    [House Hearing, 113 Congress]
    [From the U.S. Government Publishing Office]

      CARING FOR OUR KIDS: ARE WE OVERMEDICATING CHILDREN IN FOSTER CARE?

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

                                    HEARING

                                   before the

                        SUBCOMMITTEE ON HUMAN RESOURCES

                                     of the

                          COMMITTEE ON WAYS AND MEANS
                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED THIRTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                  MAY 29, 2014

                                   __________

                              Serial No. 113-HR12

                                   __________

             Printed for the use of the Committee on Ways and Means

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                            U.S. GOVERNMENT PUBLISHING OFFICE

    94-399                         WASHINGTON : 2016
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                          COMMITTEE ON WAYS AND MEANS

                         DAVE CAMP, Michigan, Chairman

    SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
    KEVIN BRADY, Texas                   CHARLES B. RANGEL, New York
    PAUL RYAN, Wisconsin                 JIM MCDERMOTT, Washington
    DEVIN NUNES, California              JOHN LEWIS, Georgia
    PATRICK J. TIBERI, Ohio              RICHARD E. NEAL, Massachusetts
    DAVID G. REICHERT, Washington        XAVIER BECERRA, California
    CHARLES W. BOUSTANY, JR., Louisiana  LLOYD DOGGETT, Texas
    PETER J. ROSKAM, Illinois            MIKE THOMPSON, California
    JIM GERLACH, Pennsylvania            JOHN B. LARSON, Connecticut
    TOM PRICE, Georgia                   EARL BLUMENAUER, Oregon
    VERN BUCHANAN, Florida               RON KIND, Wisconsin
    ADRIAN SMITH, Nebraska               BILL PASCRELL, JR., New Jersey
    AARON SCHOCK, Illinois               JOSEPH CROWLEY, New York
    LYNN JENKINS, Kansas                 ALLYSON SCHWARTZ, Pennsylvania
    ERIK PAULSEN, Minnesota              DANNY DAVIS, Illinois
    KENNY MARCHANT, Texas                LINDA SANCHEZ, California
    DIANE BLACK, Tennessee
    TOM REED, New York
    TODD YOUNG, Indiana
    MIKE KELLY, Pennsylvania
    TIM GRIFFIN, Arkansas
    JIM RENACCI, Ohio

            Jennifer M. Safavian, Staff Director and General Counsel

                      Janice Mays, Minority Chief Counsel

                                     ______

                        SUBCOMMITTEE ON HUMAN RESOURCES

                    DAVID G. REICHERT, Washington, Chairman

    TODD YOUNG, Indiana                  LLOYD DOGGETT, Texas
    MIKE KELLY, Pennsylvania             JOHN LEWIS, Georgia
    TIM GRIFFIN, Arkansas                JOSEPH CROWLEY, New York
    JIM RENACCI, Ohio                    DANNY DAVIS, Illinois
    TOM REED, New York
    CHARLES W. BOUSTANY, JR., Louisiana

                                C O N T E N T S

                                   __________
                                                                       Page

    Advisory of May 29, 2014 announcing the hearing..................     2

                                   WITNESSES

    JooYeun Chang, Associate Commissioner of the Children's Bureau,
      Administration for Children and Families, Department of Health
      and Human Services (HHS).......................................     6
    Dawna Zender Hovenier, The Mockingbird Society...................    13
    Phil McGraw, Ph.D., Talk Show Host, Dr. Phil.....................    18
    Michael Naylor, M.D., Associate Professor of Psychiatry, Chicago
      School of Medicine, University of Illinois at Chicago (UIC)....    27
    Stephen Lord, Director, Forensic Audits and Investigative
      Services, Government Accountability Office.....................    38

                           SUBMISSIONS FOR THE RECORD

    Adopt America Network, letter....................................    77
    James Harris, statement..........................................    84

                            QUESTIONS FOR THE RECORD

    JooYeun Chang....................................................    76

                          CARING FOR OUR KIDS: ARE WE
                           OVERMEDICATING CHILDREN IN
                                  FOSTER CARE?

