[Senate Hearing 112-448]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 112-448

    THE FINANCIAL AND SOCIETAL COSTS OF MEDICATING AMERICA'S FOSTER 
                                CHILDREN

=======================================================================


                                HEARING

                               before the

                FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
                   INFORMATION, FEDERAL SERVICES, AND
                  INTERNATIONAL SECURITY SUBCOMMITTEE

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 1, 2011

                               __________

         Available via the World Wide Web: http://www.fdsys.gov

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs








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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware           SCOTT P. BROWN, Massachusetts
MARK L. PRYOR, Arkansas              JOHN McCAIN, Arizona
MARY L. LANDRIEU, Louisiana          RON JOHNSON, Wisconsin
CLAIRE McCASKILL, Missouri           ROB PORTMAN, Ohio
JON TESTER, Montana                  RAND PAUL, Kentucky
MARK BEGICH, Alaska                  JERRY MORAN, Kansas

                  Michael L. Alexander, Staff Director
               Nicholas A. Rossi, Minority Staff Director
                  Trina Driessnack Tyrer, Chief Clerk
            Joyce Ward, Publications Clerk and GPO Detailee
                                 ------                                

 SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, 
              FEDERAL SERVICES, AND INTERNATIONAL SECURITY

                  THOMAS R. CARPER, Delaware, Chairman
CARL LEVIN, Michigan                 SCOTT P. BROWN, Massachusetts
DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
MARK L. PRYOR, Arkansas              JOHN McCAIN, Arizona
CLAIRE McCASKILL, Missouri           RON JOHNSON, Wisconsin
MARK BEGICH, Alaska                  ROB PORTMAN, Ohio

                    John Kilvington, Staff Director
                William Wright, Minority Staff Director
                   Deirdre G. Armstrong, Chief Clerk












                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Carper...............................................     1
    Senator Brown................................................     4
    Senator Collins..............................................     6
    Senator Coburn...............................................     8
Prepared statements:
    Senator Carper...............................................    39
    Senator Brown................................................    42
    Senator Grassley.............................................    44
    Senator Landrieu.............................................    46

                               WITNESSES
                       THURSDAY, DECEMBER 1, 2011

Ke'onte Cook, McKinney, Texas; accompanied by his mother Carol 
  Cook...........................................................     8
Gregory D. Kutz, Director, Forensic Audits and Investigative 
  Service, U.S. Government Accountability Office.................    17
Bryan Samuels, Commissioner, Administration on Children, Youth 
  and Families, U.S. Department of Health and Human Services.....    19
Matt Salo, Executive Director, National Association of State 
  Medicaid Directors.............................................    21
Dr. Jon McClellan, Seattle Children's Hospital...................    23

                     Alphabetical List of Witnesses

Cook, Ke'onte:
    Testimony....................................................     8
    Prepared statement...........................................    48
Kutz, Gregory D.:
    Testimony....................................................    17
    Prepared statement...........................................    52
McClellan, Jon, Ph.D.:
    Testimony....................................................    23
    Prepared statement...........................................   119
Salo, Matt:
    Testimony....................................................    21
    Prepared statement...........................................   113
Samuels, Bryan:
    Testimony....................................................    19
    Prepared statement...........................................    94

                                APPENDIX

Questions and responses for the Record from:
    Mr. Kutz.....................................................   124
    Mr. Samuels..................................................   131
    Mr. Salo.....................................................   146
    Mr. McClellan................................................   151
Additional statements for the Record from:
    National Alliance on Mental Illness..........................   158
    James H. Scully, Jr., M.D. Medical Director and CEO on behalf 
      of The American Psychiatric Association....................   163
    Shadi Houshyar, Vice President for Child Welfare Policy, 
      First Focus................................................   166
    Kristin Kroeger Ptakowski....................................   176
    Bazelon Center for Mental Health Law.........................   180

 
    THE FINANCIAL AND SOCIETAL COSTS OF MEDICATING AMERICA'S FOSTER 
                                CHILDREN

                              ----------                              


                       THURSDAY, DECEMBER 1, 2011

                                 U.S. Senate,      
        Subcommittee on Federal Financial Management,      
              Government Information, Federal Services,    
                              and International Security,  
                      of the Committee on Homeland Security
                                        and Governmental Affairs,  
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:37 a.m., in 
Room SD-342, Dirksen Senate Office Building, Hon. Thomas R. 
Carper, Chairman of the Subcommittee, presiding.
    Present: Senators Carper, Brown, Collins and Coburn.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. Good morning, everyone. Welcome to this 
hearing today. And I am delighted especially to welcome our 
lead-off witness, Ke'onte Cook and his mom and dad.
    Ke'onte, in a few minutes, each of us are going to make 
some statements, and then we will turn it over to you to say 
whatever you would like to say to us.
    Over the past few years, this Subcommittee has been focused 
almost exclusively on how our Federal Government can achieve 
better results for less money. Among other things, we have 
examined cost overruns in major weapons systems and 
overpayments for additional spare parts that we do not need. We 
have focused on how to manage our Federal property, on bloated 
information technology projects that waste millions of dollars 
and, most notably for today's hearing, on how we can spend 
taxpayer dollars on prescription medications in our Nation's 
public health care system. In fact, today marks the third in a 
series of hearings over the past several years examining this 
particular subject.
    Nearly 2 years ago, our Subcommittee asked the Government 
Accountability Office (GAO), to look into the potentially 
improper prescribing of mind-altering medications, also known 
as psychotropic drugs, for children in foster care whose health 
care is paid for through Medicaid and managed by the States.
    We learned through various media reports and medical 
articles that many foster children, may have been receiving 
these medications at alarming and potentially dangerous rates. 
If these reports were true, not only were taxpayer dollars 
being misspent on these medications, but more importantly, the 
health and well-being of these children was very likely in 
danger.
    We wanted an independent government audit from the GAO. In 
asking them to look at this issue, we wanted to know if 
overprescribing, or improper prescribing, of these powerful 
mind-altering medications was occurring and if it was, how 
prevalent was that and what were the costs. The report we are 
releasing today confirms some of our worst fears.
    GAO's findings reveal that foster children in the five 
States that were examined are receiving mind-altering 
medications at between 2 and 4\1/2\ times the rate of other 
children under Medicaid. In 2008, the five States combined 
spent over $59 million on mind-altering medications for foster 
children. Beyond these rates, the GAO found three alarming 
patterns in their data.
    First, thousands of children were prescribed mind-altering 
medications in excess of the maximum doses for the child's age 
as recommended by the Food and Drug Administration (FDA) and by 
medical literature. Furthermore, for the medications for which 
there is no FDA recommended dosage for their age, the GAO found 
a number of children receiving dosages beyond those even 
recommended for adults.
    Second, more than 600 foster children in these five States 
were found to be receiving five or more mind-altering 
medications at the same time. According to medical experts, one 
of whom is with us today as a witness, there is no evidence 
supporting the use of five or more mind-altering medications in 
adults, much less for children. In fact, I am told that there 
is only limited evidence that supports the use of even two 
mind-altering medications being prescribed to a child at the 
same time.
    Finally, and perhaps most disturbingly, dozens of foster 
care children under the age of one year in these five States 
and over 3,500 non-foster children in those States, were 
prescribed a mind-altering medication. According to medical 
experts, there are no established medical health uses for mind-
altering medications in infants and providing them these drugs 
can result in serious health effects for them over both the 
near term and the long term.
    We look forward to hearing more about the GAO's findings 
today. Greg Kutz from GAO has joined us to discuss them. He has 
appeared before this Subcommittee many times before, and we 
welcome him back today.
    Along with him is Dr. Jack McClellan from Seattle 
Children's Hospital. He is one of the medical experts hired by 
GAO to review their report. Mr. Bryan Samuels is here from the 
Department of Health and Human Services (HHS) to give us the 
Federal Government's perspectives, and while Matt Salo is here 
on behalf of the State Medicaid Directors. We welcome all of 
you.
    I am probably most interested, however, to hear from our 
first witness today, Mr. Ke'onte Cook, who joins us all the way 
from McKinney, Texas. Ke'onte, I would like to say you are the 
one who came the furthest for this hearing. Mr. Cook is here 
with his mom and dad. I was fortunate to spend some time with 
all of them here earlier this morning, and we look forward to 
hearing a little more about him and his experience in just a 
few minutes. I also hope that today's hearing and what comes 
from it will end up helping kids like him from all across the 
country. So something very good may happen because of your 
appearance here today.
    In anticipation of today's hearing, the Department of 
Health and Human Services sent a letter last week to all 50 
States regarding the proper use and monitoring of mind-altering 
medications for children in the foster care system. The letter 
promises that the Department will convene a meeting of all 50 
States in the next few months to discuss this issue further.
    It is my hope the Department's letter also serves as a 
signal to States that more detailed guidance is coming, 
guidance that reflects the best practices from States across 
the country with regard to the use of mind-altering medications 
to treat children.
    It is also my hope that this letter will lead to solutions, 
solutions that will help to improve the health and welfare of 
some of our Nation's most vulnerable children, foster kids, 
while also saving taxpayers' dollars at the same time.
    I believe there is plenty of blame to go around in this 
report. Unfortunately, it appears that the Federal Government, 
State and local governments, doctors, nurses and perhaps others 
have not kept up with the increased frequency with which mind-
altering medications have been prescribed over the past decade 
for children.
    There also appears to be a lack of cooperation between the 
Health and Human Services Department and the State Medicaid 
programs throughout the country concerning this issue. States 
have worked out piecemeal solutions based on their own 
experiences, and frankly, in at least some cases, those 
solutions were not arrived at until after young lives were 
damaged or lost.
    As I mentioned and as we will hear in testimony today, the 
children discussed in GAO's report are some of the most 
vulnerable members of our society. It is our responsibility to 
take up their cause. As a former governor, I know that the 
foster care system is complex. But that complexity is no excuse 
for not dealing with this issue head-on. We all have a 
responsibility to ensure that the Medicaid program works for 
all children that it serves, whether they are in foster care or 
not.
    I oftentimes describe the 50 States as laboratories of 
democracy. And what this report reveals is that some States are 
managing their program better than others. That should not come 
as a surprise. There are best practices in use in some States 
that really do work in helping foster children. Every State 
should be adopting those practices or tailoring them for 
adoption. In addition, the American Academy of Child and 
Adolescent Psychiatry (AACAP) has promulgated some very good 
guidelines which both the GAO and others site. And if they are 
not already doing so, most States should follow those 
guidelines. What we cannot do is wait for another tragedy to 
happen before we make the right decisions. We cannot stand idly 
by while children's lives or health are potentially put into 
danger.
    Now to be clear, it is important to realize that these 
drugs we will be talking about this morning are often used in 
dire, or even tragic, situations. In most cases, they are 
prescribed as intended and used in an appropriate manner, to 
help children who have experienced significant trauma in their 
young lives. In these cases, there is no doubt about their 
value.
    What is in doubt are the patterns and practices identified 
in GAO's testimony today. What is in doubt is the effectiveness 
and necessity of having children take five or more mind-
altering medications at the same time. What is in doubt is an 
infant being given anti-psychotic medication. In these cases, I 
do not see any gray areas. What I do see is more black and 
white--what is appropriate and humane, and what is not.
    We need to begin the process now of developing a consensus 
about what is appropriate and humane when it comes to 
prescribing mind-altering medications to children and end the 
bad practices that are putting children in danger. We need to 
act quickly before one more child's life or health is placed in 
jeopardy or before one more taxpayer dollar is spent 
inappropriately. Senator Brown.

