4@, ASPE OFFICE OF HUMAN BRIEF SERVICES POLICY ASSISTANT SECRETARY FOR PLANNING AND EVALUATION October 2023 Behavioral Health Diagnoses and Treatment Services for Children and Youth Involved with the Child Welfare System Medicaid Claims Data Provide Detailed Information about Behavioral Health Services for Children Involved with the Child Welfare System Laura Radel, Sarah Lieff, Chandra Couzens, Mir M. Ali, and Kristina West KEY POINTS Many Medicaid and Children's Health Insurance Program (CHIP)-enrolled children and youth who are also involved with the child welfare system had behavioral health diagnoses. Nationally in 2019, more than 40 percent of Medicaid or CHIP-enrolled children and youth ages 3 to 17 involved with the child welfare system had been diagnosed with such conditions. Children and youth involved with the child welfare system used more behavioral health services than other children and youth on Medicaid. In all age groups, Medicaid or CHIP-enrolled children and youth involved with the child welfare system were several times more likely to use each type of behavioral health service analyzed than those in other Medicaid eligibility groups. Over 45 percent used behavioral health services, primarily outpatient services (40.3 percent) and psychotropic medications (26.3 percent). Those with behavioral health diagnoses usually received some behavioral health treatment. Most Medicaid or CHIP-enrolled children and youth involved with the child welfare system who had behavioral health diagnoses received behavioral health services {90 percent), as did more than 10 percent of those without such diagnoses. Psychotropic medications were commonly prescribed. Of the Medicaid or CHIP-enrolled children and youth involved with the child welfare system who had a behavioral health diagnosis, more than half received psychotropic medication, and nearly a third received two or more classes of psychotropic medications during the year. Many children and youth without a behavioral health diagnosis also received psychotropic medications. Seven percent of Medicaid or CHIP-enrolled children and youth involved with the child welfare system ages 3 to 17, and 9 percent of those ages 12 to 17, who did not have a behavioral health diagnosis in their Medicaid claims nonetheless had been prescribed psychotropic medication. Rates of psychotropic medication use among children and youth involved with the child welfare system varied widely by state. At the low and high ends of the distribution, 6.0 percent of child welfare-involved Medicaid or CHIP-enrolled children and youth ages 3 to 17 in Georgia received psychotropic medication, compared with 47.2 percent in Virginia. October 2023 ISSUE BRIEF 1 BACKGROUND Child welfare and behavioral health professionals have long been aware that children and youth in foster care and those exiting foster care to adoption and guardianship homes frequently have behavioral health conditions (Burns et al., 2004; Pires et al., 2013; Medicaid and CHIP Payment and Access Commission [MACPAC], 2015). There have also been longstanding concerns that children and youth in foster care are overprescribed psychotropic medications (Raghavan et al., 2005; Raghavan et al., 2012; Stambaugh et al., 2012; MACPAC, 2015). Concerns often focus on psychotropic medications because limited safety and efficacy data exist for individuals under age 18 and because, even when appropriately prescribed, administration of these medications requires comprehensive behavioral health assessment which may be difficult to obtain (American Academy of Child and Adolescent Psychiatry, 2015). In addition, antipsychotic medications specifically have potential metabolic side effects such as weight gain and predisposition to type 2 diabetes, and their long-term effects on brain development remain unclear (Ninan et al., 2014; Burcu et al., 2017; Libowitz and Nurmi, 2021). While federal guidance and statutes emphasize close monitoring of psychotropic medications for youth in the child welfare system (Naylor et al., 2007; U.S. Government Accountability Office, 2017; Fernandez-Alcantara et al., 2017; U.S. Department of Health and Human Services, Administration for Children and Families, 2012}, oversight has been difficult (U.S. Department of Health and Human Services, Office of Inspector General, 2018). In part because of data limitations, most previous studies of behavioral health services utilization in the child welfare system have focused on a limited number of states, or have examined a single class of medications, such as antipsychotics. In this brief, "involved with the child welfare system" refers to children and youth whose Medicaid eligibility was based on their participation in the Title IV-E foster care and permanency programs. These children and youth were either in foster care or had exited foster care to the home of an adoptive parent or guardian and their adoption or guardianship agreement included continued Medicaid coverage. METHODS This analysis focuses on behavioral health diagnoses and services utilization among child and adolescent