The audit reviewed the cases of 168 children who were prescribed psychotropic drugs while in protective custody and enrolled in one of two MassHealth benefit programs. In total, there are nearly 4,000 children, nearly a quarter of all those in DCF protective custody, who had a prescription for at least one psychotropic medication during the audit period from June 1, 2019, to December 31, 2023.

Medications for anxiety and depression, antipsychotics, stimulants and mood-stabilizing drugs help children manage mood swings, anger and delusions, the report said. But they can have serious side effects, including mania, seizures and suicidal thoughts.

DiZoglio emphasized how vulnerable children in DCF’s protective custody can be.

“Many of these children are left without the assistance of family members and other supports and that’s why they end up in custody,” she said.

Daniel Mahoney, deputy chief counsel for the child and family law division in the state public defender’s office, described DCF’s handling of children’s medications as a longstanding concern in the state.

“The audit shows a lack of consistent court approval and documentation for potentially harmful medications prescribed to children in DCF custody,” he said in an emailed statement, “which undermines legal and medical safeguards designed to protect these children “.

As early as 2009, the Office of the Child Advocate raised concerns about the agency’s use of psychotropic drugs, according to its annual report 2015. The agency was supposed to do more than manage children, according to the children’s advocate, who has an oversight role for DCF. Prescriptions should be one facet of a larger behavioral health plan that is routinely reviewed and evaluated, the report said.

A spokesperson for the Children’s Advocate said both his office and DCF recognize the importance of keeping proper records.

However, the audit found that, despite previous warnings from the children’s advocate, children who had been treated with medication still did not receive complementary treatment. Of the sampled cases, 25 children did not receive any therapy and 34 did not receive therapy for more than four months. The study group included 28 children who expressed suicidal thoughts and took psychotropic drugs.

DCF did not respond to a request for an interview Thursday, but issued a statement saying it largely agrees with the audit’s findings and is addressing them. The agency has a team of experts, including a child psychiatrist, a consultant psychiatric nurse and a psychiatric social worker, who provide guidance on prescribing psychotropic drugs for children. The psychiatrist also oversees a monitoring program that reviews requests for antipsychotic prescriptions for children.

The agency relies more on records from MassHealth to better track prescriptions and now conducts a medical evaluation whenever a child is prescribed an antipsychotic, according to the statement.

Maintaining accurate and current medical records is a challenge throughout the field of child welfare, said Dr. Christopher Bellonci, psychiatrist and chief medical officer at Judge Baker Children’s Center, which provides services and training related to children’s behavioral health. Digital data systems can be cumbersome, foster parents and caseworkers cannot share complete information about medical care, and accurate record keeping is often time-consuming.

“There are a lot of places where this can go wrong,” Bellonci said. “That’s not an excuse by any means, but it’s a reality.”

There were 36 children in the sample who received antipsychotic medication, but four were treated without court permission, the audit found. That’s a violation of state regulations that require the agency to get court permission, called a Rogers Order, before giving antipsychotic drugs to children too young to give legal consent. Six children were given antipsychotics after a court order expired. In one case, the child was still taking medication eight months after the court order expired.

In most cases, DCF did not keep accurate records of consent or court approval for psychotropic drugs, according to the audit.

DCF offered several explanations for its failure to obtain the necessary court approval. In one case, agency auditors said, the child was not in protective custody and was prescribed medication before interacting with DCF. In another case, the prescription was filled but never taken. In another case, the COVID-19 pandemic caused delays in the court hearing.

The audit found that DCF’s records contradicted or could not confirm the agency’s explanations. It also stated that even if a child did not take medication, a prescription should not have been filled without a judge’s order.

Furthermore, the auditor found that DCF does not require monitoring of the Rogers process to ensure that it is being followed properly.

The agency responded in the auditor’s report that it would do better to pursue the actions in court.

The audit found that all but two of the 168 children who were prescribed psychotropic drugs had gaps in their digital medical records. Those records are critical to child care, DiZoglio said, and if a child needs emergency care, a doctor will rely on them to determine a safe course of treatment. Of the reviewed cases from the two MassHealth plans, nearly 88 percent either had no or incomplete information about children’s prescriptions related to mental or behavioral health treatment.

Record keeping for doctor’s appointments and mental health services was equally spotty.

“DCF could create a treatment plan that is not safe or effective for a child because important information is missing that would affect that child’s health care,” the auditor’s report states.

Also, the department does not have procedures in place to give extra attention to child prescribers doses that exceed Food and Drug Administration recommendations.

Jason Laughlin can be reached at [email protected]. Follow L @jasmlaughlin.