               OPENING STATEMENT OF SENATOR BROWN

    Senator Brown. Mr. Chairman, that was a very good opening 
statement, and I want to commend you and your staff for 
identifying this issue. One thing I have enjoyed about being on 
this Subcommittee is the wide range of topics that we 
investigate and try to understand and try to do it better. So 
thank you for bringing this up.
    And a lot of what you said is, quite frankly, 
unacceptable--to think that infants are getting drugs one year 
or younger and that somebody is getting five or more mind-
altering drugs at once.
    And foster children, often being removed from neglectful 
and abusive homes, are one of the country's most vulnerable 
populations. When tragic and traumatic circumstances obviously 
define their early lives, it is no wonder the studies show the 
tendency for more mental health conditions than in other 
children.
    I was especially concerned in reading the results from 
Massachusetts, and it is something that I can assure you, Mr. 
Chairman, we will not be taking lightly. We are going to 
immediately try to figure out why Massachusetts in particular 
was much higher than other States that were reviewed.
    And as our witnesses will discuss today, there are few 
options facing folks. For example, the challenges surrounding 
foster care, State authorities, caseworkers, and parents, they 
do not have a lot of options on treatments. I understand that, 
but we know basically from the study that including prescribing 
heavy-duty psychotropic drugs such as antidepressants, and in 
some cases even antipsychotics, are sometimes given first 
rather than as the last option.
    And with the use of these medications, although they have 
been shown to effectively treat mental disorders, the side 
effects and risks that they pose oftentimes outweigh the 
benefits, specifically to children. I, quite frankly, note that 
I do not believe they are well understood.
    That is why we have asked GAO to look at this issue more 
closely, and their investigation has produced some alarming 
results. Not only are foster children being prescribed these 
drugs at a higher rate than the nonfoster kids in general, but 
also in ways that hold significantly higher risks, such as 
multiple medications at once, as you have noted, exceeding the 
Federal FDA recommendations.
    And in Massachusetts, nearly 40 percent of the foster 
children population analyzed in the report were prescribed at 
least one psychotropic drug at a rate almost four times that of 
nonfoster children in my home State. In over 900 cases in 
Massachusetts, foster children were being prescribed three or 
more drugs at once. And while the scope of the report does not 
address the appropriateness of these prescriptions in a case-
by-case basis, it does reignite the debate over whether the 
rates of prescribing match the scientific evidence behind the 
medical conditions.
    So regrettably, the concerns raised in this report are not 
just limited to foster children. Though high risk prescribing 
practices for foster children were found at higher rates than 
nonfoster children in most cases, the significantly larger 
population of nonfoster children covered by Medicaid makes 
these statistics just as alarming. For instance, thousands of 
prescriptions, a total of 5,265 according to the report, were 
filled for infants under one year old.
    When I read that, Mr. Chairman, I said to myself, what? How 
can you do that?
    This is just the data from five States. So we just imagine 
what it is like nationwide.
    And considering that experts have found no mental health 
indications for the use of psychotropic drugs in infants, this 
is particularly shocking and disturbing. As our witnesses will 
testify today, providing these powerful drugs to infants could 
result in serious adverse effects that will potentially affect 
them for the rest of their lives. And the risks seem to me, and 
I believe every member of this Committee, simply too great.
    Medicaid, which is run by the States and administered by 
the Department of Health and Human Services, reimburses the 
costs of these drugs to foster children. And as of today, HHS 
has limited authority to adequately oversee State monitoring 
programs. Well, Mr. Chairman, maybe we need to change that, to 
be that check and balance that they need. As a result, States' 
comprehensive oversight policies are a mishmash of programs of 
various effectiveness, as you also noted.
    Although HHS provides informational resources such as best 
practices to help inform State monitoring programs for children 
in State custody, each Sate is responsible for designing and 
implementing its own program. GAO has examined five States. And 
many of these programs, quite frankly, fall short, and 
comprehensive oversight is desperately needed.
    It is obvious that consistent and comprehensive guidelines 
in this area are needed to ensure and effectively treat and 
reduce harmful risks to children in the Medicaid program, and 
particularly with foster children. In addition, better 
oversight in this area can have a broad impact in reducing the 
fraud, waste and abuse that we have noted for the last year and 
identified in the Medicaid program in general. And every dollar 
we save there can be used in a more effective and cost 
conscious way.
    The Child and Family Services Improvement and Innovation 
Act that recently passed Congress was a good step, but it, 
quite frankly, does not go far enough. I encourage HHS to 
rapidly endorse guidelines and best practices and use its 
current authority to push State Medicaid and child welfare 
agencies to improve as quickly as possible.
    So once again, Mr. Chairman, thank you for holding this 
hearing.
    I look forward to hearing your testimony, young man. I know 
we spoke briefly. Thanks.
    Senator Carper. Thank you, Senator Brown.
    Ke'onte, the way this works, I have the privilege of 
chairing this Subcommittee. I am a Senator from Delaware. 
Senator Brown the senior Republican Member of this 
Subcommittee, and he is from the State of Massachusetts. And 
sitting next to him is Senator Susan Collins from Maine, and 
she is the senior Republican Senator on the entire Homeland 
Security and Governmental Affairs Committee, and she is going 
to make a statement next. Susan.

              OPENING STATEMENT OF SENATOR COLLINS

    Senator Collins. Thank you very much, Mr. Chairman. Let me 
thank you for holding this hearing to examine the potential 
overuse of psychotropic drugs by children in foster care, who 
are covered by the Medicaid program.
    On any given day, more than a half a million children are 
in foster care in our country. Typically, these children have 
been placed in care because they have been abused or neglected 
by their parents. Children in foster care also tend to have 
more serious mental, emotional or behavioral disorders than 
other children. As a consequence, they are exceedingly 
vulnerable.
    I am very troubled by recent reports that the use of 
powerful psychotropic drugs to treat depression, anxiety and 
other mental health disorders is particularly high for children 
in foster care, especially in certain States like Texas. The 
statistics that the GAO found in analyzing Texas are truly 
astounding. In that State, foster children were 53 times more 
likely to be prescribed five or more psychiatric medications at 
the same time than nonfoster children.
    While some children with behavioral and mental disorders 
may benefit from taking these drugs, children in foster care 
appear to be at particular risk of being given too many of 
these drugs and often concurrently. They often experience 
frequent changes in their foster placements and, as a result, 
are much less likely to receive the careful medical and 
psychological oversight that would normally be exercised by a 
parent.
    State agencies also appear to do far too little to monitor 
the use of these medications. That is why I was pleased to join 
my colleagues on this Committee in requesting that the 
Government Accountability Office compare the rates of 
psychotropic prescriptions for foster and nonfoster children on 
Medicaid. We also asked the GAO to review State efforts to 
monitor the prescription of these powerful medications for 
children in foster care.
    According to the GAO, foster children in the five States 
examined were prescribed these powerful drugs at more than two 
to more than four times the rate that these drugs were 
prescribed to nonfoster children who were also participating in 
Medicaid.
    I am alarmed that the GAO found that in hundreds of cases 
five or more psychotropic drugs were prescribed at the same 
time. Moreover, in thousands of cases, the prescribed doses 
exceeded the maximum guidelines.
    Of greatest concern was the finding that my two colleagues 
have already alluded to, and that is that these powerful drugs 
were prescribed to thousands of infants who were less than one 
year old.
    Given the possibility for serious adverse side effects, I 
find it hard to imagine any scenario that would justify the 
prescription of five or more of these powerful drugs to a 
child, and I find it impossible to imagine that it would ever 
be appropriate to prescribe them for an infant. The scientific 
literature supports this skepticism.
    We have a moral responsibility to provide for the health 
and welfare of these children. We provide funding for their 
medical care, for the foster systems that support their welfare 
and for the schools that they attend. Our responsibility, 
however, does not end with just writing the check. That is what 
this hearing is all about. The GAO report suggests that we have 
a long way to go before we have fulfilled our responsibilities 
to these children and young people.
    Earlier this year, Congress did pass legislation to require 
States to establish protocols for the prescription of 
psychotropic drugs to children in foster care as a condition of 
eligibility for Federal child welfare funds. This new law, 
however, does not specify what these protocols should be. As a 
consequence, we found that there is tremendous variation from 
State to State, and none of the States examined by the GAO met 
the standards established by the American Association for Child 
and Adolescent Psychiatry.
    While my first concern is obviously for the welfare of 
these children and for short and long-term impact on their 
health, I am also concerned about the costs involved. Many of 
these drugs are very expensive. If they are being 
overprescribed and needlessly prescribed, it not only has an 
adverse impact on the health of these vulnerable children, but 
it also costs our Medicaid programs a lot of money.
    Clearly, more needs to be done to strengthen the oversight 
of the care provided to children in foster care. The GAO has 
recommended that the Department of Health and Human Services 
endorse best practices guidelines.
    And I think it is not a coincidence, Mr. Chairman, that the 
Department appears to now be acting in light of your calling 
this hearing.
    I look forward to hearing the additional recommendations 
and particularly the testimony of our first witness, and I 
thank you for allowing me to give an opening statement today.
    Senator Carper. We are delighted that you are here. Thank 
you for your comments.
    Ke'onte, those of us who serve in the Senate today have our 
own families in many cases. We have careers that we have spent 
years of our lives on. Senator Brown and I spent some years in 
the military. He was in the Army. I was in the Navy.
    Senator Collins, in addition to serving as a U.S. Senator, 
she did a great job of telling other Senators what to do for a 
number of years, and how to do it well, and she is from Maine, 
as I said earlier.
    One of us, Senator Coburn, who is about to speak next, is 
from Oklahoma, and he is also a physician. Until just a few 
years ago, he still--even as a member of the House and as a 
member of the Senate--still delivered babies. He is what is 
called an obstetrician and gynecologist (OB-GYN) and he has 
done a lot of good work in his life, and he still does. Senator 
Coburn.

              OPENING STATEMENT OF SENATOR COBURN

    Senator Coburn. I am anxious to hear Ke'onte's testimony. I 
will just make one point. Access to a government health care 
program is not access to real care, and we are seeing that in 
this hearing today.
    Senator Carper. Let me now introduce our lead-off witness, 
and his name, as you have gathered by now, is Ke'onte Cook. 
Ke'onte is 12 years old and is a former foster care child. He 
has recently been adopted by Mr. and Mrs. Scott Cook.
    And Scott and Carol, we welcome you two today.
    Mrs. Cook is actually joining Ke'onte at the witness table, 
and I believe Mr. Cook is seated right over Ke'onte's right 
shoulder.
    Ke'onte and his family live in McKinney, Texas, where he is 
now attending middle school. His many interests include 
volunteering, competing in cross country meets, playing the 
clarinet and spending time with his family.
    On behalf of all my colleagues and myself, Ke'onte, we want 
to thank you for being with us here today, and we want to thank 
your mom and your dad for joining us as well. Thank you for 
bringing them with you. All right.
    And with that, you are recognized to say whatever is on 
your mind. Please proceed.