Medicaid and Children's Health Insurance Program (CHIP) beneficiaries in the child welfare population. It relies on administrative data on Medicaid claims from the Transformed Medicaid Statistical Information System (T- MSIS) Analytic Files (TAF). The analysis used 2018-2019 data from the TAF annual Demographics and Eligibility (DE) file and the four claims files: inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX). Claims records from 2018 to 2019 were used to identify behavioral health conditions in 2019 and claims from 2019 were used to identify behavioral health service and medication use. For national analyses, the study population was limited to beneficiaries who were enrolled in Medicaid or CHIP for at least six consecutive months in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands; eligible for full or comprehensive benefits; and 3 to 17 years of age. The child welfare population was identified using the child's most recent eligibility group code from the DE file, which identifies children who received Title IV-E (of the Social Security Act) foster care maintenance payments or federal adoption assistance or guardianship subsidies. The analysis included 719,908 children and youth involved with the child welfare system and 31,473,608 children and youth in other Medicaid eligibility categories. Thus, the child welfare group represented 2.2 percent of all child beneficiaries. Behavioral health October 2023 ISSUE BRIEF 2 conditions were identified using standardized data definitions laid out by the Centers for Medicare and Medicaid Services (CMS) in the Chronic Conditions Data Warehouse (CCW).! For this population, we examined the percentage who received any psychotropic medication in the year. Psychotropic medication classes include antidepressants, antipsychotics, anticonvulsants, antimanic medications, antiparkinsonian medications, anxiolytics-sedatives, benzodiazepines-barbiturates, central nervous system (CNS) agents, hypnotics, and stimulants. To assess data quality, we used measures contained in the CMS DQ (Data Quality) Atlas.? In analyses that disaggregate states, we excluded states with unusable procedure codes on OT professional claims in 2019 (Utah) and states with unusable linkages of claims to beneficiary records in 2019 (Alabama, Rhode Island). In addition, we examined the number of beneficiaries with the child welfare eligibility group code in each state in the TAF and compared these data with publicly available caseload data from the Children's Bureau of the U.S. Department of Health and Human Services.® We excluded states where the eligibility group code in the TAF identified only a small portion of the child welfare population (Oklahoma, Oregon, Pennsylvania). Analysis of data in this brief was conducted by staff at Mathematica under contract to the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. RESULTS Many Medicaid or CHIP-enrolled children and youth in the child welfare population have behavioral health diagnoses, including for a range of mental health conditions. As shown in Figure 1 and Appendix Table 1, more than one in five children ages 3 to 5 in the child welfare group (22.2 percent) and nearly half of children and youth 6 to 11 and 12 to 17 in this group (44.9 and 49.5 percent, respectively) had behavioral health diagnoses listed on their Medicaid claims. Relatively common diagnoses include trauma/stressor related disorders, attention deficit hyperactivity disorder (ADHD), behavior/conduct disorders, anxiety, depression, and mood disorders. Rates of each type of disorder increased with age. Among younger children, ages 3to 5, trauma/stressor related disorders were by far the most common behavioral health diagnosis, with nearly 16 percent of children in the child welfare group having such a diagnosis. Older children and youth experienced a broader range of diagnoses. Among other child Medicaid beneficiaries {i.e., not involved with the child welfare system), such as those who are eligible for Medicaid because of low family income or a disability, ADHD was the most commonly diagnosed condition, at 6.5 percent among children and youth ages 3 to 17 (Figure 2). 1To identify beneficiaries with behavioral health conditions, we used CMS''s standardized approach for identifying people with behavioral health conditions in claims data, available from the CCW. For most behavioral health conditions, the CCW algorithm requires "at least 1 inpatient claim or 2 other non-drug claims of any service type" during a two-year reference period to identify beneficiaries considered to have a behavioral health condition during a particular year. More information is available at https://www2.ccwdata.org/web/guest. 2 Data for states were considered unusable based on DQ Atlas thresholds for the following topics: Total Medicaid and CHIP Enroliment; Claims Volume: IP, LT, and OT; Diagnosis Code: IP, OT; Procedure Codes: OT Professional; National Drug Code: RX; and race/ethnicity. For more information, see the DQ Atlas at https://www.medicaid.gov/dg-atlas/welcome. 