                                  ----------

                             THURSDAY, MAY 29, 2014

                 U.S. House of Representatives,
                           Committee on Ways and Means,
                               Subcommittee on Human Resources,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 2:30 p.m., in
    Room 1100, Longworth House Office Building, the Honorable Dave
    Reichert [chairman of the subcommittee] presiding.
        [The advisory of the hearing follows:]

    HEARING ADVISORY

    FROM THE
    COMMITTEE
     ON WAYS
    AND
    MEANS

      Chairman Reichert Announces Hearing on Caring for Our Kids: Are We
                    Overmedicating Children in Foster Care?

        Washington, May 29, 2014
        Congressman Dave Reichert (R-WA), Chairman of the Subcommittee on
    Human Resources of the Committee on Ways and Means, today announced
    that the Subcommittee will hold a hearing on the use of psychotropic
    medications among children in foster care. The hearing will take place
    at 2:00 p.m. on Thursday, May 29, 2014, in room 1100 of the Longworth
    House Office Building.

        In view of the limited time available to hear from witnesses, oral
    testimony at this hearing will be from invited witnesses only.
    Witnesses will include experts on the prescription and use of
    psychotropic drugs by children, and especially children in foster care.
    However, any individual or organization not scheduled for an oral
    appearance may submit a written statement for consideration by the
    Committee and for inclusion in the printed record of the hearing.

    BACKGROUND:

        Recent reports have highlighted how children in foster care are
    prescribed psychotropic drugs at very high rates. According to data
    compiled by the Congressional Research Service, between 2008 and 2010,
    nearly one out of every four children in foster care was using a
    psychotropic medication on any given day--more than four times the rate
    among all children. A recent Wall Street Journal story and a multi-part
    Denver Post series highlighted how youth in foster care may be
    prescribed these powerful, mind-altering drugs because they are
    misdiagnosed as having mental health disorders instead of being
    recognized as having problems stemming from the abuse and neglect they
    have experienced.
        Congress has taken a number of steps in recent years designed to
    prevent the overuse of psychotropic drugs by children in foster care.
    The Child and Family Services Improvement Act of 2006 (P.L. 109-288)
    required States to describe how they consult with doctors to assess the
    health and well-being of children in foster care and determine
    appropriate medical treatment for them. The Fostering Connections to
    Success and Increasing Adoptions Act of 2008 (P.L. 110-351) required
    States to ensure children in foster care have access to health and
    mental health care services and develop strategies for overseeing drugs
    prescribed to them. Most recently, the Child and Family Services
    Improvement and Innovation Act of 2011 (P.L. 112-34) added that States
    must develop protocols covering the use of psychotropic medication for
    children in foster care.
        States have also taken positive steps to address concerns about the
    use of psychotropic medications by children in foster care. These
    efforts include reviewing new prescriptions before they are approved,
    monitoring existing prescriptions, and examining data on prescription
    rates among youth in foster care. For example, in Illinois, board
    certified child psychiatric consultants review all psychotropic
    medication requests. Connecticut has hired a Chief of Psychiatry to
    oversee medications for youth in foster care. Texas has a data system
    designed to ensure that psychotropic medications are prescribed within
    established guidelines.
        In announcing the hearing, Chairman Reichert stated, ``Our future
    lies with our nation's children. For kids in foster care, we have an
    added responsibility to help them succeed, including helping them
    overcome the trauma they experienced before, and in some cases since,
    they left their home. Recent news reports have highlighted how powerful
    psychotropic drugs are prescribed at high rates to children in foster
    care, including by individuals who may misdiagnose the effects of
    trauma on these children as a mental health problem. I look forward to
    hearing from experts on this issue, learning what States are doing to
    ensure the proper use of these medications, and discussing how the
    Federal Government can better support efforts to provide youth in
    foster care with the help they need to become successful adults.

    FOCUS OF THE HEARING:

        This hearing will focus on what is known about the use of
    psychotropic medications by children in foster care, how States have
    implemented recent Federal laws designed to ensure such medications are
    used appropriately, and how the Federal Government can continue to work
    with States to improve the oversight of these medications to ensure
    youth in foster care receive appropriate help.

    DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

        Please Note: Any person(s) and/or organization(s) wishing to submit
    for the hearing record must follow the appropriate link on the hearing
    page of the Committee website and complete the informational forms.
    From the Committee homepage, http://waysandmeans.house.gov, select
    ``Hearings.'' Select the hearing for which you would like to submit,
    and click on the link entitled, ``Please click here to submit a
    statement or letter for the record.'' Once you have followed the online
    instructions, submit all requested information. Attach your submission
    as a Word document, in compliance with the formatting requirements
    listed below, by June 12, 2014. Finally, please note that due to the
    change in House mail policy, the U.S. Capitol Police will refuse
    sealed-package deliveries to all House Office Buildings. For questions,
    or if you encounter technical problems, please call (202) 225-1721 or
    (202) 225-3625.

    FORMATTING REQUIREMENTS:

        The Committee relies on electronic submissions for printing the
    official hearing record. As always, submissions will be included in the
    record according to the discretion of the Committee. The Committee will
    not alter the content of your submission, but we reserve the right to
    format it according to our guidelines. Any submission provided to the
    Committee by a witness, any supplementary materials submitted for the
    printed record, and any written comments in response to a request for
    written comments must conform to the guidelines listed below. Any
    submission or supplementary item not in compliance with these
    guidelines will not be printed, but will be maintained in the Committee
    files for review and use by the Committee.

        1. All submissions and supplementary materials must be provided in
    Word format and MUST NOT exceed a total of 10 pages, including
    attachments. Witnesses and submitters are advised that the Committee
    relies on electronic submissions for printing the official hearing
    record.

        2. Copies of whole documents submitted as exhibit material will not
    be accepted for printing. Instead, exhibit material should be
    referenced and quoted or paraphrased. All exhibit material not meeting
    these specifications will be maintained in the Committee files for
    review and use by the Committee.

        3. All submissions must include a list of all clients, persons,
    and/or organizations on whose behalf the witness appears. A
    supplemental sheet must accompany each submission listing the name,
    company, address, telephone, and fax numbers of each witness.

        The Committee seeks to make its facilities accessible to persons
    with disabilities. If you are in need of special accommodations, please
    call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four
    business days notice is requested). Questions with regard to special
    accommodation needs in general (including availability of Committee
    materials in alternative formats) may be directed to the Committee as
    noted above.
        Note: All Committee advisories and news releases are available
    online at http://waysandmeans.house.gov/.