 TESTIMONY OF KE'ONTE COOK,\1\ MCKINNEY, TEXAS, ACCOMPANIED BY 
                       CAROL COOK, MOTHER

    Mr. Cook. Thank you, Mr. Chairman. Chairman Carper, Ranking 
Member Brown and Members of the Subcommittee, thank you for 
allowing me to share part of my life with you today, and my 
experiences with medications during foster care.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Cook appears in the appendix on 
page 48.
---------------------------------------------------------------------------
    My name is Ke'onte Cook. I am 12 years old and in the 7th 
grade. This year, I participated in cross country with my 
middle school in which I ranked in the top 15 of my class, 
allowing me to go to regionals. I am currently first chair for 
clarinets in my band, and I have three small roles in my school 
play, Cinderella, that was showed this month on December 15th--
also, the date for my second year anniversary in my adopted 
home. One of my favorite things to do is dance for fun, 
especially hip-hop and the robot.
    I was adopted 2 years ago in 2009, and I was in foster care 
from ages 6 to 10\1/2\. Besides the medicines, foster care was 
all right to me except for my third foster home. The first two 
foster homes seemed more like they cared about me, but the 
third home always felt awkward, and I felt pressured by them 
when I chose my adoptive home.
    I was pretty ignorant about the medicines I was on at the 
time. I also did not know what type of drugs I was on during 
foster care or how many drugs I was on since I was put into 
foster care at age six. All I knew was that if I did not take 
them like I was told to I could not watch TV, play video games 
or play with my toys.
    About a year after I was adopted, I found out I was on 20 
different drugs total and sometimes I took up to five drugs at 
one time. At one point, I was on Vyvanse 70 milligrams for 
attention deficit hyperactivity disorder (ADHD); Seroquel 200 
milligrams as a mood stabilizer; Guanfacine 2 milligrams for 
impulse control and ADHD; Buspar for depression; and Clonidine, 
0.2 milligrams for insomnia. I have also been told that the 
amounts of some of the drugs I was given were more than most 
adults take.
    Some of the things I was diagnosed with were post-traumatic 
stress disorder, insomnia, ADHD, depression, but I was never 
told I was diagnosed with anything other than the ADHD. They 
seemed way too much for a regular kid, which I am, and I was 
very confused when my adoptive parents told me what I was on 
and why.
    I have been in the mental hospital three times during 
foster care, and every time I had to get on more meds or new 
meds to add to the ones I was already taking. Some of the meds 
were for bipolar and seizures, and I am not bipolar and never 
had a seizure. Sometimes the meds they gave me made me easy to 
get irritated, which I feel is not good for a kid to 
experience. The meds made my appetite go away, too, for a long 
time. I would barely eat anything. I remember having a bowl of 
spaghetti, and I ate about three bites, and then I was done. I 
had side effects no one told me about, no one told me I would 
have or talked with me about before taking a new med. I was so 
out of it when I had the side effects sometimes it seemed like 
it did not bother me at all.
    One time I went to visit my youngest sister in her adoptive 
home. Her mom told me that she did not want to give me my meds 
because it made me glazed and tired. My adoptive parents said 
that when I stayed for my trial weekend with them in October 
2009, my meds put me in a lights-out mode 15 minutes after I 
had taken them. Some of the meds I took made me have 
stomachaches. I would get so tired all of a sudden. It felt 
like I would collapse wherever I was in the house. My foster 
parents would tell me something, and I would not be able to 
process it like a normal person would. Sometimes I would even 
try turning my head away and then closing my mouth to refuse 
taking the meds, but I had to take them eventually.
    I think putting me on all these stupid meds was the most 
idiotic thing I have ever experienced in foster care and was 
the worst thing someone could do to foster kids. I was upset 
about my situation, not bipolar or ADHD, and I think therapy is 
a better choice over meds if meds are not a necessity in that 
moment. And I should know because I went to therapy with my 
adoptive parents for 1\1/2\ years with Dr. Jason Mischalanie, 
an attachment therapist who helped me understand why I acted 
the way I did and to figure out how to react in a better way to 
the things that upset me rather than the way I was doing them. 
Now I am not only more focused in school, succeeding above 
other classmates in reading, band, athletics, not going to the 
office anymore for bad behaviors, and I am happy.
    Chairman Carper, Ranking Member Brown and Members of the 
Subcommittee, thank you for inviting me to Washington, D.C. to 
tell my story.
    Senator Carper. Ke'onte [Applause.]
    We have a lot of witnesses that come before this 
Subcommittee. I do not ever remember having one as young as 
you. And it is rare that we have one as eloquent as you have 
been this morning. Thank you for just an amazing statement.
    Mr. Cook. Thank you too, Mr. Chairman.
    Senator Carper. How long have you been in Washington, 
D.C.--you and your mom and dad?
    Mr. Cook. A day and a half.
    Senator Carper. Have you done anything that was fun?
    Mr. Cook. At the Lincoln Memorial, there is something that 
looked like a slide, and I slid down it and ran into the sign 
that says do not touch. [Laughter.]
    Senator Carper. It turns out I got up early this morning. I 
usually go home to Delaware at night, but I got up early this 
morning. Senator Brown and I like to run and work out, and I 
ran down to the Lincoln Memorial today. It is my favorite run. 
It is 5 miles down there and back.
    And so you are right. I saw a sign that looked like 
somebody knocked it over. [Laughter.]
    I wonder who might have done that, Scott.
    Well, we are glad you are here--
    Mr. Cook. Thank you.
    Senator Carper [continuing]. And hope you have had a little 
bit of fun as well. And thank you for preparing and for joining 
us here today.
    You mentioned in your testimony that you had lived in three 
foster homes before finding the Cooks, or before they found 
you, and you became their adopted son and they became your 
adoptive parents. And I think I understood you to say that your 
experience in the first two foster homes was generally pretty 
good and not so good in the third one.
    Do you recall whether it was in the first home, the second 
home or the third home when you first began taking these drugs? 
Do you have any recollection of that?
    Mr. Cook. It was the first home.
    Senator Carper. And were you taking a lot of them or some 
of them?
    Mr. Cook. I was taking about three a day.
    Senator Carper. Do you recall why the doctors or someone 
thought you should be taking those?
    What was it about your behavior that people thought, well, 
he should be taking some kind of mind-altering drug? What was 
it?
    Mr. Cook. I would throw tantrums because I was upset and I 
could not let it out in the way that I needed to. So then they 
thought, well, let's just put him on meds so he will basically 
be quiet.
    Senator Carper. Ok. And it sounds like you kind of like 
zoned out. Is that what you said? You sort of zoned out?
    It is hard to do well in school when you are zoned out. It 
is hard to do well in the Senate when you are zoned out. 
[Laughter.]
    But somewhere along the line somebody figured out, and 
maybe it is when you came to live with your mom and dad, that 
this was not working and there was a better way to help you 
deal with whatever behavior problems you were having. Who 
helped figure that out?
    And what turned out to be more helpful than taking those 
medicines?
    Mr. Cook. Therapy with an attachment therapist.
    Senator Carper. Can you talk just a little bit about that 
for us, please?
    Mr. Cook. I would go every Saturday, and we would talk 
about how I was doing in school, and we would talk about deep 
conversations about my mom, and that would help me get over my 
anger about my mom.
    Senator Carper. Right. But it worked?
    Mr. Cook. It did.
    Senator Carper. Yes, it worked.
    I have a fellow that--Senator Coburn and I serve on the 
Finance Committee together, and we had a witness. A bunch of 
witnesses came to see us a couple months ago, and they were 
talking to us about how to reduce this big budget deficit we 
have. We are spending more as a government than we actually 
take in, in taxes.
    And one witness was talking to us about how do we get 
better health care results, and he said here is what we should 
do. He said we should find out what works and do more of that. 
That is all he said. Find out what works and do more of that.
    And in this case, we need to find out what works and do 
more of that.
    We have 50 States across this country. In some of those 
States, they are figuring out what works. We need to find out 
what works and, throughout the country, do more of that.
    I said when we had a chance to meet earlier today and talk; 
I said to Ke'onte, you have been--for a guy 12 years old, you 
had a pretty rough ride. It sounds like you have ended up in a 
really good place for yourself and for your mom and dad, but 
you had a rough ride. And a lot of foster kids do in life.
    But I think because of your presence here today a whole 
bunch of kids, thousands of kids across this country, kids that 
are foster kids and kids that are not, are going to have a 
chance for a better life, a more productive life, to be better 
students and to go on and be a real success.
    I just want to ask if I do not know if there might be one 
thing that you would like to pass or share with us, like 
advice. This is like a child advises the elders. So maybe one 
piece of advice you have for all of us here today, one thing 
that you think maybe we could take away from your testimony to 
help more children across the country--what would that one 
thing be?
    Mr. Cook. That meds are not going to help a child with 
their problems. It is just going to sedate them and make them 
tired, make them forget it for a while, and then it comes back 
and it happens again.
    What I learned in therapy is that when you are taking 
therapy you talk about the deepest thing, it hurts, then it 
comes back, but you can handle it better.
    Senator Carper. Well, that is a mouthful. Thank you for 
those words of wisdom.
    And with that, let me turn to Senator Brown. Thank you.
    Senator Brown. Thank you, Mr. Chairman.
    Mr. Chairman, I have seen you run, OK, and I know how fast 
he does a mile, and I think he can beat us both. All right? 
[Laughter.]
    Senator Carper. He can run us into the ground.
    Senator Brown. And that loop is only 3\1/2\ miles, not 5. 
[Laughter.]
    Senator Carper. It is 5. Trust me.
    Senator Brown. OK, I feel better then.
    Well, thank you. Everyone is in a good mood because this is 
obviously a nice young witness.
    And I am curious actually, Mrs. Cook and Mr. Cook. How did 
you identify, obviously, the overprescription? Was it the fact 
that he, in his own words, was zoning out?
    I mean, what led you to take that proactive step to get 
your child back?
    Ms. Cook. We have had about 3\1/2\ years of experience in 
foster care and lots of training, including a little bit of 
training from Nancy Thomas. She actually came and helped teach 
kind of a course at our foster care community, for attachment 
therapy.
    And stemmed from that, we learned. We just got really 
educated fast about how foster kids, they do; they come with a 
lot of baggage. They are sad. Why would they not be sad? Their 
situation is not a happy one.
    And it is so easy to just find something to help them feel 
better for the moment, and that is not the right thing. And 
there are so many ways to help them through consistency and 
just not letting them down and being there for them.
    So really, it was right from the time when we had foster 
care. When we got him, we knew something was off. We knew that. 
The medications--that is terrible. He was just lights-out. That 
was it. You can just tell that there was more to the situation.
    But we only had him a weekend. So of course, we had to give 
him his meds correctly that weekend. But when we got him, we 
asked the physician at his new pediatrician. We said, what can 
we do to start getting him off these things? We need to start 
seeing how he really reacts.
    And he was very interesting for the first few months. He 
gave us some fun times, but that is it. It took a few months, 
and he was already a different child.
    Senator Brown. Well, I could only imagine. Of course, it is 
going to be interesting. He was on some very serious 
medications, affecting a young man. So I want to commend you 
and your husband for taking that step.
    Is this your first adoption from foster care?
    Ms. Cook. Yes, this is our first actual adoption.
    Senator Brown. So what made Ke'onte so special?
    Ms. Cook. Well, we were looking.
    Senator Brown. Get out the earmuffs. [Laughter.]
    Ms. Cook. I have told him this so many times because I 
really want him to know that I really feel like God brought him 
to us because we were originally looking for a little girl, but 
we were not necessarily picky. We really prayed that God would 
bring us who he wanted us to have. And after not having our 