3 These data are available at https://www.acf.hhs.gov/cb/report/programs-expenditure-caseload-data-2019. October 2023 ISSUE BRIEF 3 Figure 1. Medicaid Beneficiaries Involved with the Child Welfare System Had High Prevalence of Behavioral Health Diagnoses, 2019 495 50 449 40 30 253 = S 20 15.8 14.8 14.6 o 11 12.2 111 Type of Behavioral Health Disorder W Ages 3-5 OAges 6-11 B Ages 12-17 Children and youth in the child welfare eligibility group were diagnosed with most behavioral health conditions at three to four times higher prevalence compared to children and youth in other Medicaid/CHIP eligibility groups. Figure 2 and Appendix Table 1 compare behavioral health diagnosis rates for children and youth ages 3 to 17 in the child welfare group with those in other eligibility groups. In the child welfare population, 43.0 percent of children and youth ages 3 to 17 had any behavioral health condition, compared with 13.6 percent of children and youth in other Medicaid eligibility categories. All examined behavioral health disorders were several times more prevalent among children and youth in the child welfare eligibility group than among other beneficiaries of the same ages. For instance, trauma/stressor related disorders were nearly 5 times more prevalent, ADHD was over 3 times more prevalent, behavior/conduct disorders were 4.5 times more prevalent, and depression was 3 times more prevalent in the child welfare group. In addition to the data on ages 3 to 17, Appendix Table 1 shows behavioral health diagnoses for subgroups of children and youth ages 3to5,6to11,and 12 to 17. October 2023 ISSUE BRIEF 4 Figure 2. Children and Youth (Ages 3 to 17) Involved with the Child Welfare System Had Substantially Higher Prevalence of Behavioral Health Conditions Than Those in Other Medicaid Eligibility Groups, 2019 50 3.0 40 30 22.9 1.5 =t < 20 @ E 156 11.7 e 10 47 6.5 8.7 7.5 7.0 ; 3.3 LB R e o 0 T T T T T T - == oo & Q & A o & < & & \9\2\ & & &° & & N N 0 <0 & < O & & & ¥ & K S 8 O ,a\:a'o (9'-)0( bQ(} Q Oob e ? \,\\00 ¢ & o < & L ™ i O o S Q \° \© P ] .o 6\@ o & SN & D 2 > > 9 e N & % K ?'6\ Type of Behavioral Health Disorder B Child Welfare @ Other Beneficiary Groups Children and youth involved with the child welfare system were several times more likely to use behavioral health services of each type than those in other Medicaid eligibility groups. Across behavioral health service types and age groups, children and youth involved with the child welfare system, including those who had exited the system to adoption or guardianship, used behavioral health services at rates several times higher than children and youth in other Medicaid eligibility groups. As shown in Figure 3 and Appendix Table 2, outpatient behavioral health services and psychotropic medications were the most common service types received. Outpatient services were delivered to 40.2 percent of children and youth in the child welfare eligibility group and 13.0 percent of other Medicaid beneficiaries in the same age range. Psychotropic medications were received by 26.3 percent of the child welfare group and 9.1 percent of other children and youth on Medicaid. These figures are across the full population of each group, regardless of whether the child had a behavioral health diagnosis. Not shown in the figure but available in Appendix Table 2, 13.3 percent of children and youth in the child welfare group received psychotropic medications from multiple classes, compared with 3.1 percent of children and youth in other Medicaid eligibility groups (see also Radel et al., 2023). Appendix Tables 3 and 4 show behavioral health services for children and youth with and without behavioral health diagnoses, respectively. As with other tables in this brief, these tables include figures for the full age range of children and youth ages 3 to 17 and for subgroups ages 3to 5, 6 to 11, and 12 to 17. As expected, children and youth with behavioral health diagnoses received behavioral health services at much higher rates than those without such diagnoses. Differences in service receipt were less prominent between the child welfare population and other Medicaid child beneficiaries among those with behavioral health diagnoses. Ninety percent of child welfare beneficiaries with behavioral health diagnoses received any behavioral health service in 2019, compared with 85 percent of other child beneficiaries with such diagnoses. October 2023 ISSUE BRIEF 5 Figure 3. Children Involved with the Child Welfare System Were Frequent Users of Behavioral Health Services, 2019 Medication assisted treatment Residential Intensive outpatient Inpatient Telehealth Emergency Psychotropic medication Type of Behavioral Health Service Outpatient Any behavioral health service 451 0.00 5.00 1000 1500 20.00 2500 30.00 3500 4000 4500 50.00 Percent Receiving Service O Other Medicaid Eligibility Categories @ Child Welfare Psychotropic medications are a particularly common form of behavioral health service. Overuse of psychotropic medications for children and youth in the child welfare system has long been a concern because many such medications