        Chairman REICHERT. The committee will come to order.
    Welcome to today's hearing on this very important topic of
    whether youth in foster care are being prescribed medications,
    whether or not they are being prescribed appropriately. We will
    hear from our witnesses that too often the answer is no.
        We know from research that foster children are prescribed
    mind-altering psychotropic drugs at very high rates, far higher
    than other children. CRS found that between 2008 and 2010
    nearly one out of every four children in foster care was
    overmedicated. That is more than four times the rate among
    children overall. In too many cases, government programs may be
    trying to medicate away the troubles that these youths have
    experienced that will remain with them for many years after the
    medications end.
        Dawna Hovenier is a young woman who was recently in foster
    care in my home State of Washington. She was unnecessarily
    medicated with a number of mind-altering drugs and will explain
    how that helps no one, least of all the youth who need it the
    most, and Dr. Phil McGraw will second this assertion that one
    of the most critical reasons to address the problem of
    overmedication is to ensure children receive proper treatment
    and not just chemical straitjackets that keep them from acting
    out.
        Congress has taken a number of steps in recent years to
    highlight this issue, and we expect States to continue focusing
    more attention on prevention as a result of these changes.
    Federal law passed in 2006, 2008, and 2011 sharpened the focus
    of States on medical needs of foster youth, including the need
    to develop protocols preventing the overprescribing of
    medications.
        Illinois is a leading example, as we will hear from Dr.
    Michael Naylor, whose office reviews all medication requests
    for children in foster care in Illinois. This effort has
    prevented overmedication of children, likely saving taxpayers
    money, but more importantly resulting in better care for
    children. Other States, including Texas and Connecticut, have
    similar programs, and part of our task is to ensure that all
    States are taking the necessary steps and learning from each
    other's best practices.
        Ultimately the best solution for children is to be in a
    permanent, loving home with parents who watch out for them each
    and every day. This subcommittee knows that, and has focused
    its efforts during the past year in getting more foster youth
    into those sort of permanent, loving homes. And H.R. 3205, the
    Promoting Adoption and Legal Guardianship for Children in
    Foster Care Act, which passed the House last year, incentivizes
    States to move more children, especially older children, into
    adoptive homes, and just last week the House passed H.R. 4058,
    the Preventing Sex Trafficking and Improving Opportunities for
    Youth in Foster Care Act, which requires States to more quickly
    move children out of foster care into permanent homes. I am
    hopeful that we will enact these bills this year. That will
    help more children move from foster care into loving homes,
    improving their lives in many ways, vastly decreasing the
    likelihood of using or needing psychotropic drugs.
        We welcome all of our witnesses today, and we look forward
    to their testimony. I was meeting today with one of the foster
    youth out there in the audience, Courtney is out there. She and
    I had a chance to talk, and she told her story of moving from
    foster home to foster home to foster home and even living in a
    foster home that was not legally a foster home anymore, and
    State authorities didn't even know that it had been removed
    from the foster home approved list. So we have a lot of work to
    do in this area, and this is one of those issues that really
    tightly is wound into bringing better care to our children
    across this country.
        And I now yield time to Mr. Doggett for his opening
    statement.
        Mr. DOGGETT. Thank you, Mr. Chairman.
        I certainly share all the sentiments that you just
    expressed and appreciate this bipartisan inquiry. I think that
    while no doubt medication can be one appropriate tool in a
    treatment plan for some children, it has instead become the
    first line of consideration for too many children in our foster
    care system.
        The Congressional Research Service looked at the year 2010
    and found that 40 percent of children in longer-term foster
    care over the age of 6 were using psychotropic medicines. That
    is a pretty staggering level. Other studies found the next
    year, in 2011, that those who are enrolled in Medicaid,
    children in foster care were prescribed psychotropic
    medications at rates of 3 to 11 times higher than nonfoster
    children. The pill is not the answer in many of these
    situations.