foster kids, it was really hard. So when we moved to Texas.
    Our caseworker, she was amazing. From a refuge house, an 
adoption agency in Dallas, she sent this video, this little 
book. She goes, I know you said you were looking for a little 
girl, but you know, just something about this hit me, and I 
think you should look at it.
    And we did. And it was a Wednesday's Child feature on him, 
and it was actually the second time that he was Wednesday's 
Child. He had been on it 2 years prior.
    And there was a possible adoption from the first time he 
had been seen on it, but it fell through. It did not happen.
    And so, they let him come back 2 years later and do it 
again, and we saw that and his story. He just wanted a home. He 
wanted somewhere to belong. And you could tell from the first 
time to the second time he had a little less hope in his tone.
    And we had looked at some of the other Wednesday's Child 
just because we were on that Web site at that time, and no one 
else hit us like Ke'onte did.
    And we just knew. After the situation of not having the 
girls that we had in Florida, we knew he needed someone and we 
needed someone to need us back. It was just perfect in the way 
that he was brought in so quickly, right before Christmas. It 
was amazing.
    Senator Brown. Great.
    And Ke'onte, I see you are giving the thumbs-up there. That 
is great.
    When you were going through your transition and you were 
being medicated, what are your thoughts or memories about 
transitioning from being highly medicated to where you are now?
    Obviously, I am presuming it was filled with some real 
struggles and battles. So what gave you the strength to 
actually become the young man that you are now and be where you 
are here today, testifying before the U.S. Congress?
    Mr. Cook. It was basically that I had hope that it would 
soon be over and I would not have to go through the same 
struggles that we did during those few months ago. So that 
drove me to get through it, and that is why.
    Senator Brown. Great. Well, thank you for testifying. Good 
luck to you and your family. God bless.
    And I look forward to hearing the rest of the testimony. 
Thank you, Mr. Chairman.
    Senator Carper. Thank you, Senator Brown. Senator Collins.
    Senator Collins. Thank you very much, Mr. Chairman.
    Ke'onte, that must have been a wonderful Christmas present, 
when you went to live with the Cooks and when they became your 
parents. I bet that was one of your best Christmases ever.
    Mr. Cook. Hm. [Laughter.]
    Ms. Cook. You can say it.
    Mr. Cook. It was awkward.
    Senator Collins. It was hard?
    Mr. Cook. I kind of love my DS more, but you know. 
[Laughter.]
    But then I grew attached. So I cannot say anything now.
    Senator Collins. Well, they probably will get better and 
better. That, I am sure of. I bet when you look back you will 
consider it as being a great Christmas present.
    I am curious, when you were put on these medications, 
whether any of the doctors explained to you what the 
medications were for and how you might feel when you were 
taking them. Did they talk to you about that?
    Mr. Cook. They did not say anything.
    Senator Collins. They did not say anything? They just said, 
here is your medications; take it?
    Mr. Cook. Basically.
    Senator Collins. Did your previous foster parents explain 
to you what the medications were for or how you might feel?
    Mr. Cook. Only one. And then they did not tell me how I 
would feel. They just told me what it was for, and it was for 
ADHD.
    Senator Collins. That had to be really scary, not to know 
what you were taking or why you were taking it. And I just 
cannot imagine the doctors piling on drug, after drug, after 
drug without explaining to you what it was for, how long you 
should take it, what the impact might be, how you would feel 
and what you should do if you did not feel well taking it.
    Did any of them ask you--did any of the doctors tell you to 
be sure to come back to see them or call them if the drugs made 
you feel zoned out?
    Mr. Cook. They did, but the foster parents did not go back 
like they were supposed to.
    Senator Collins. I see.
    Ms. Cook, what kind of differences after the very difficult 
transition period did you notice in Ke'onte's behavior once he 
was off most of those medications?
    Ms. Cook. His behaviors were it was just a light and day 
difference. He went from break-dancing on the principal's 
conference room desk in her office to not even going to the 
principal's office for a whole month, in just a short period of 
time. When he started school, it was January to May. He was 
almost a different child altogether.
    He was happy. He was always smiling. I mean even to this 
day he smiles all the time. He is happy. You can tell. Even if 
I give him a consequence--he has to do chores for forgetting 
his homework--he is happy. I mean not to do the chores, but he 
is there with us, doing the chores, almost like you are not 
supposed to enjoy that.
    No, he is happy, and you can tell. And he does not have the 
tantrums. He is not upset for no reason. If he is upset, he is 
upset, and it is a real reason and not just for no reason.
    His tantrums--he would be on the floor and just be wailing, 
or he would tear things up in his room. It was like he did not 
know how to be a real kid. He had been kind of doped up for 4 
years. It was almost like we had to show him what a kid his age 
is supposed to be like.
    Senator Collins. Thank you.
    Ke'onte, I just want to thank you so much for coming here 
today. I think it is very brave of you to tell your story, and 
it is going to help a lot of other children, and it is going to 
help us make sure there are better policies in place.
    So I thank you very much for coming forward
    And Ms. Cook and Mr. Cook, I think you are a great family. 
Thank you.
    Mr. Cook. Thank you.
    Senator Carper. Amen. Dr. Coburn.
    Senator Coburn. Ke'onte, you have a great smile.
    Mr. Cook. Thank you.
    Senator Coburn. It is infectious. Are you on any medicines 
now?
    Mr. Cook. No, not at all, just a couple of vitamins.
    Senator Coburn. Think about that. As a physician, I can 
tell you three of the medicines you were on are contraindicated 
for a child your age, and were not approved, never been 
studied.
    The other thing, looking at these medicines, is each one 
interacts with the other one. In other words, two out of the 
five work against three out of the five.
    So probably the most important question I would have for 
you is about this therapy that you had on Saturdays; did you 
ever experience anything like that while you were in foster 
care?
    Mr. Cook. Not exactly. We would go to a therapist. It would 
more be like a psychiatrist, and basically what we would do, we 
would talk about how the week was going. If we were good, we 
would get donuts or chips, and then we would just quit and then 
play.
    Senator Coburn. But nobody spent the time talking to you 
about the disappointment with your birth mom? Nobody allowed 
you an opportunity to express your feelings about some of your 
anger?
    Mr. Cook. Not at all.
    Senator Coburn. Yes. Has there ever been a time--and maybe 
Ms. Cook, you can answer this. Were you ever on Social Security 
disability?
    Was Ke'onte ever on Social Security disability as a 
consequence of being on these medicines?
    Ms. Cook. Not that I am aware of, no.
    Senator Coburn. OK. All right.
    What would be the message, Ke'onte, that you would have for 
other kids who are not yet adopted that are in foster care that 
are on medicines? What would your experience tell them?
    It is a tough question, I know.
    Mr. Cook. My experience would tell them that there is 
someone coming. You just have to wait for them and sit tight.
    Senator Coburn. That is a great answer. All right. Thank 
you, Mr. Chairman.
    Senator Carper. Well, as we approach Christmas, that 
thought of someone is coming, all you have to do is hold on and 
sit tight, is probably in the minds of a lot of kids your age 
and across the country.
    Fortunately, for a lot of kids your age and younger across 
the country, they have never had to go through what you have 
gone through. They are lucky they were born on third base, if 
you will, and pointed to a home where they had loving, caring 
parents who took wonderful care of them and made sure that they 
had what they needed and, frankly, were not subjected to what 
they did not need and was not good for them.
    I, too, want to thank you very much for joining us today 
and for speaking with the wisdom of someone well beyond your 
years.
    And I just want to say to your mom and dad it is just a joy 
to be here with you, and I think Ke'onte is here representing 
all the good that can come from kids when they have the kind of 
home that you have provided for him. He has received the kind 
of treatment and care that really has helped him. So we thank 
you for being role models on your own.
    And finally, I would say as I said at the beginning, 
Ke'onte, some real good is about to come out of what was not so 
good in your life and the lives of a lot of other kids. Some 
real good is going to come, and not just in Texas, and not just 
in Delaware or Massachusetts or Maine or Oklahoma but in all 50 
States. So you can feel, I think, good and proud of that.
    And as we think about gifts that we are going to send to 
our friends and family this Christmas, I can think of few gifts 
of greater value than that.
    And with that having been said, Mr. Cook, you are excused 
from the witness table and you are free to take your mom and 
dad with you. I understand you have not had any breakfast yet 
maybe, or at least not enough, and so we are going to excuse 
you and you can head out and get some chow.
    And then I guess do you head on back to Texas today?
    Mr. Cook. No, New York. We go talk to Diane Sawyer.
    Senator Carper. Diane Sawyer. Oh, how about that? All 
right. Well, give her our best.
    Mr. Cook. I will.
    Senator Carper. All right. Good luck. God bless. Thanks so 
much.
    Well, we welcome our second panel, all accomplished 
witnesses, some of whom have been good enough to join us 
before.
    I will just say to Senator Collins and Senator Coburn, ole 
Ke'onte is going to be a tough act to follow, but I think this 
panel might be up to it. So I am going to take just a moment 
and introduce each of them and then ask them to go forward with 
their testimony. Thank you all for coming today.
    The first witness on our second panel, Mr. Greg Kutz, 
Director of GAO's Forensic Audits and Special Investigations 
Unit, Mr. Kutz has spent over 20 years at GAO, working to 
uncover abuse of any number of things--government credit cards, 
Hurricane Katrina/Hurricane Rita fraud, problems with U.S. 
border security among any other issues. He has testified before 
us on any number of times. We thank him for agreeing to join 
us, to be here again today.
    If we had to pay you on a per witness basis, our Nation's 
debt would probably be a little higher. So thanks for coming 
and doing this.
    Our second witness is Mr. Bryan Samuels. He is the 
Commissioner of the Administration on Children, Youth and 
Families at the Department of Health and Human Services.
    Prior to his current position, Mr. Samuels served as the 
Chief of Staff for Chicago Public Schools, the third largest 
school system in the Nation.
    Who was the head of Chicago Public Schools when you were 
there?
    Mr. Samuels. I think it is a guy by the name of Arne 
Duncan.
    Senator Carper. Would you say that again?
    Mr. Samuels. A guy by the name of Arne Duncan.
    Senator Carper. What ever happened to him?
    Mr. Samuels. I think he moved to Washington.
    Senator Carper. Yes, he did. He is doing a good job.
    Before that, Mr. Samuels served as the Director of the 
Illinois Department of Children and Family Services where he 
worked daily with the Illinois foster care system.
    Our next witness is Matt Salo, good to see you--Executive 
Director of the National Association of Medicaid Directors 
which represents Medicaid directors across our country.
    And prior to being named executive director, Mr. Salo 
worked on reform and issues at the National Governors 
Association, an organization I am very familiar with. Actually, 
it is an organization I loved being a part of for 8 years.
    And you served there as Health Policy Analyst for State 
Medicaid Directors. Thank you very much for that service too.
    Our final witness today is Dr. Jon McClellan. I understand 
that you go by Jack. A child psychiatrist at Seattle Children's 
Hospital and a professor in the Department of Psychiatry at the 
University of Washington, his research focuses on the 
identification of genes vital to the study of psychiatric 
diseases and the diagnosis and treatment of severe mental 
health disorders in youth.
    Dr. McClellan is a member of the American Academy of Child 
and Adolescent Psychiatry and spent many years on the committee 
there that develops treatment guidelines for patients.
    And again we thank you.
    We thank all of our witnesses for being here. Your entire 
testimonies will be made part of the record. And if you can 
summarize your testimonies, or give your testimonies, within 5 
minutes or so, that would be fine. If you go way beyond that, I 
will have to ask you to sum it up and we will turn it over to 
the next witness.
    Mr. Kutz, you are lead-off witness. Welcome. Please 
proceed.