have not been assessed or approved for use by children and have potential negative side effects (Naylor et al., 2007; American Academy of Child and Adolescent Psychiatry, 2015). T-MSIS data enable us to quantify the receipt of such medications relatively easily, in more detail than was previously possible, and across the entire U.S. National analysis shown in Figure 4 and Appendix Table 2 shows the proportion of children and youth in the child welfare group who receive various classes of psychotropic medications, by age group (3 to 5, 6 to 11, and 12 to 17 years). Stimulants are the most common type of medication prescribed in each age group, at 2.2 percent, 19.1 percent, and 18.6 percent respectively. Similar proportions of both the youngest and oldest groups receive medications from multiple classes, a practice known as polypharmacy. In the child welfare group, 1.9 percent of children ages 3 to 5, 11.8 percent of children ages 6 to 11, and 19.1 percent of children ages 12 to 17 experienced polypharmacy. In each age range, rates of polypharmacy were several times higher in the child welfare population than among children and youth in other Medicaid eligibility categories. Other commonly prescribed medications are antidepressants, received by nearly 17 percent of children ages 12 to 17 in the child welfare population, and antipsychotics, received by nearly 12 percent of the same group. Figures for each class of medication broken down by whether the child or youth had behavioral health diagnoses are in Appendix Tables 3 and 4. Among child welfare beneficiaries with behavioral health conditions, about half {52 percent) received psychotropic medications, with 33 percent receiving stimulants, 21 percent receiving antidepressants, and 17 percent receiving antipsychotics. In addition, 9 percent of youth ages 12 to 17 in the child welfare group who did not have a behavioral health diagnosis received at least one psychotropic October 2023 ISSUE BRIEF 6 medication, and over 3 percent received medications from multiple classes. These rates were more than double those of beneficiaries in other Medicaid eligibility groups without behavioral health diagnoses (see Appendix Table 4). Figure 4. Children Involved with the Child Welfare System Were Often Prescribed Psychotropic Medications, 2019 25 19.1 19.1 20 18.6 16.9 15 11.8 11.9 Percent Medication Class W Ages 3-5 OAges 6-11 W Ages 12-17 Rates of psychotropic medication use among child welfare beneficiaries vary widely by state. States at the high and low ends of the distribution varied widely. For example, 6.0 percent of children and youth ages 3 to 17 in the child welfare population in Georgia received any psychotropic medication, compared with 47.2 percent in Virginia (Figure 5). The states with the lowest rates of medication among child welfare beneficiaries are Georgia (6.0 percent), Hawaii (10.0 percent), and California (14.9 percent). The states with the highest medication rates are Virginia (47.2 percent), Arkansas (40.4 percent) and Delaware (38.4 percent). In addition, Puerto Rico had the second highest prescribing rate of any U.S. state or territory after Virginia. Medication rates among the broader population of Medicaid child beneficiaries also varied but were much lower than among children and youth in the child welfare system. October 2023 ISSUE BRIEF 7 Figure 5. Percentage of Beneficiaries Receiving Any Psychotropic Medication Varies Widely by State, 2019 U.S. Virgin Islands BOE 4.03 Georgia -%.-7'_!. 6.0 Hawaii L'O 0 California -..5-_ Alaska -2' District of Columbia L Nevado S New Jersey I"-IZ'I 8 Arizona hm 8 Colorado -&L._.__zz 0 New Mexico -___zzs | Idaho fl New York New Hampshire s-" WaShington il m- 14.9 15.4 m15.4 18.4 ---- 2 7.5 ------- 23.6 B child Welfare (Natiohai Rate: 26.19) [T] Other (National Rate: 9.02) Florida %-2'3 8 South DAoL | -- L e-25.] lllinois -L . -26.4 Connecticut T ---E 28.2 Montana kZfl 8 Massachusetts T 10.8 : ; ; 29.6 Michigan -..EMME.? WyYOming - \ 302 North Dakota e -"- : 306 Minnesoto E---"0A . . 307 West Virginia Ifl-:fij Texas e -0iC ' ) 3.4 Indiano e --2.0, ; 319 Vermont -E ' 322 MO --.O 326 Marylond ---0 ' 32.7 Maine * - 32.8 --- | Tennessee 120 Wisconsin Kentucky lowa Mississippi Nebraska Kansas Ohio South Carolina North Carolina Louisiana Delaware Arkansas Puerto Rico | 332 33.4 34.4 351 35,1 35.1 3352 = 35.6 35.8 36.2 37.0 38.4 40.4 Virginia : 5 10 15 20 25 30 35 40 Source: TAF v5, 2018-2019. Notes: See the Methods section of this brief for notes on data limitations and exclusions. October 2023 ISSUE BRIEF 429 DISCUSSION This analysis documents high rates of behavioral health conditions and service utilization among children and youth in the child welfare system. For most behavioral health conditions, children and youth in the child welfare group received diagnoses at three to five times the rates of children and youth in other Medicaid eligibility categories. Children and youth in the child welfare system frequently have had traumatic experiences, and their exposure to adverse childhood experiences is high (Greeson et al., 