        Having been abused or neglected and then removed from their
    homes, every child coming into the foster care system has
    suffered some degree of trauma. We have heard firsthand in this
    committee about the problems with psychotropic drugs a couple
    years ago and continue through our research to see other
    examples of that, and we have heard firsthand from foster
    children about the trauma and how it has impacted their lives.
    This issue was addressed in this committee when our colleague,
    Chairman McDermott, chaired the committee back in 2008 and
    required States to develop health oversight plans for children
    in foster care, including the oversight of prescription
    medicines. In 2011, Congress strengthened that provision to
    include specific protocols for reviewing the prescribing of
    these medications to foster children.
        I look forward to hearing from each of our witnesses on how
    child welfare and Medicaid policies have changed in response to
    these specific laws. My home State of Texas, with the
    leadership of CASA, the Court-Appointed Special Advocates,
    recently changed the law there and took a number of steps to
    prevent unnecessary overmedication of children in foster care
    including the legislation that will give guardian ad litems a
    greater role in the oversight of these medications. Improved
    oversight of medications is only part of the solution. Children
    in foster care need access to comprehensive treatment for
    mental and emotional health needs, which requires additional
    efforts in both Medicaid and the child welfare system.
        I appreciate the presence here today and the leadership for
    this hearing from our colleague Karen Bass of California who
    heads our Foster Care Caucus. The administration's budget calls
    for $750 million over the next 5 years toward this goal. This
    is an investment that is equal to about one-quarter of 1
    percent of one of the measures that our committee approved
    earlier today. I believe that we do need to come together with
    common purpose and hear of any ways we can change the law in
    this area, but we also have to have the resources present to be
    able to get the job done effectively and not just respond after
    some crisis or horrible situation has hit the news media.
        Thank you, Mr. Chair, and I look forward to hearing from
    our witnesses.
        Chairman REICHERT. Thank you, Mr. Doggett.
        I would like to just mention briefly, I would like to thank
    Ms. Bass for her work in helping us organize this hearing and
    her work in helping foster children. It is a pleasure to have
    you attending our hearing this morning, and also a moment just
    to thank Mr. McDermott for his hard work as past chairman and
    past ranking member of this committee and also Mr. Doggett for
    his support. So, as you can all see, this is a bipartisan
    effort, rarely seen. We are together on this, and we are going
    to make a difference and help people.
        So thank you again, Mr. Doggett.
        Without objection, each member will have the opportunity to
    submit a written record and statement and have it included in
    the record at this point. I want to remind our witnesses to
    please try and limit your testimony to 5 minutes. However,
    without objection, all of the written testimony will be made a
    part of the permanent record, and on our panel this afternoon,
    we will be hearing from JooYeun Chang, Associate Commissioner
    of the Children's Bureau Administration for Children and
    Families, U.S. Department of Health and Human Services; Dawna
    Zender Hovenier, the Mockingbird Society; Dr. Phil McGraw, talk
    show host, ``Dr. Phil Show''; Dr. Michael Naylor, M.D.,
    Associate Professor of Psychiatry, School of Medicine,
    University of Illinois at Chicago; and Stephen Lord, Director
    of Forensic Audits and Investigative Services, U.S. Government
    Accountability Office.
        I would like to mention that we have other experts in the
    audience who know a thing or two about the foster care system
    because they have lived it, and as I mentioned just a little
    bit earlier, a lot of our foster youth are in the audience
    today, and I think we probably have over 60. And you know what,
    I am going to do something a little bit unusual, I am going to
    ask the foster kids, if they want to, to raise your hand or
    stand because we want to give you a big applause, round of
    applause for your success.
        As you can see, they are not shy. We are so happy to have
    you here. So each of these youth have spent the morning with a
    Member of Congress, and as I said, Courtney and I got to spend
    a little time together and talk about my life and her life. We
    found some similarities as runaways, but I was fortunate enough
    to make it back to my home and not into a foster home. So thank
    you for coming today.
        Ms. Chang, please proceed with your testimony.