TESTIMONY OF GREGORY D. KUTZ,\1\ DIRECTOR, FORENSIC AUDITS AND 
  INVESTIGATIVE SERVICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Mr. Kutz. Mr. Chairman and Senator Coburn, thank you for 
the opportunity to discuss the use of psychotropic drugs for 
foster and other children paid for by Medicaid.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Kutz appears in the appendix on 
page 52.
---------------------------------------------------------------------------
    My testimony has two parts. First, I will discuss our 
analysis of psychotropic prescriptions for these children, and 
second, I will discuss state programs to oversee the use of 
these drugs to treat foster children.
    First, as you have mentioned, foster children in the five 
States that we analyzed were prescribed psychotropic drugs at 
rates that were 2.7 to 4.5 times higher than nonfoster children 
in Medicaid in 2008.
    Federal and State officials, academic studies and the child 
psychiatry experts that we contracted with pointed to several 
factors to help explain these differences. For example, greater 
exposure of foster children to neglect and physical abuse often 
leads to mental health conditions that need treatment. Other 
factors include frequent foster placements and varying state 
oversight programs, which I am going to discuss in a moment.
    These higher rates do not necessarily indicate 
inappropriate activity. However, we did identify a number of 
high risk indicators in both groups but more prevalent, as you 
have mentioned, for foster children.
    For example, over 1,700 children were prescribed 5 or more 
psychotropic drugs at the same time. Our experts said that no 
clinical evidence supports this practice, which can increase 
the risk of adverse reactions and long-term side effects such 
as diabetes.
    Over 20,000 children had doses above those set by the FDA, 
which also can increase the risk of side effects without 
providing additional benefit.
    And over 3,500 infants were prescribed antihistamine drugs, 
and a small number were prescribed other psychotropic drugs. 
Whether used for mental or nonmental health conditions, our 
experts expressed significant concern over adverse reactions 
for these babies.
    We will investigate a number of high risk cases and report 
the results back to you next year.
    Moving on to my second point, we found that State programs 
to oversee the use of these drugs for foster children can be 
improved. We reviewed programs in these six States that you 
mentioned against guidelines from the American Academy of Child 
and Adolescent Psychiatry.
    States have no requirements to follow any specific 
guidelines although the recent legislation mentioned requires 
protocols in this area. All six States have programs that cover 
some or many of these guidelines, but none address them all.
    For example, AACAP says that States should identify 
caregivers who can give consent for drug treatment, which all 
States do. However, three States do not require caregivers to 
seek input from the child who is actually taking the drugs, 
which we heard from the first witness.
    Five States have fully or partially established guidelines 
for the use of psychotropic drugs. However, none have fully 
implemented guidance and programs to monitor the rates of 
adverse reactions.
    And AACAP recommends consultation programs that involve 
child psychiatrists meeting with consentgivers, physicians and 
children.
    One State covers all of these guidelines, at least 
partially, while another States covers none. The remaining 
States fall in the middle.
    In conclusion, psychotropic drugs can be an important tool 
to treat mental health conditions. However, evidence supporting 
the effectiveness and safety of these drugs for children is 
limited. We recommend that HHS endorse guidance to the States 
for monitoring the use of these drugs for foster children. More 
consistent and comprehensive guidance should better protect 
these vulnerable children.
    Mr. Chairman, that ends my statement, and I look forward to 
your questions.
    Senator Carper. Thanks very much. Excellent statement.
    Mr. Samuels, please proceed. Welcome.