2011; Papovich, 2019; Liming, Akin and Brook, 2021). Their parents frequently also have behavioral health conditions. For these reasons, the high rates of behavioral health conditions among this group are not surprising. Routine behavioral health screening within the child welfare system may also drive high rates of diagnosis. Typically, states require that children entering foster care receive a behavioral health screening shortly after placement (Allen, 2010). Federal Child and Family Services Reviews conducted as part of oversight of states' foster care programs between 2015 and 2018 found that in 77 percent of applicable cases child welfare agencies performed required initial or ongoing assessments of children's behavioral health care needs (Children's Bureau, 2020). Similarly, in 2019 those in the child welfare group received behavioral health services at rates several times higher than children and youth in other Medicaid eligibility groups. Use of psychotropic medications and outpatient mental health services were particularly high. These results may indicate higher severity of behavioral health conditions among the child welfare Medicaid and CHIP eligibility group. It is also possible that the child welfare system may facilitate access to behavioral services beyond what is typically received by other Medicaid beneficiaries. For example, routine behavioral health assessments at the time of foster care entry, categorical Medicaid eligibility, and access to case management services may increase access to behavioral health care. Psychotropic medication use among child welfare beneficiaries varied significantly across states. These differences across states might partially reflect underlying differences in rates of behavioral health conditions, both within the child welfare population and between the child welfare group and other Medicaid beneficiaries. The variation across states suggests that a beneficiary's location within the systems of child welfare, health care, and public health might impact medication use more than individual factors such as health conditions (Leslie et al., 2011). The wide variation in medication use rates across states could potentially be related to differences in state child welfare, public health, or health care systems. For example, access to primary care physicians or behavioral health providers, as well as clinician style and practice patterns might vary across states. Further, despite efforts to expand oversight in the last two decades, states have varied in adopting child welfare system policies and procedures related to the behavioral health of children and youth in their care such as screening for behavioral health conditions, developing prescription guidelines, or increasing behavioral health knowledge among stakeholders (U.S. Government Accountability Office, 2017). For example, Texas developed an oversight process that dramatically reduced prescription of psychotropic medications to children in the state's foster care system (National Center for State Courts, 2022). This study takes advantage of data improvements in the TAF compared with its predecessor, the Medicaid Analytic Extract (MAX). To our knowledge, this brief and related publications coming out of this research represent the first T-MSIS analyses to focus on the child welfare population. The analysis illustrates the types of issues that can be analyzed using these data, which have been available annually since 2017. Children categorically eligible for Medicaid based on their eligibility for federal Title IV-E foster care and permanency programs may be identified through their eligibility code. Not analyzed here, additional codes allow October 2023 ISSUE BRIEF 9 identification of individuals eligible for Medicaid or CHIP based on having aged out of foster care as well as those whose eligibility derives from other state adoption subsidies not covered by Title IV-E. This study did not focus on expenditures. Past research has demonstrated that children in the child welfare Medicaid eligibility group use a disproportionate share of Medicaid expenditures (Raghavan et al., 2012; Pires et al., 2013; MACPAC, 2015). For instance, Pires and colleagues found in 2013 (using data on expenditures during 2008) that while children and youth involved with the child welfare system represented 3 percent of Medicaid beneficiaries under age 18, they accounted for 29 percent of total behavioral health care spending for those in that age range. Similar patterns are visible in diagnoses and services in this analysis and undoubtedly still exist with respect to expenditures as well. LIMITATIONS While these analyses provide important insights into the behavioral health needs and service utilization of children involved with the child welfare system, there are limitations. Most significantly, it is challenging to identify the child welfare population accurately in Medicaid claims data, both overall and particularly to pinpoint children and youth in foster care. We describe the particular challenges below. Given these issues and comparisons