       STATEMENT OF JOOYEUN CHANG, ASSOCIATE COMMISSIONER OF THE
     CHILDREN'S BUREAU, ADMINISTRATION FOR CHILDREN AND FAMILIES,
              U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

        Ms. CHANG. Thank you.
        Chairman Reichert, Ranking Member Doggett, and Members of
    the Subcommittee, thank you for inviting me to testify today.
        The administration is very concerned about the
    overmedication of children in the foster care system. We are
    grateful to you for having this hearing and bringing more
    attention to the issue. My name is JooYeun Chang, and I am the
    Associate Commissioner of the Children's Bureau. I have worked
    as a national advocate on child welfare policies, both as a
    senior staff attorney at the Children's Defense Fund as well as
    at Casey Family Programs Foundation, where I worked closely
    with State and local child welfare agencies.
        In my current role, I oversee the Federal foster care and
    adoption assistance programs as well as a range of prevention
    and post-permanency initiatives. At the Department of Health
    and Human Services, we are working with State child welfare
    agencies to ensure that vulnerable children in their care
    receive appropriate care and services and that they are
    effectively monitoring for psychotropic medication use.
        Children who come into foster care often have been exposed
    to multiple traumas, including abuse and neglect and subsequent
    removal from their homes. The CDC's Adverse Childhood
    Experiences Study and other research tells us that the impacts
    of these negative life experiences affect children in all
    domains, from brain development to physical health, to how a
    young person reacts emotionally to various situations and how
    they are or are not able to interact with others.
        We know from our research that children who enter foster
    care are at much higher risk for developing both physical and
    emotional disorders, especially traumatic stress, and the child
    welfare system currently struggles to fully meet their needs.
    If inadequately treated, these experiences can lead to
    worsening health conditions and may hinder a foster parent's
    ability to meet the child's needs, potentially resulting in
    multiple placements for that child.
        This lack of stability can lead to increasingly restrictive
    and costly placements and make it more difficult for that child
    to find a permanent, loving family. These undesired outcomes
    can negatively impact the well-being of children and youth in
    foster care and also mean additional cost for the child welfare
    and other public systems. The need for action in this area is
    clear.
        Our own data show that 18 percent of children in foster
    care are taking one or more psychotropic medications, and the
    GAO has estimated an even higher rate of 21 to 39 percent.
    Children in care are prescribed psychotropic medications at far
    higher rates than other children served by Medicaid and often
    in amounts that exceed those indicated by FDA approved labeling
    for such drugs.
        We appreciate the important role that Congress, led by this
    committee, has played in bringing attention to these issues,
    specifically the 2008 enactment of Fostering Connections to
    Success and Increasing Adoptions Act, which required for the
    first time ongoing oversight and coordination of health care
    services for children in foster care, to the more recent
    enactment of the Child and Family Services Improvement and
    Innovation Act in 2011 that requires States to report to HHS
    protocols they have in place for monitoring the use of
    psychotropic medications.
        We have worked across the agency and collaboratively across
    the Department to provide guidance to States on monitoring the
    use of psychotropic medications for children in foster care,
    and we have also shared information about evidence-based
    interventions that address the underlying issues of trauma. We
    reviewed the progress that had been made and saw that there was
    a practice gap that needed to be filled.
        Child welfare agencies often did not have access to
    adequate research-based nonpharmaceutical mental health
    treatments and, as a result, often rely on medication as a
    first line of treatment. If we are serious about reducing the
    use of psychotropic medication, we must also ensure that child
    welfare agencies have access to evidence-based interventions.
    Therefore, along with CMS, we developed the proposal you see in
    the President's fiscal year 2015 budget, one we hope you will
    give thoughtful consideration to. This proposal presents a
    concerted effort to reduce overprescription of psychotropic
    medications for children by increasing the availability of
    evidence-based psychosocial treatments that meet the complex
    needs that children who have experienced maltreatment often
    have.
        Increased access to timely and effective screening,
    assessment, and nonpharmaceutical treatment will reduce
    overreliance on psychotropic medication, improve child
    emotional and behavioral health, and increase the likelihood
    that children in foster care will exit to positive, permanent
    settings with the life skills and resources they need to be
    successful.
        The administration looks forward to working with you to
    address this crucial issue and improve services to some of our
    most vulnerable young people. Again, thank you for the
    opportunity to speak with you today. I would be happy to answer
    any of your questions.
        Chairman REICHERT. Thank you, Ms. Chang.
        [The prepared statement of Ms. Chang follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman REICHERT. And before Ms. Hovenier begins, I would
    just like to point out that she is quite a remarkable young
    woman, and as a 21-year-old alumni of Washington's foster care
    system, she spent 7 years in foster care, primarily in Pierce
    County in western Washington, just south of Seattle area. She
    has become a strong advocate for foster care reforms, working
    with the Mockingbird Society, an advocacy organization for
    young people impacted by foster care and homelessness in
    Washington State. And I know she hopes her advocacy will
    improve the foster care system for young people who come after
    her, and I believe that you will.
        Thank you for being with us today, and you can go ahead.
    She says she is not nervous. I told her I was.
        But go ahead, you have 5 minutes, Ms. Hovenier.

