In alignment with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has executed a thorough performance audit of the Department of Children and Families (DCF), specifically examining the operations and practices relevant from July 1, 2019, through December 31, 2023.
- This assessment scrutinized whether DCF consistently obtained the necessary court approvals for administering antipsychotic medications and meticulously documented its consent regarding psychotropic medications prescribed to children under its protective custody, in adherence to the mandates stipulated in Sections 11.14(3)(a), (4)(a), and (6)(a) of Title 110 of the Code of Massachusetts Regulations, along with DCF Policy 2010-001: Medical Examinations for Children Entering DCF Placement or Custody;
- The audit further investigated whether children in DCF’s protective custody received timely follow-up visits and the essential psychosocial services linked to their psychotropic medication prescriptions, in accordance with guidelines set forth by the American Academy of Child and Adolescent Psychiatry’s 2005 “Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline” and accompanying 2015 recommendations regarding psychotropic medication usage;
- Additionally, the review examined if DCF maintained comprehensive medical passports for children in protective custody who were prescribed psychotropic medications, in compliance with guiding policies such as DCF Policy 85-003: Health Care Services to Children in Placement and Section 475 of the Social Security Act; and
- Finally, the audit looked into whether DCF exercised adequate oversight over children in its custody who were administered psychotropic medications surpassing the FDA’s recommended maximum dosages.
- The audit also revealed whether DCF updated its internal control plans to address the unique challenges posed by the COVID-19 pandemic, complying with the guidance established by the Office of the Comptroller of the Commonwealth;
- Furthermore, it assessed whether DCF ensured that all employees with access to COVID-19 funds underwent cybersecurity awareness training as mandated by the Executive Office of Technology Services and Security’s Information Security Risk Standard IS.010;
- The evaluation included inquiries into whether DCF made consistent outreach efforts to connect with eligible youths aging out of DCF care, enabling proper allocation of funds from the John H. Chafee Foster Care Independence Program grant in accordance with the grant agreement ACYF-CB-PI-21-04.
Below is a detailed summary of our findings, the implications of those findings, and our recommendations, conveniently linked for further review.
In addition, we identified an issue regarding DCF oversight of children in its custody receiving psychotropic medication in amounts that exceeded the FDA’s recommended doses. For more information on this issue, please refer to the “Other Matters” section of this report.
During our audit, additional areas of concern that were outside the original scope of our objectives came to our attention. Given the high-risk nature of these areas, we diligently examined them while maintaining engagement with the auditee. These areas encompassed human trafficking prevention measures, in addition to DCF’s implementation of recommendations proposed by the Massachusetts Commission on LGBTQ Youth. The results of this additional work are also presented within the “Other Matters” section of this audit report.
1. Psychotropic medications are utilized to address mental health disorders affecting children, including schizophrenia, depression, bipolar disorder, anxiety disorders, and attention deficit/hyperactivity disorder.
2. A medical passport serves as a comprehensive record of healthcare services a child has received or is currently receiving, documenting their existing medications, relevant mental health history, and crucial treatment programs.
**Interview with Dr. Amelia Schaffer, Child Psychologist and Advocate for Foster Children**
**Interviewer:** Thank you for joining us today, Dr. Schaffer. We’ve seen some concerning findings from a recent audit of the Massachusetts Department of Children and Families (DCF) regarding the administration of psychotropic medications to children in protective custody. What are your initial thoughts on these findings?
**Dr. Schaffer:** Thank you for having me. I’m indeed alarmed by the findings. The report highlights critical gaps in oversight and documentation that are essential for ensuring the safety and well-being of vulnerable children. It’s disturbing to think that children could be prescribed powerful medications without proper court approval or adequate follow-up care.
**Interviewer:** One of the key findings indicated that DCF did not always obtain or renew court approvals for administering antipsychotic medications to children. What are the risks associated with this lack of oversight?
**Dr. Schaffer:** When DCF fails to obtain court approval, it undermines the checks and balances that are supposed to protect these children. Specifically, it means that there is no impartial review of whether the prescribed treatment is in the child’s best interest. This lack of oversight could expose children to inappropriate treatments that could lead to adverse side effects or even worsen their condition.
**Interviewer:** The audit also pointed out that there were issues with documenting medication and follow-up services in their system. How do these documentation lapses affect the care these children receive?
**Dr. Schaffer:** Accurate documentation is crucial for coordinating care. Without it, health providers may make decisions based on outdated or incomplete information, which could lead to overprescribing or missing important mental health services. This kind of oversight disconnect can severely impact children’s health outcomes, especially for those already facing emotional and psychological challenges.
**Interviewer:** Another alarming finding was the report of suicidal ideations among some children in the sample. How critical is the integration of psychosocial services alongside medication for these children?
**Dr. Schaffer:** It is absolutely vital. Psychotropic medications can be effective, but they are often much more successful when combined with therapeutic interventions. Psychosocial services help children process their experiences and cope with their emotions, while medication addresses specific mental health symptoms. Without a comprehensive treatment plan that includes both, we risk not addressing the root causes of their distress.
**Interviewer:** The audit suggested recommendations for improving monitoring and documentation practices within DCF. What specific changes do you think should be prioritized?
**Dr. Schaffer:** First and foremost, DCF must prioritize standardized training for all personnel on the importance of documentation and legal requirements regarding psychotropic medications. They should implement regular audits to assess compliance with court approvals and ensure timely follow-up services. Additionally, creating a centralized system for health records that is regularly updated and accessible to all relevant providers is crucial for maintaining continuity of care.
**Interviewer:** with the ongoing challenges of the COVID-19 pandemic impacting DCF operations, do you have any thoughts on how they can better adapt to these changes while ensuring the safety of children in their care?
**Dr. Schaffer:** Absolutely. DCF needs to enhance its use of technology for telehealth services, ensuring that children still receive necessary psychosocial support remotely. They also need to maintain strong communication with foster families and community organizations to ensure that children transitioning out of care still have access to resources. A proactive approach to these adjustments can help mitigate some of the disruptions caused by the pandemic while still safeguarding these children’s well-being.
**Interviewer:** Thank you, Dr. Schaffer, for your insights on this critical issue. Your expertise highlights the importance of proper oversight and comprehensive care for children in foster care.
**Dr. Schaffer:** Thank you for addressing these important issues. We must continue advocating for these children and ensuring they receive the care and protection they deserve.