TESTIMONY OF BRYAN SAMUELS,\1\ COMMISSIONER, ADMINISTRATION ON 
  CHILDREN, YOUTH AND FAMILIES, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Mr. Samuels. Welcome. Chairman Carper and Senator Coburn. I 
want to express appreciation for the invitation to be here and 
to talk to you today.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Samuels appears in the appendix 
on page 94.
---------------------------------------------------------------------------
    This is obviously a serious issue. HHS clearly shares the 
concerns that this Committee has, and we really do look forward 
to working with Congress to address the issues and reform a 
system that cares for the most vulnerable children in our 
society.
    I have to say to you, however, that the issue of 
psychotropic drugs in foster care is not a new issue. It is not 
a new problem.
    I was the Child Welfare Director in the State of Illinois 
between 2003 and 2007. During my tenure, on a regular basis, 
foster parents, adoptive parents, biological family members 
approached me to express their concerns about the impact of 
psychotropic medications on the well-being of their children. I 
can also describe for you examples of visiting residential 
treatment programs where well over 50 percent of these young 
people were being prescribed psychotropics, and I can provide 
you one example in which 100 percent of children in a 
residential treatment program were on a psychotropic drug. So 
again, unfortunately, this is not a new problem.
    I can tell you that when I was the director what I did was 
to put in place a comprehensive oversight process. We had 
strict processes related to informed consent. We trained all of 
our caseworkers and social workers on all of the necessary 
procedures. We established an independent review of all 
prescriptions made for children who were in foster care, and we 
established an electronic database that captured every child in 
the State that was on a psychotropic. That electronic database 
allowed us to also review patterns of prescription and to look 
at particular prescribers to identify whether they were engaged 
in practices that we believed to be inappropriate.
    Now I would like to try to tell you, or convince you, that 
I took these steps because of my great child welfare expertise. 
I cannot tell you that. The first day on the job as Director of 
Child Welfare was the first day I had ever worked in child 
welfare. However, I can tell you that I spent the last 26 years 
of my life on high dosages of psychotropic medications. So I 
both appreciate the benefits that come from being on a 
psychotropic as well as the side effects.
    I also have the same challenge that has been mentioned 
earlier, which is I, too, worry about the long-term effects of 
psychotropics on my own health and well-being. So I do 
appreciate the challenge that we are talking about here, and I 
really do believe that there are things that States can do to 
correct their practices and to operate more effective programs.
    And I have to tell you part of our response to 
psychotropics also involved expanding the array of services 
that children had. We found that there were many children in 
the State of Illinois that were being misdiagnosed with a 
mental illness and being prescribed psychotropics that were 
intended for adults. In reality, much of the behavior that 
these prescriptions were being made for were behaviors that 
were better explained by the trauma that comes from abuse and 
neglect and the trauma that comes from a child being removed 
from their homes. And so, instead of continuing to focus on an 
acute approach to intervening in the lives of these young 
people we put in place more therapeutic interventions that had 
the basis of evidence to demonstrate that they were both 
appropriate and safe for children in foster care.
    So again, unfortunately, this is not a new problem.
    If you go to the Internet, any Web site--try Google--and 
type in child welfare and psychotropics, you will see hundreds 
of articles that pop up. They go back to the mid-90s, and they 
articulate even in the mid-90s that there were more than 13 
percent of children in foster care that were prescribed 
psychotropics. So it is an important point to be made.
    I provided you three slides. I will not go into them in 
great detail, but what I will tell you is that this data comes 
from the National Survey of Child and Adolescent Well-Being. It 
is a study that has been funded by Congress for the last 8 
years. From this study, there have been articles published 
beginning in 2004 that document that more than 12 percent of 
all children in foster care were prescribed psychotropics.
    More recent data from this study demonstrate that about 16 
percent of children between the ages of 11 and 17 known to 
child welfare are being prescribed psychotropics. More than--
almost 20 percent of children who are between the ages of 6 and 
11 known to child welfare are being prescribed psychotropics. 
And most importantly, almost 50 percent these of children who 
are being prescribed psychotropics are being prescribed more 
than two psychotropics.
    The other slide also intends to show you that this issue of 
prescriptions cuts across all placement types so that the 
children that are remaining in their home but being provided 
child welfare services (CWS) versus children that are being 
removed from their homes and placed with foster care parents, 
in both instances, the rate of psychotropic prescription is 
almost identical. So this issue cuts across all placements in 
child welfare.
    So I am going to summarize by just making five quick points 
about the steps that HHS is prepared to take to address this 
issue.
    First, we do support the recommendation of the GAO, and we 
will take steps in the next 90 days to provide specific 
guidance to States about putting into place the appropriate 
protocols and procedures to oversee psychotropics.
    We also are committed to doing consumer education. We want 
to make sure that foster parents, adoptive parents and 
biological parents understand the drugs that their children are 
being prescribed, and we want the young people to understand 
the prescriptions that they are being prescribed.
    We also will put in place, and will work with States to put 
in place, the kind of oversight activities that actually make 
them better, that put them in the possession of real data so 
that they can make good decisions.
    We also are prepared to provide support so that States are 
much more effective at screening, diagnosing and treating 
issues related to trauma and exposure to violence.
    And we already know--we know this from the Centers for 
Disease Control (CDC), we know it from the Substance Abuse and 
Mental Health Services Administration (SAMHSA) and we know it 
from the National Institute of Mental Health (NIMH) that there 
are evidence-based practices, therapeutic practices, 
psychosocial interventions that work for almost all of the 
issues that children in foster care have.
    We are prepared to take these steps. We welcome the 
opportunity to have further conversations with Congress about 
additional steps that we can take to meet the needs of children 
who are absolutely the most vulnerable young people in our 
society.
    So thank you, Chairman.
    Senator Carper. Thank you for sharing that testimony and 
for giving us a glimpse into your own life and the relevance. I 
think it is especially appropriate that you are a witness here 
today. Thank you.
    Mr. Salo, please proceed.

    TESTIMONY OF MATT SALO,\1\ EXECUTIVE DIRECTOR, NATIONAL 
               ASSOCIATION OF MEDICAID DIRECTORS

    Mr. Salo. Great. Thank you, Chairman Carper and Senator 
Coburn. We appreciate being invited to testify here today. I 
wish it were on a happier issue, but I do think that the silver 
lining is we are laying the groundwork for trying to do better, 
which clearly is what we need to do.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Salo appears in the appendix on 
page 113.
---------------------------------------------------------------------------
    Medicaid is the Nation's health care safety net. It is 
jointly financed by the States and the Federal Government and 
will spend more than $400 billion this year providing health 
care to more than 60 million people. And it is administered by 
the States under broad Federal guidelines, which leads to 
enormous variation across the States. We have talked about that 
a little bit. But it is also a very complex program within any 
given State.
    But the one piece that obviously we are talking about here 
is the fact that Medicaid is essentially the sole funding 
source for health care for kids in the foster care system.
    Now pharmaceutical coverage and expenditures have been a 
large and growing concern of the Medicaid directors for a 
number of years. Psychotropics, in particular, pose a unique 
concern because the trends in the costs and utilization are far 
outstripping every other baseline. And analysis of the data 
shows us that this is due to a variety of reasons, some of 
which are legitimate, some of which, less so.
    And clearly, we have talked a little bit about 
overutilization and misutilization, and the challenge is we are 
seeing this everywhere. We are seeing this in adults. We are 
seeing this in seniors. We are seeing this in kids. And as 
clearly noted in the GAO report, it is particular true for, 
quite frankly, some of the most vulnerable kids in our 
country--kids who are in foster care.
    Psychotropics show an enormous amount of promise in 
treating very serious concerns. But obviously, there are clear 
concerns with how current prescribing patterns can negatively 
impact this very vulnerable population. And the report pointed 
out several potential problems, and they must be taken very 
seriously.
    And I want to be very clear that there is no question that 
subjecting the most vulnerable people in our society to bad 
medicine is unacceptable and that we can and should and will do 
better by them.
    But I also want to sort of lay out that this is not just a 
Medicaid challenge, that this is, quite frankly, a result of a 
number of serious flaws in the broader U.S. health care system:
    The prescribing patterns in this country today, from 
physicians and others;
    The serious shortfalls in clinical research to tell us how 
are we supposed to treat kids as opposed to adults let alone 
children in the foster care system.
    Quite frankly, as talked about, a lack of effective 
oversight from a variety of levels of government, and on behalf 
of the State agencies, we accept that and we take that on and 
we will try to do better;
    But also includes the lack of widespread health information 
technology which can try to really put a hold on questionable 
prescribing patterns.
    And then at the end of the day, the fragmented nature of 
the relationship between acute care and behavioral health care 
in this country.
    And so, the solutions that we need to embrace are going to 
have to involve all of these pieces--a variety of levels of 
government, mental health professionals, primary care 
practitioners, researchers and others.
    I want to highlight a couple of sort of unique challenges 
and then talk about a couple of quick solutions.
    One of the things that States face in trying to do proper 
oversight of this is resistance in the community. It is no 
surprise that trying to do things like prior authorization, a 
common-sense tool for very serious medications like this, is 
sometimes completely prohibited at the State level. This is due 
to influence of the manufacturers. This is due to the influence 
of advocates. This is due to the influence of the general 
public who do not like to see government get in between a 
patient-physician relationship. These are all legitimate 
issues, but they do lead to challenges in trying to lay out 
some oversight here.
    And as has been mentioned, the unique situations that these 
kids face in the foster care system and the reasons why they 
are in the foster care system to begin with really is a result 
of a variety of traumas which are under-diagnosed and really do 
require specialized treatment approaches.
    So in light of time, I would just sort of lay out a couple 
of different solutions.
    The GAO recommended additional Federal guidance. We 
absolutely welcome that and are going to work with all of the 
different parts of HHS, whether it is the Medicaid side, the 
Administration for Children and Families (ACF) side, SAMHSA, to 
try to work with that. We embrace that.
    But we clearly need more clinical research on how these 
drugs affect kids. We need to do more to break down the 
barriers to trying to do coordinated care for the most fragile 
and vulnerable people in this country, whether it is the dual 
eligibles, whether it is adults with chronic conditions or 
whether it is kids in the foster care system. And whatever 
Medicaid can do and should do, we also need to make sure that 
the medical community and their representative associations are 
also at the table. And then finally, I pledge that through our 
association we will work to try to not only develop--identify, 
develop, disseminate best practices in this area across the 
country.
    So I look forward to answering your questions, and thank 
you for having me.
    Senator Carper. Thank you, Mr. Salo.
    Dr. McClellan, I am going to slip out just for a minute to 
say goodbye to Ke'onte and his family. You go right ahead. I 
will be back within less than minute. OK. Thank you.

