between state Medicaid programs and child welfare systems, and (4) standardized risk stratification to improve care via psychotropic stewardship. The lack of effective accountability measures and mechanisms for internal quality review continues to serve as a barrier to these proposed solutions.¹⁰⁵

The primary limitation of the study is that guidelines may have been missed by the searches. Inconsistent reporting of the guidelines also makes it difficult to confirm whether a digital resource is the latest version, and it is even possible that new guidelines will have been released before publication. The inconsistency of guideline format also creates the possibility that the Table does not account for relevant characteristics of the guideline. Furthermore, some literature suggested requirements (eg, for monitoring), but they were excluded from the Table when no formal documentation enforcing the requirement could be found in guidelines. Finally, although the number of foster youth and the prescription rates per state are the best publicly available data, the lag in reporting means that some analyses are based on factors that may have changed as the guidelines and programs changed.

Conclusions

Concerns for “too much, too many, too young” have long existed among foster care youth. In addition to higher rates of psychotropic use, foster care youth also experience higher rates of psychotropic polypharmacy (eg, prescribed >1 medication within the same class), off-label medication use, supratherapeutic medication dosing, and low rates of evidence-based medication monitoring.^1,2,6,12,13 Variability in state psychotropic oversight programs, reporting methods, and data collection contributes to barriers to psychotropic prescribing optimization.⁹ Ongoing congressional inquiries and class action lawsuits highlight the need for systematic improvement to support this vulnerable patient population.