with other counts of children and youth involved with the child welfare system, we expect we have undercounted children and youth involved with the child welfare system and particularly those in foster care. However, the large numbers we did identify provide a robust view of the behavioral health issues and services of this population and we have not identified reasons to believe those included in our analysis would have different behavioral health needs than those we may have missed. T-MSIS reports a single eligibility group code for each beneficiary. If a beneficiary is eligible for Medicaid/CHIP through multiple pathways, the state assigns the eligibility pathway affording the highest level of medical coverage. For example, children in foster care who have disabilities may qualify for Medicaid/CHIP through Supplemental Security Income (SSI) eligibility and thus appear in the data as SSI beneficiaries rather than child welfare beneficiaries. Approximately 5 percent of children in foster care in 2019 received SS| benefits (Stoltzfus, Davies and Morton, 2021). These analyses rely on the Medicaid eligibility code indicating participation in the federal Title IV-E foster care, adoption, or guardianship programs. While often interpreted in the literature as identifying children in foster care (e.g., Leckman-Westin et al., 2018; Pires et al., 2013), the code includes children receiving federal benefits through any of these three programs and excludes many children in foster care who are not Title IV-E eligible, though most children in foster care who are not Title IV-E eligible receive Medicaid benefits through other eligibility categories (Child Welfare Information Gateway, 2022; MACPAC, 2015). In federal fiscal year 2019, 40 percent of children in foster care nationally were Title IV-E eligible, and data from Title IV-E claims indicate that 23 percent of Title IV-E beneficiaries overall were children in foster care, 72 percent received adoption subsidies, and 5 percent received guardianship assistance payments. {Data for these programs, including average monthly caseloads and Title IV-E participation rates, can be found on the Children's Bureau website.) Thus, most children and youth in our analytical sample were most likely adopted from foster care, not currently in foster care. Children adopted from foster care typically continue to be Medicaid eligible until they turn 18, regardless of family income, disability, or other factors that limit Medicaid eligibility for other groups. In addition, for a range of reasons, adopted children and those in guardianships may have different behavioral health conditions and diagnostic patterns, and may use services differently, than children in foster care. The current child welfare involvement of children and youth in foster care may amplify their access to and use of behavioral health services in ways that are different from adopted children and youth. Conversely, adoptive October 2023 ISSUE BRIEF 10 families and foster families may have different inclinations about use of behavioral health services and psychotropic medications. In addition, for many adoptive families Medicaid coverage is secondary to private family health care insurance (Kelly, 2020). Therefore, Medicaid claims may not fully represent the health care utilization of such children and youth. Because children and youth in foster care and adoption may have different Medicaid service utilization patterns, results here should not be taken as representative of either population alone. Eligibility group code data may be missing, inaccurate, or unusable for some states. CMS, in the DQ Atlas, categorizes states as low, medium, or high concern or as unusable or unclassified, based on (1) the percentage of beneficiaries missing an eligibility group code and (2) the number of large mandatory eligibility groups with no enrollment in the TAF.* Two states are unclassified, 47 states have data of low or medium concern, and 4 states have data of high concern. Supporting data on the DQ Atlas indicate how many states show no enrollment for the 12 large mandatory groups (including Title IV-E adoption assistance, foster care, or guardianship care) but do not specify which of these groups each state is missing. In our national analyses, we did not exclude states with medium or high concern since the aim was to aggregate, not compare, data across states. As noted in the Methods section, six states were excluded from the state-specific analysis because of data quality issues. Finally, when claims are used to identify beneficiaries with behavioral health conditions, most beneficiaries with such conditions, by definition, have received some behavioral health service. Individuals with behavioral conditions were identified using the CCW algorithm, which provides a standardized method for researchers to identify classes of conditions in Medicare and Medicaid research files. In identifying behavioral health conditions, the algorithm requires "at least 1 inpatient claim or 2 other non-drug claims of any service type" with condition-specific