TESTIMONY OF DR. JON MCCLELLAN,\1\ CHILD PSYCHIATRIST, SEATTLE 
                      CHILDREN'S HOSPITAL

    Dr. McClellan. Thank you, Mr. Chairman and Senator Coburn. 
Thank you for inviting me today to participate in this 
important discussion regarding the use of psychotropic 
medications in foster children.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. McClellan appears in the appendix 
on page 119.
---------------------------------------------------------------------------
    As noted, I am a child psychiatrist at Seattle Children's 
Hospital, a professor at the University of Washington. I am 
also the Medical Director of Child Study and Treatment Center 
which is the State psychiatric hospital for youth in Washington 
State.
    The high risk practices identified by the GAO study raise 
significant concerns regarding the treatment of severely 
mentally ill and vulnerable youth. Although the focus of the 
study is on foster care, the concerns raised are relevant to 
all children and adolescents prescribed psychotropic drugs.
    Children in foster care often have emotional and behavioral 
difficulties. The high rate of medication used in this 
population is not a new discovery nor does the use of these 
drugs always imply bad practice. Several psychiatric 
medications have been studied and approved for use in children 
and adolescents. When used correctly, these treatments can help 
reduce suffering and enhance the functioning of young people.
    However, it is also well documented that many children in 
the child welfare system do not receive high quality 
psychiatric services. Treatment too often occurs during times 
of crisis without adequate support or access to skilled 
clinicians and programs capable of providing effective social 
and behavioral interventions. In these situations, the 
medications become stop-gaps used to prevent the child from 
hurting themselves or others, or to help control disruptive 
behavior that threatens the child's foster placement. The lack 
of effective long-term treatment exacerbates the risk for 
excessive an inappropriate medication use.
    This problem is evident in the problems of high risk 
prescriptions identified by the GAO study. As a group, children 
in foster care were more likely than other children to be 
treated with multiple psychiatric drugs and were also more 
likely to be treated with dosages that exceed recommended 
standards of care. These practices impacted thousands of 
children. Some young people were prescribed as many as 10 
different psychotropic drugs at the same time per the data. 
Some children younger than 5 years of age were prescribed as 
many as five different medications concurrently.
    Unfortunately, these practices are not uncommon. In my 
State hospital, kids are often admitted taking four or more 
medications. A few years ago, one young boy admitted to Seattle 
Children's Hospital was taking 13 different psychotropic drugs. 
There is no research that justifies these practices.
    The most troubling finding of the GAO study is the use of 
psychotropic drugs in infants. Most of the prescriptions in 
babies were for antihistamines, some of which may have been 
used to treat other types of medical problems. Regardless, 
there is little research supporting the use of these medicines 
in very young children and the prescriptions remain concerning.
    Furthermore, dozens of babies were prescribed 
antipsychotics, antidepressants, Clonidine or Lithium. Some 
infants were prescribed more than one drug. The use of 
psychotropic medications in babies defies both standard of care 
and common sense.
    The findings of the GAO study strongly suggest the need for 
better oversight. The best principles outlined by the American 
Academy of Child and Adolescent Psychiatry provide a useful set 
of monitoring guidelines.
    Washington State had implemented a model system to oversee 
psychotropic drugs. Criteria were developed to identify 
prescriptions that exceed safety thresholds based on dose, 
number of medications and age of the child. For prescriptions 
flagged by this process, a second opinion by a child 
psychiatrist is required before the medication is dispensed. 
This oversight system has reduced high risk prescriptions and 
over a two-year period saved the State $1.2 million.
    The results of the GAO study also strongly call for more 
research. A hodge-podge of prescribing practices occurs in part 
because none of our current treatments work well enough. 
Genetics and neurobiological sciences have advanced 
substantially over the last decade, in large part due to the 
leadership of the National Institute of Mental Health. 
Nonetheless, given the marked complexity of brain functioning, 
the underlying causes of most psychiatric illnesses remain 
unknown. Without known causes, research on intervention 
inevitably struggles. We need continued investment, both fiscal 
and intellectual, in order to develop safer and more effective 
treatments and to eventually find cures.
    Thank you for listening and look forward to questions.
    Senator Carper. Dr. McClellan, thank you. Senator Coburn.
    Senator Coburn. Thank you.
    I am going to have to leave, and I am going to submit some 
questions to the record for each of you.
    Dr. McClellan, thank you for being here. Your expertise is 
important in what we are talking about here, for a lot of our 
foster kids do not have true organic disease outside of the 
trauma they have experienced. Not many of them are 
schizophrenic. Not many of them have true bipolar disease. But 
what they have is situational disease based on what has 
happened.
    In your opinion, is it a shortfall in what we have set up 
through Medicaid that we do not have the type of psychotherapy 
versus drug therapy to work on some of these problems, and what 
would be your recommendation if we had the resources available?
    What would you do to change this to where we actually put 
the resources not just in the research but in the actual 
treatment? Because what we heard from Ke'onte is he is not on a 
drug now and yet he had all these diagnoses which probably 
psychotherapy has helped cure. Plus, the situation has helped.
    Can you help me with understanding this?
    Dr. McClellan. No, it is an excellent point. The system of 
care is not adequate built around--it is not just kids in 
foster care or the welfare system. The entire system of 
psychiatric services for kids is not well organized, they are 
not organized enough.
    There are a number of evidence-based care, evidence-based 
psychosocial treatments that have been shown to work in kids. 
It is hard to access them. It is hard to find providers that 
can do them. There is a long waiting list, and many communities 
have no one in the area that can provide it.
    Senator Coburn. So we have a shortage, first of all, of 
child psychiatrists?
    Dr. McClellan. Child psychiatrists.
    Senator Coburn. And child therapists?
    Dr. McClellan. Well, child therapists capable of providing 
these kinds of psychosocial interventions.
    Senator Coburn. Right.
    Dr. McClellan. And so, accessing them, finding skilled 
providers and then finding consistent providers over time with 
a wraparound team that stays with the kid over time is really 
what is needed. It takes an investment in the front end, but 
you will not only have better outcomes, but you will keep kids 
off the medicines that they do not need.
    Senator Coburn. Yes, and you will have continuity of care 
which is probably one of the most important things.
    Dr. McClellan. Yes.
    Senator Coburn. The Cook family actually got continuity of 
care to Ke'onte in terms of his therapy. It was consistent. I 
guarantee you they had him there. They had the same therapist 
working with him all the time. They built a relationship and 
trust which allowed the therapy to actually work.
    There is no evidence that psychotropic drugs, not 
antihistamines but true psychotropic, are effective or 
indicated in infants, correct?
    Dr. McClellan. There are absolutely, that I know of, no 
studies at all that have ever--it would not make any sense to 
study it.
    Senator Coburn. So that is one thing that can be fixed 
tomorrow. That can be a ruling coming out of HHS--this will not 
happen, and we will not pay for it. So that is something that 
could be fixed tomorrow.
    I will have a couple of other questions for you.
    Again, you all do not know how valuable Dr. McClellan is 
and how few of him there are.
    Dr. McClellan. You should tell my children that.
    Senator Coburn. I will.
    In my practice, finding a child psychiatrist when it is 
really needed is so difficult to get. And it is not just in a 
foster home. It is in an insurance-paying patient, to find 
that. So one of the things we have to do is create the funds so 
there are more Dr. Jack McClellans. We have to do that because 
we have a need.
    The second point I will make before I run--most of the 
time, are symptoms of a greater problem, which is the family 
destruction in our country. And we are treating symptoms rather 
than some of the underlying problems. So we have to bear that 
in mind. Although we address treating the symptoms, we also 
need to go back and see what we can do in terms of firming that 
up. That is our biggest cultural problem, which we are paying a 
tremendous amount to do.
    Dr. McClellan. It is true that the best intervention 
Ke'onte got is from his new parents.
    Senator Coburn. Yes. Mr. Samuels, thank you for your 
testimony. HHS--the law states HHS says the States have to have 
a plan.
    Mr. Samuels. It does.
    Senator Coburn. But there is no regulation at HHS that says 
you all have to oversight that plan and look at it and do the 
oversight. Is that correct?
    Mr. Samuels. What we are required to do, again by statute, 
is to make sure that a State has a plan.
    Senator Coburn. Yes.
    Mr. Samuels. We do not have authority to intervene or to 
determine whether a plan is consistent or inconsistent with 
best practice.
    Senator Coburn. OK. But that does not mean you cannot 
create a regulation that says you are going to submit your 
plans, we are going to look at the plans and then do the 
oversight to compare what their performance is against their 
plan.
    Mr. Samuels. That is correct. And in our response to the 
GAO report we indicated that we would put out an HHS-endorsed 
protocol and we would do that in the first 90 days. But the 
larger consideration is whether you start a regulatory process 
today that would lead to a single standard for which all States 
would have to meet.
    And the reality is--and again, it is the right thing to be 
talking about, but the reality is the Federal regulatory 
process would require about a year and a half's period of time 
in order to have that single confirmed standard that we could 
apply to all. And so, we are going to start with the guidance 
but move in as specific a direction as we can as it relates to 
holding States accountable.
    Senator Coburn. OK.
    And Mr. Kutz, thanks for the study. You guys do great work.
    Mr. Kutz. Thank you.
    Senator Coburn. I am for you. I think you all know that.
    Mr. Kutz. We are aware of that.
    Senator Coburn. I have lost my thought. I am having a Rick 
Perry moment. [Laughter.]
    I think what I would like to know is in terms of where we 
have all these medicines used and the costs associated with the 
medicines and how that impacts, not just in terms of child 
psychiatry, is there--I guess the point is did you look at who 
were writing the prescriptions because my guess is the people 
with the qualifications to write a prescription were not 
necessarily the people with the qualifications to actually give 
the prescription and make the judgments. Somebody untrained in 
child psychiatry, like me, might have been writing the 
prescription because that is who was available. So the 
expertise in terms of making that judgment did not follow.
    Did you look at who was writing the prescriptions?
    Mr. Kutz. No, but as I mentioned in my opening statement we 
are planning to delve into some of the high risk cases and we 
will look at that as part of that, along with the diagnoses and 
whether the State controls worked, et cetera. So any input you 
have into that----
    Senator Coburn. I think what you are going to find is 
people like Dr. Jack McClellan were not the ones writing the 
vast majority of these prescriptions. It was people not trained 
in child psychiatry, not clinically, did not have the clinical 
expertise to be doing what they were doing. And what they were 
doing was treating a symptom rather than a disease. What can I 
do to solve this problem for this foster parent.
    We have such a shortage of qualified people to actually 
address these, and so, I would love to make sure that you do 
that so we end up getting to see----
    Mr. Kutz. Yes, any input you have----
    Senator Coburn [continuing]. What the source was.
    Mr. Kutz. OK. Any input you have into that with your 
expertise, we would be happy to meet with you to go over that, 
but that would be something we can build into our plan at this 
point, yes.
    Senator Coburn. OK.
    Mr. Samuels. Senator Coburn, it is worth noting that 
through the National Survey of Child and Adolescent Well-Being 
(NSCAW), the study that I described earlier that Congress 
funds, we actually do track who is making the prescription, and 
so it could be an important database for GAO to consider in 
terms of trying to get their arms around that data 
specifically.
    Senator Coburn. Yes. I would just tell you my practice 
wasn't limited to delivery of babies. I did a wide family 
practice. And I never once felt comfortable giving an 
adolescent any psychotropic drug. So I did not because I did 
not feel competent to do it, and so I always tried to get a 
referral to somebody that was more competent than me.
    And in our work day today, that is not happening. So we are 
not deferring to somebody of better training and more 
qualification as we treat. What we are doing is throwing a 
medicine at a symptom rather than treating the underlying 
problem.
    And I apologize for having to leave. Thank you, Mr. 
Chairman.
    Senator Carper. Those were great questions and points.
    As Mr. Kutz knows, what we do here in this Subcommittee, 
week after week, month after month, is to try to drill down on 
how to get better results for less money. And today, we are 
especially focused on better health care results for less 
money.
    Dr. Coburn raised in his comments and questions the notion 
of whether or not any infant, any child under the age of one, 
should be taking these psychotropic or mind-altering drugs and 
suggested that is something that is inappropriate, that it 
should not be allowed, that we can stop that fairly easily.
    Let me ask--and I will just start with Mr. Samuels if I 
could--is it that easy?
    Mr. Samuels. It is not that easy. In many respects, what we 
could do today is to provide States the guidance that they 
would need to make their own decisions. We do not currently 
have the authority to either prescribe a specific set of steps 
that they take nor do we have the authority to intervene on any 
particular patterns of psychotropic prescriptions that we might 
find in the data. And so, it would require an act of Congress 
if you wanted us to be able to immediately intervene and stop 
the practice of making prescriptions to infants.
    Senator Carper. Let me just ask anyone on the panel. Mr. 
Salo, do you want to comment on that, please?
    Mr. Salo. Sure. I think Bryan is right. I mean one of the 
challenges is in the law itself. One of Medicaid's challenges 
is we are required by law to cover essentially every drug that 
is approved by the FDA, with very few exceptions.
    We can do prior authorization, and I think that is a key 
best practice that we have talked about in certain 
circumstances.
    Senator Carper. Talk about that. How would it work?
    Mr. Salo. So in an instance where you have a prescriber who 
is looking at prescribing a psychotropic for a child under one, 
which in most cases sounds horrible although I do know that 
there are some instances in which that turns out to be 
Benadryl, that might be--
    Senator Carper. I am sorry. In some instances, that turns 
out to be what?
    Mr. Salo. Benadryl.
    Senator Carper. Benadryl, OK.
    Mr. Salo. That might be more legitimate. So just sort of 
doing a blanket ``you cannot do any of this'' may not work.
    But under the current system, if a prescriber chooses to do 
something more, a stronger medicine for a young child, some 
States are putting in place things called--they have a variety 
of names, but prior authorization or red flags, in which the 
system sort of says: Wait a minute. You just dinged. You 
prescribed this perhaps inappropriate drug for this patient.
    And then, that sets off sort of a warning at which point a 
couple of different things can happen. Either the physician 
then has to say: No, I really know what I am doing. This is the 
right thing.
    And they push it through.
    Or, you have sort of a more kind of comprehensive peer 
review team where the State agency or other peers will sort of 
give feedback back to that prescriber to say: You just did X. 
Are you aware that maybe Y or Z might be more appropriate?
    So those kinds of things can work. I think those are key 
best practices. Probably easier to do those than just outright 
prohibitions under the current law, although, as I had 
mentioned earlier, you do run into challenges at the State 
level sometimes, trying to do those types of controls. Some 
State laws just outright prohibit you from doing that for a 
variety of reasons that I mentioned.
    Senator Carper. You say that some State laws actually 
prohibit--
    Mr. Salo. So some State laws actually prohibit prior 
authorization--
    Senator Carper. Oh, really?
    Mr. Salo [continuing]. For example, for atypical 
antipsychotics because it is the view of the State legislature 
that this is for a variety of reasons, whether driven by the 
manufacturers of the drugs who do not want people saying you 
should put any barriers up or whether it is just sort of a 
community sense that you know what, we should not have 
government involved in this patient-physician relationship.
    So State legislative laws are not set in stone. They can be 
changed, but they require a different kind of tactic than some 
of the best practices we have been talking about here.
    Senator Carper. All right.
    Dr. McClellan, any comments on this point?
    Dr. McClellan. I do not know anything about the State laws 
other than the State of Washington. We did set up a system 
where if you want to prescribe an antipsychotic to a child 
underneath the age of six it requires a second opinion. And 
there is a process in place where there is a group of child 
psychiatrists mostly through the university. And there is a 
form. There is a phone call.
    And sometimes they are approved, and sometimes they are 
not. But that process has definitely helped with high risk 
prescriptions, and it has reduced the use of antipsychotics in 
younger children.
    Senator Carper. OK. Thanks.
    Does the introduction of electronic health records (EHRs) 
have the potential for being a valuable tool in ensuring that 
children at very early ages are not administered these drugs 
and particularly in ensuring that children at younger ages, 
whether they are foster kids or not, do not receive a toxic 
mixture of these drugs?
    My mom, who is now deceased, passed away about 3 or 4 years 
ago, and she had Alzheimer's disease. She had heart disease, 
arthritis, all kinds of problems in a lot of years of her life.
    With my sister in Kentucky and me in Delaware and my mom in 
Florida, what we did over time is we increased the around-the-
clock care for her within her home.
    We kept her medicines in what looked like one of my dad's 
old fishing tackle boxes. Some of you have probably seen these 
before. And it was divided into medicines before breakfast, at 
breakfast, between breakfast and lunch, at lunch and so forth 
throughout the day. We kept it under lock and key because she 
would forget what she had taken and what she had not.
    And she had about five different, maybe six, doctors down 
there. About every other month, my sister and I would take 
turns going down to be with her, go visit her doctors and all. 
It turned out none of the doctors ever talked to each other, 
and all the doctors were prescribing these different medicines 
and did not know what the other doctors were prescribing.
    My guess is if it happened with my mom it is probably still 
happening with a lot of these kids. And my sense is that we did 
not have electronic health records for my mom, but we ought to 
have them for a lot of patients today, including a lot of 
children.
    Would you all, whoever wants to, just talk about how this 
can help us in this particular concern, how to address this 
particular concern?
    Mr. Samuels. What I can say is that at HHS we did bring 
together a broad group of entities within the umbrella of HHS 
to look at this issue, and the Centers for Medicare and 
Medicaid Services (CMS) did identify electronic records as a 
potential solution to part of this issue so that you could in 
real time monitor the decisions that were being made by 
clinicians. It would provide a great resource.
    As I indicated, in Illinois, we created a system where we 
had an electronic database that had all of the children in 
foster care who were on psychotropics. It also had what 
psychotropics they were on, and who was prescribing them. So it 
allowed us to see where there are going to be interactive 
effects, where there are going to be issues of that child being 
on multiple psychotropics from different doctors, and it also 
allowed us to flag doctors who were clearly exceeding what 
would be best practice and intervene specifically with them.
    So it was a great tool for us. Electronic records represent 
a real resource and asset in trying to address this issue in 
real time.
    Senator Carper. Right.
    Mr. Salo. Yes, no question. That is absolutely right. It is 
a key ingredient. It is not the panacea. It is not a silver 
bullet. It has to be a part of trying to look more holistically 
at how we are delivering care because you cannot just have a 
health record and then continue to treat behavioral health 
issues as completely separate from physical acute care. It is a 
part of that mix.
    And I think one of the things that it could help resolve, 
one of the States that I talked to in preparing for this, one 
of their frustrations was in trying to build the capacity of 
the child welfare caseworkers and staff in this particular 
issue.
    These are really hardworking folks, but for the most part 
they are college educated. They have a Bachelor of Arts (BA), a 
Bachelor of Science (BS) and in many cases, a Master in Social 
Work (MSW). But if they are put in situations where they are 
having to countermand decisions made by practicing physicians, 
PhDs, et cetera, there are identified, clear liability issues 
for the State staff, and so they had to back away.
    If you build that kind of thing into an electronic system, 
you do not really have that kind of problem. So, yes.
    Senator Carper. Senator Brown.
    Senator Brown. Thank you, Mr. Chairman.
    I think there are issues. Reading the report, I really was 
shocked at the results, especially as it affects Massachusetts 
as I referenced earlier.
    I look at it as there are a couple of different tiers here. 
One is what is the best interest of the child. In listening to 
the witness, the young man who spoke before us, and 
recognizing--I think he indicated he was on 20 different drugs 
at one point. It is abuse. It is child abuse. It is medical 
malpractice. And it is also; if you take the reason that we are 
here, it is the cost to the government too, the taxpayer 
dollars that are paying for this abuse and this malpractice.
    In listening to you, Mr. Samuels, you indicated that there 
is no authority to kind of fix it. Well, I mean, do you want 
the authority to fix it? Do you want that authority?
    Is it something you want us to start working on, or what?
    Mr. Samuels. Sure. So let me be clear. I am not suggesting 
that we cannot go a long way in fixing the problem, and I think 
we have articulated some of the steps that we could take.
    But clearly, yes, this is a problem that we are all 
concerned about, and it is something that we need to fix. And 
if Congress was given the opportunity or we were given the 
opportunity by Congress to fix this problem, we would move 
aggressively to do so.
    Senator Brown. That being said, Mr. Chairman, I would ask 
that you--Mr. Samuels--that you actually provide us with the 
tools that you need to do your job. If that is something that 
we can get to the Committee Chair, we will look at it and see 
if we cannot get support because, I mean, I felt heartbroken 
listening to the previous testimony.
    And I am saying to myself: OK, now. So how does something 
like that happen? Where is the breakdown?
    If you do not have the authority to fix it, who has the 
authority? Are you saying the States have the authority?
    In the State of Massachusetts, I have already sent out the 
letter today, based on this hearing, saying how does this 
happen and who is responsible and how do we fix it? That is one 
of the things that we have always tried to do here.
    So could I ask that you and whoever else would have an 
interest in this get this information to us?
    Mr. Samuels. We would both put together a set of 
recommendations as well as work with your staff to craft a 
solution that this body could support and move forward.
    But can I make one other point which I think is really 
important here?
    Senator Brown. Sure.
    Mr. Samuels. I think it is really important to recognize in 
the larger child welfare context that over the last 14 years 
most of the energy, both in terms of Congress as well as the 
States, has focused on the issue of reducing the size of the 
foster care system. So we have focused more on trying to 
resolve issues of permanency and get kids home than we have 
focused on what is their social and emotional well-being and 
what contribution does the child welfare system have to make to 
it when it removes them from their home or validates that they 
have been abused or neglected.
    So another strong message that this Subcommittee could 
send, both to the other Members as well as the broader country, 
is that we have an obligation to do more than just do safety 
and permanency. We have an obligation to affect the mental and 
physical well-being of children and that means addressing the 
exact issues that you see before because in many instances the 
assumption is well, if we can just get them medicated long 
enough and stabilize them long enough we can find a solution, 
move these children to that solution and then somebody else 
will make sure that they are OK.
    And I think we have a Federal obligation to say that this 
is unacceptable and that all of us should be working toward 
their well-being. Whether they leave the system through 
adoption, guardianship or they age out, we all have an 
obligation to work to their well-being.
    Senator Brown. In listening to the testimony and reading 
the reports and referencing other reports that have been done, 
how do you consider it in the best interest or the well-being 
of the child when you are basically overmedicated to the point 
as was referenced in our earlier testimony as being a zombie 
and being glassed over and having no knowledge of what is going 
on really and having no ability to function as a young child?
    Do you even have any ability to get out of that cycle of 
abuse and neglect. Are you talking stabilizing, or are you 
talking about just overly drugging to the point where they are 
just vegetables and they are going to do whatever they are 
told?
    It is basically, hey, here is another pill. Just go in the 
corner and shut up. Play with your Nintendo or whatever.
    But at that point, they cannot even do that they are so 
drugged up.
    So I do not disagree with you, I think it is important to 
get that information.
    And Dr. McClellan, you are the expert here, I mean, and we 
obviously have Dr. Coburn who is an expert on everything 
apparently.
    Dr. McClellan. It is a good job. [Laughter.]
    Senator Brown. That is going to cost me. That will be on 
the front page of something, I am sure. But all kidding aside, 
he is a great man and has a working knowledge of everything.
    That being said, I enjoyed listening. I am bouncing back 
and forth because we are dealing with the defense 
authorization.
    But in hearing his testimony, in hearing him up here 
speaking to Senator Collins, it is clear that the drugs were 
counterproductive. They were reacting to each other. No wonder 
Ke'onte was taking insomnia pills, sleeping medication, because 
the drugs that he was taking were firing him up so much.
    Is there any instance at all that some child under one year 
old would be given the medication that is referenced in this 
report? Is there any instance at all that you are aware of?
    Dr. McClellan. I have not looked at the actual medical 
records for the kids in this report.
    Senator Brown. In your experience then.
    Dr. McClellan. I think before you say about any case you 
would have to look at it, but I cannot think of a situation 
where it would be indicated. I just cannot think of one.
    Senator Brown. So how do they do it? How do they get away 
with it?
    Where is the check and balance?
    Where is somebody raising a red flag and saying hey, why 
are you giving this 6-month-old this drug when it is absolutely 
not appropriate to be prescribed for it? Where are the so-
called red flags?
    I mean, is it a State-by-State issue? Is that the problem, 
that there is a complete lack of the ability for us to go in 
and monitor that stuff?
    I am still trying to zero in on where there is the 
breakdown, and I will take an answer from anybody.
    Dr. McClellan. I cannot speak from a policy standpoint. I 
mean oftentimes pharmacies--physicians sometimes just write--
    Senator Brown. Where is the doctor's responsibility? Where 
is the doctor's responsibility to say hey, this is not right?
    Dr. McClellan. Oh, I agree with that, but at some level the 
oversight has to then pick up on for clinicians, and it is 
either doctors or nurse practitioners who are writing the 
prescriptions.
    I mean, again, the number of prescriptions that were for 
babies for psychotropics other than antihistamines were very 
small. So you are talking a very small number of prescribers 
compared to all the other work that was done.
    Senator Brown. Right.
    Dr. McClellan. There are outliers in every field, and there 
does need to be some checks and balances to pick up when 
someone is just not doing their job very well.
    Senator Brown. Mr. Salo, I think you wanted to jump in.
    Mr. Salo. Yes. I would just add that I think there are a 
lot of breakdowns, and some of it is in medical practice. There 
are certain things you just should not be doing.
    And some of it is in failure on our part as States or as 
HHS to red-flag it and to catch it and to stop it. There are 
reasons why there are different practices out there. But we 
need to do better, clearly.
    And I would just make one final point, that clearly we need 
to do better for these kids, but this is a problem throughout 
the system too.
    Senator Brown. Oh, yes.
    Mr. Salo. And let's keep that in mind.
    Senator Brown. Yes, I know. Well, we are focused on the 
kids right now, but I do not disagree with you.
    What I would hope, Mr. Chairman, is that certainly, my 
staff would be ready whenever you are ready, but I would hope 
that we could get the guidance from our witnesses to let us 
know what we can do. OK, we have identified it. Now where do we 
go from here?
    As you have said, we need to learn--I am paraphrasing--we 
need to learn how to do it better, and I do not disagree on 
this issue.
    So Mr. Chairman, I mentioned I am back and forth. I have to 
get down on the floor and work on some issues
    Senator Carper. Sure.
    Senator Brown [continuing]. Affecting our soldiers.
    Senator Carper. Good luck.
    Senator Brown. So thank you all for your testimony.
    Senator Carper. Yes, thanks very much for being here today.
    One of the things that witnesses before us hear almost 
every time we have a hearing is I mention one of my core 
values--if it is not perfect, make it better. And I think that 
certainly applies here too today. Obviously, this is not a 
perfect situation. I do not know that we ever can make it 
perfect, but we sure can make it better.
    What do we need to do as members of the Senate and members 
of the Congress, members of the Legislative Branch? What do we 
need to do to make this better, Mr. Kutz.
    Mr. Kutz. We have talked about reimbursement, and what 
Senator Brown was saying is this is all paid for by the Federal 
Government and State governments. Medicaid is matching, mostly 
Federal in some cases, otherwise, 50-50.
    But the issue of whether in some cases the government 
should reimburse legally under current law is one we are 
looking. We are still looking to get answers from HHS about 
drugs that are not FDA-approved and in these drug compendia, et 
cetera. What is the legal authority right now that the 
government is reimbursing those drugs?
    And then we have heard here some of these other high risk 
practices. Should there be some restrictions of whether the 
Federal Government reimburses for infants getting these drugs, 
or 5 or more, 10 or more or whatever the case may be?
    So I think reimbursements. As you have mentioned at the 
beginning of the hearing, we are talking about taxpayer dollars 
here. Is there something better that can be done to help 
taxpayer dollars and protect the children at the same time?
    Senator Carper. Thank you. Mr. Samuels.
    Mr. Samuels. I would rattle off two or three issues that I 
think are really important.
    The first one that I would really push hard for is the 
recognition that we need to build capacity to provide 
therapeutic interventions, that there simply are not enough 
clinicians and not enough clinicians trained in effective 
interventions to really meet the needs of these children, and 
so we have to build capacity in this area.
    We certainly would support that. We have put some ideas 
forward. We would be glad to continue to talk to you about that 
issue.
    The second one that I would really recommend is even if we 
cannot have an electronic record system that allows us to look 
at this more closely in the immediate future I think that there 
are probably opportunities for us to look more closely at the 
Medicaid data from a national perspective. Most of the reports 
that you see, including the GAO report, are based on Medicaid 
data. However, the data does not allow us to differentiate 
foster children from other children in a way that allows us to 
see patterns that are troubling and concerning.
    And so, instead, what we do is rely on academic researchers 
or the good work of folks at the GAO to go look at this data 
and then come back and tell us something. We ought to have a 
national overarching ability to know who is doing what in 
prescribing psychotropics for kids in foster care.
    And then, the last point that I would make is that--in my 
earlier comments and echoed by Senator Coburn--much of the 
challenges that young people in foster care have are related to 
behavioral issues that they need help on. And instead of 
recognizing issues of trauma we are overdiagnosing children 
with mental illness, and we ought to build the capacity in 
child welfare to be able to differentiate children who are 
expressing traumatic symptoms because of stuff that has 
happened to them versus children that are showing symptoms of a 
mental illness. If we can make those separations, then we can 
reduce the use of psychotropics and target effective 
interventions for the children who would benefit most.
    Senator Carper. OK. That was a very good summation. Mr. 
Salo.
    Mr. Salo. Yes, I would agree with that last point 
wholeheartedly, and I think just a couple of other things.
    The easy thing to do is just to continue to use the bully 
pulpit and to shine through the use of the GAO and others.
    Senator Carper. Through hearings?
    Mr. Salo. Through hearings and just shine light on little-
known problems like this.
    I think there is also clearly a role for helping build 
capacity, not just for electronic health records and HIT, 
building capacity for the research, the clinical research that 
is out there, so we know so little about how these drugs 
interact with each other and how they work with kids in 
general, and we know very little about how the unique 
challenges faced by kids in foster care interact with all 
those.
    And then, I think the last piece is just continue to demand 
accountability. I think that is certainly something that we are 
talking a lot about with Medicaid. Medicaid is a very process-
driven system, and in many ways Medicaid is less of an 
entitlement to the beneficiary than it is an entitlement to 
streams of revenue for a bunch of different providers.
    And I think there is a way to kind of think more 
holistically about how we use Medicaid, not just to reimburse 
for things but to drive better health outcomes, and I think 
that is an ongoing conversation we would love to have with you.
    Senator Carper. OK. Good.
    Dr. McClellan, how do we make it perfect? How do we make it 
better, if not perfect?
    Dr. McClellan. Yes, I will have to send you that in 
writing, I think. I mean it is a very complicated system. I 
agree with what has been said.
    I go back to your point about figure out what works and do 
more of it. We actually know a lot of psychosocial 
interventions that are effective for treating trauma problems 
and treating behavior problems. And yet, most kids cannot 
access them, and many of the people who are out there providing 
do not use them. And the system has to be more reinforcing for 
those that do and urging those that do not to change their 
ways.
    Senator Carper. All right. Good. Thank you all for your 
responses. I appreciate that.
    I have one more question. I am going to read it. I am not 
going to ask you to answer, but I will ask you to answer it for 
the record, and we will follow up in writing on this.
    In the testimony today from GAO, they reported that the 
State of Maryland did not have reliable data for its foster 
children, I believe, in 2008. I am told that this is why we 
only had five States examined and not six.
    I am also told that the data that the GAO received from 
Maryland was--I think this is a quote--``materially different'' 
than the data that Maryland provided to Health and Human 
Services. I find that troubling, and the fact that they do not 
have a good accounting for the children under their care.
    I am going to ask Mr. Samuels and Mr. Salo to respond for 
the record. And basically, we will be asking you were you aware 
that Maryland could not account for all of its foster children 
apparently in its records in 2008, and we will ask if you are 
aware of any other States that have similar difficulty in 
accurately maintaining data for foster children under their 
care.
    And finally, we will ask, does this lack of accountability 
by a State have adverse effect on its foster care and Medicaid 
Federal grant funds?
    So those will be for the record. There will be some other 
questions, I expect, for the record from me and my guess, from 
others as well.
    Let me ask John Collins who has done a lot of work on this 
hearing. John, how long do our colleagues on the Subcommittee 
have to submit questions?
    Mr. Collins. Two weeks.
    Senator Carper. Two weeks. So we will get our questions in 
to you within two weeks. We just ask that you respond promptly.
    I will close just by saying this; I mentioned this to 
Ke'onte when I slipped outside to say goodbye to him, and his 
mom, and dad, after he had a bite to eat. We talked a little 
bit about Christmas coming up.
    And I said to him at Christmas time a lot of us, especially 
young kids--I remember when we were all kids, especially when I 
was a kid--we really look forward to what we are going to get. 
And it was a source of great joy to go down on Christmas 
morning and find out what was under the tree for us, my sister 
and me.
    But I have learned over time that the real source of joy is 
not what we get but what we give, and that is a valuable lesson 
that hopefully all of us learn somewhere along the line, 
hopefully, sooner rather than later.
    I also learned along the way that in adversity lies 
opportunity. These kids, these foster kids especially, have 
gone through a lot of adversity in their lives, and there is 
also some opportunity here. The opportunity we have is to use 
really the gift of Ke'onte's testimony, and yours, and the good 
will of, I think, a lot of us to be able to help a whole bunch 
of kids to end up having a better--not just a better childhood 
but a better life and a more productive life. And that is a 
gift for us to give back to others.
    I am one of those people who have these core values. One of 
them is to figure out is there a better way to do everything. 
How do we get a better result?
    But I do not give up on stuff. When I can see that there is 
a wrong that needs to be righted, I just do not give up. I am 
pretty persistent. With that in mind, we are going to stay on 
this one, and we invite all of you to stay on it with us.
    We did not invite anyone today to come from the 
pharmaceutical industry. I think a conversation with the 
representatives from the pharmaceutical industry and from the 
pharmacies, pharmacists themselves, probably would be helpful. 
If we really want to help a bunch of kids, we will be reaching 
out to them and asking them to meet with us, probably not in a 
hearing--maybe--but probably at least to have a good 
conversation and feel how they can be part of the solution here 
as well.
    Again, my thanks to each of you for sharing your time, 
especially to our friends from GAO and those who work with you 
on your study. We are deeply grateful for the work that you 
have done here as well as in so many other areas.
    With that having been said, this hearing is adjourned. 
Thank you all. God bless.
    [Whereupon, at approximately 12:34 p.m., the hearing was 
adjourned.]
                            A P P E N D I X

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