diagnosis codes during a two-year period, though the services claimed need not be specific to the behavioral health diagnosis. Our count may be an underestimate if some beneficiaries had a behavioral health condition but did not receive services that met CCW criteria or the relevant diagnosis code was not included in the claim. Alternatively, our figures may overestimate the number of individuals with behavioral health conditions if some beneficiaries received treatment that met CCW criteria but did not truly have these conditions. In addition, our findings may overestimate receipt of behavioral health services among those with behavioral health conditions because the denominator does not include individuals with behavioral health conditions who did not receive any behavioral health services. REFERENCES 1. Allen, K. (2010). Health Screening and Assessment for Children and Youth Entering Foster Care: State Requirements and Opportunities. Center for Health Care Strategies, Inc. Available at: https://www.chcs.org/media/CHCS CW Foster Care Screening and Assessment Issue Brief 111910.p df 2. American Academy of Child and Adolescent Psychiatry. 2015. Recommendations about the Use of Psychotropic Medications for Children and Youth Involved in Child-Serving Systems. https://www.aacap.org/App_Themes/AACAP/docs/clinical _practice center/systems of care/AACAP_Psy chotropic_Medication _Recommendations 2015 FINAL.pdf 4 DQ Atlas. https://www.medicaid.gov/dg-atlas/landing/topics/single/map?topic=g3m20&tafVersionld=25 October 2023 ISSUE BRIEF 11 10. 11. 12. 13. Burcu, M., Zito, J.M., Safer, D.J., Magder, L.S., dosReis S., Shaya, F.T., and Rosenthal, G.L. {2017). Concomitant use of atypical antipsychotics with other psychotropic medication classes and the risk of type 2 diabetes mellitus. Journal of the American Academy of Child and Adolescent Psychiatry 6{8): 642-651. https://doi.org/10.1016/j.jaac.2017.04.004 Burns, B.)., Phillips, S.D., Wagner, H.R., Barth, R.P., Kolko, D.J., Campbell, Y., and Landsverk, J. (2004). Mental health need and access to mental health services by youths involved with child welfare: a national survey. Journal of the American Academy of Child and Adolescent Psychiatry 43(8): 960-970. https://doi.org/10.1097/01.chi.0000127590.95585.65 Child Welfare Information Gateway. (2022). Health-Care Coverage for Children and Youth in Foster Care- and After. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. https://www.childwelfare.gov/pubs/issue-briefs/health-care-foster/ Fernanes-Alcantara, A.L., Caldwell, S.W., and Stoltzfus, E. (2017). Child Welfare: Oversight of Psychotropic Medication for Children in Foster Care. Congressional Research Service. https://crsreports.congress.gov/product/pdf/R/R43466/8 Greeson, J. K. P., Briggs, E. C., Kisiel, C. L., Layne, C. M., Ake, G. S., Ko, S. J., Gerrity, E. T., Steinberg, A. M., Howard, M. L., Pynoos, R. S., & Fairbank, J. A. (2011). Complex Trauma and Mental Health in Children and Adolescents Placed in Foster Care: Findings from the National Child Traumatic Stress Network. Child Welfare, 90(6), 91-108. https://www.jstor.org/stable/48625371 Kelly, J. (2020). A Guide to Adoption Subsidies and Assistance for Adoptive Parents. National Council for Adoption. https://adoptioncouncil.org/publications/a-guide-to-adoption-subsidies-and-assistance-for- adoptive-parents/ Liming, K.W., Akin, B., and Brook, J. (2021). Adverse Childhood Experiences and Foster Care Placement Stability. Pediatrics 148:6:22021052700. Leckman-Westin, E., Finnerty, M., Scholle, S.H., Pritam, R., Layman, D., Kealey, E., Byron, S., Morden, E., Bilder, S., Neese-Todd, S., Horwitz, S., Hoagwood, K., and Crystal, S. (2018). Differences in Medicaid antipsychotic medication measures among children with SSI, foster care, and income-based aid. Journal of Managed Care & Specialty Pharmacy 24(3): 238-246. https://doi.org/10.18553/imcp.2018.24.3.238 Leslie, L.K., Raghavan, R., Hurley, M., Zhang, J., Landsverk, J., and Aarons, G. (2011). Investigating geographic variation in use of psychotropic medications among youth in child welfare. Child Abuse and Neglect 35(5): 333-342. https://doi.org/10.1016/j.chiabu.2011.01.012 Libowitz, M.R., and Nurmi, E.L. (2021). The burden of antipsychotic-induced weight gain and metabolic syndrome in children. Frontiers in Psychiatry 12: 623681. https://doi.org/10.3389/fpsyt.2021.623681 MACPAC. (2015). Report to Congress on Medicaid and CHIP. https://www.macpac.gov/publication/june- 2015-report-to-congress-on-medicaid-and-chip/ (See especially Chapter 3: "The Intersection of Medicaid and Child Welfare," Chapter 4: "Behavioral Health in the Medicaid Program-People, Use, and Expenditures," and Chapter 5: "Use of Psychotropic Medications among Medicaid Beneficiaries," each of which includes analyses on the child welfare population.) October 2023 ISSUE BRIEF 12 14, 15, 16. 17. 18. 19. 20. 21. 22, 23. 24. National Center for State Courts. (2022). Oversight of Psychotropic Medications Prescribed to Children in Foster Care. https://www.ncsc.org/ data/assets/pdf file/0022/83803/Oversight-of-Psychotropic- Medications-Prescribed-to-Children-in-Foster-Care.pdf Naylor, M., Davidson, C.V., Ortega-Piron, D.J., Bass, A., Guierrez, A., and Hall, A. (2007). Psychotropic medication management for youth in state care: consent, oversight, and policy considerations. Child Welfare 86(5): 175-192. Ninan, A., Stewart, S.L., Theall, L.A., Katuwapitiya, S., and Kam, C. (2014). Adverse effects of psychotropic medications in children: predictive factors. Journal of the Canadian Academy of Child and Adolescent Psychiatry 23(3): 218-225. Papovich, C. (2019). Trauma and Children in Foster Care: A Comprehensive Overview. Forensic Scholars Today. Concordia St. Paul. Available at: https://www.csp.edu/publication/trauma-children-in-foster-care- a-comprehensive-overview/ Pires, S., Grimes, K., Gilmer, T., Allen, K., Mahadevan, R., and Hendricks, T. (2013). Identifying Opportunities to Improve Children's Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies. https://www.chcs.org/media/ldentifying-Opportunities- to-Improve-Childrens-Behavioral-Health-Care2.pdf Radel, L.F., Ali, M.M., West, K., and Lieff, S.A. (2023). Psychotropic medication and psychotropic polypharmacy among children and adolescents in the US child welfare system. JAMA Pediatrics (published online August 21). https://doi.org/10.1001/jamapediatrics.2023.3068 Raghavan, R., Brown, D.S., Thompson, H., Ettner, S.L., Clements, L.M., and Key, W. (2012). Medicaid expenditures on psychotropic medications for children in the child welfare system. Journal of Child and Adolescent Psychopharmacology 22(3):182-189. https://doi.org/10.1089/cap.2011.0135 Raghavan, R., Zima, B.T., Andersen, R.M., Leibowitz, A.A., Schuster, M.A., and Landsverk, J. (2005). Psychotropic medication use in a national probability sample of children in the child welfare system. Journal of Child and Adolescent Psychopharmacology 15(1): 97-106. https://doi.org/10.1089/cap.2005.15.97 Stambaugh, L.F., Leslie, L.K., Ringeisen, H., Smith, K., and Hodgkin, D. (2012). Psychotropic Medication Use by Children in Child Welfare. OPRE Report #2012-33. Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. https://www.acf.hhs.gov/sites/default/files/documents/opre/psych med.pdf Stoltzfus, E., Davies, P.S., and Morton, W.R. (2021). Children in Foster Care and Social Security Administration Benefits: Frequently Asked Questions. Report R46975. Washington, D.C.: Congressional Research Service. Available at: https://sgp.fas.org/crs/misc/R46975.pdf U.S. Department of Health and Human Services, Administration for Children and Families. {2012). Oversight of Psychotropic Medication for Children in Foster Care; Title IV-B Health Care Oversight & Coordination Plan. ACYF-CB-IM-12-03. https://www.acf.hhs.gov/sites/default/files/documents/cb/im1203.pdf October 2023 ISSUE BRIEF 13 25. U.S. Department of Health and Human Services, Office of Inspector General. (2018). Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication. OEI-07-15-00380. https://oig.hhs.gov/oei/reports/oei-07-15-00380.asp and https://oig.hhs.gov/oei/reports/oei-07-15-00380.pdf (Specific reports are also available for several individual states.) 26. U.S. Government Accountability Office. (2017). Foster Care: HHS Has Taken Steps to Support States' Oversight of Psychotropic Medications, but Additional Assistance Could Further Collaboration. 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vIS'0TY I N I I TS SUOIHPUO Y3|eaY |eJ0IARYS] OU Y3IM SSOY1 4O JUNOD [10] :JOJRUIWOUS(] ade pue snjels aJeyam pJIyYo Aq '6T0Z Ul SRIIAIDS Y}|eaY [elOlARYD] PaAIa231 JBY3 SUOIIPUOI Y3|e3Yy [BIOIARYDI( INOYIIM SDLIBIDIUA] dIHD PUB PIEJIPIIAl JUSISI|OpE pue pliyd jo 38ejuadiad 't 3|qel Xipuaddy ec 43119 HOYvas3y €207 139010 *9|ge1 siy) 01 ose Ajdde yoiym 'g-T s9|qe] xipuaddy wody sajou [euonippe 39S *(TT > N) 9zis 9jdwes |[ews 01 anp passaiddns aie ejep = sq "GA 6T0TZ-8T0Z '(4vL) s3|ld anAjeuy (SISN-L) WalsAS uojiew.ofu| [e211S[31S PIEJIPBIA PAWIOJSUBI] :821N0S U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports ABOUT THE AUTHORS Laura Radel is a Senior Social Science Analyst in the Office of Human Services Policy in the Office of the Assistant Secretary for Planning and Evaluation. Sarah Lieff is a Researcher and Chandra Couzens is a Research Analyst at Mathematica which conducted the analysis under contract to the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Mir Ali is a Health Economist and Kristina West is a Senior Policy Analyst, both in the Office of Behavioral Health, Disability and Aging Policy in the Office of the Assistant Secretary for Planning and Evaluation. SUGGESTED CITATION Radel, L., Lieff, S., Couzens, C., Ali, M. M., and West, K. (2023). Behavioral Health Diagnoses and Treatment Services for Children Involved with the Child Welfare System. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. COPYRIGHT INFORMATION All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. DISCLOSURE This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. For general questions or general information about ASPE: aspe.hhs.gov/about October 2023 RESEARCH BRIEF 23