      STATEMENT OF DAWNA ZENDER HOVENIER, THE MOCKINGBIRD SOCIETY

        Ms. HOVENIER. Thank you, Chairman Reichert, Ranking Member
    Doggett, and committee members for giving me the opportunity to
    speak.
        My name is Dawna Zender Hovenier. I am 21-years old and
    have spent 7 years in foster care in Washington State. On my
    18th birthday, I aged out of foster care and was released after
    spending 7 months in an adolescent psychiatric hospital.
        My hope is that the government will quit spending millions
    of dollars forcing kids like me to take drugs they do not need
    and give them things they do need, such as a volunteer CASA who
    believes in them, skilled mental health professionals who they
    can talk to and, most of all a loving, compassionate family
    that believes in them.
        I was ordered into the psychiatric hospital after my social
    worker told the court I had borderline personality disorder,
    major depressive disorder, and suicidal ideation. I was forced
    to take strong doses of psychotropic medication and told I
    could probably never live on my own. Only my CASA and the man
    who became my father agreed with me that I did not need the
    drugs.
        The 7 months I was locked up and forced to take these drugs
    felt like being in jail. After reviewing my records, I
    discovered that the foster care system paid $15,000 a month,
    about $120,000 total, to lock me up and take these drugs.
        Last year, I earned my certified nurses aide certificate
    after successfully completing 2 years of classes at Bellingham
    Technical College. My GPA? It was a 3.92. I am currently
    enrolled at Whatcom Community College in Bellingham,
    Washington. Thanks to Federal and State funding for former
    foster youth, I was able to complete all my prerequisites
    required for a nursing degree. I am hoping to be accepted into
    an RN program to pursue my dreams of becoming a nurse.
        I have lived independently for more than 2 years. I have
    been off all psychiatric medications for more than 3 years. I
    have never felt better or happier.
        What happened? How did I transition from being diagnosed a
    mentally disabled foster youth to a model student and
    productive member of society? I don't have time to tell my
    whole story. Despite everything I experienced growing up, I
    know I was lucky. When I was 16, the man who recently became my
    father and is here with me today adopted my then 10-year-old
    brother from foster care. My younger brother was also forced to
    take strong doses of psychiatric drugs. He has been off them
    since his adoption more than 5 years ago.
        My dad hired an attorney to fight the State's plan to
    transfer me to an adult psychiatric facility. He picked me up
    on my 18th birthday and sent me to live with his friends. They
    are now my family, too. So today it feels like I have two dads
    and a mom.
        The next 6 months were among the most difficult in my life.
    Because of my diagnosis in foster care, we could not find a
    psychiatrist willing to take me off the medications, so we had
    to do it ourselves. This meant battling many intense withdrawal
    symptoms. One of the medications I was on can cause seizures,
    resulting in death if not carefully discontinued. My dad wrote
    a book about adopting my brother from foster care, and some of
    the professionals who read it advised him on how to get me off
    these medications.
        Six months after aging out of foster care I managed to
    graduate from Mount Baker High School with my class. A few
    months later, I moved into my own apartment. My new family
    helped me find an excellent therapist, who supported me in my
    decision to get off these medications.
        Today I am able to talk about my feelings, but when I was
    in the psychiatric hospital, I was so drugged up, I didn't even
    know how I felt. My twin sister said I was like a zombie. I
    know some of the kids I was locked up with needed medication.
    They heard voices that weren't there and got violent sometimes,
    but I believe many of the foster kids were like me and needed
    loving parents to guide them.
        When I think about the government spending over $120,000
    locking me up and forcing me to take these drugs, it makes me
    very angry. I wish that the money could have been spent helping
    foster youth.
        Despite all of this, I have been so lucky. A few months
    ago, on the same day as my brother's adoption 5 years ago, my
    dad adopted my twin sister and me. What really helped me get
    off the medication was being surrounded by people who loved me
    and wanted to help me. I believe what most foster youth need is
    love, not drugs.
        Although I can never get back the 7 months that I was
    locked up and forced to take these drugs, I hope that telling
    my story here today and continuing to work with the Mockingbird
    Society will help other youth like me and encourage change.
        In closing, I want to thank the Mockingbird Society for
    making it possible for me to come from Seattle to be here
    today. They are an awesome youth advocacy organization that
    helps young people share our experiences about foster care and
    gives us a chance to be heard.
        Thank you, Chairman Reichert, for inviting me here today. I
    want to thank you for all the work you do for foster youth.
        Dr. Phil, I also want to thank you for everything you have
    done.
        And I am grateful to my CASA for being the person who knew
    me and told the court that I did not need these drugs, and for
    all my family, my twin sister, and my therapist for supporting
    me to get off these medications. Thank you.
        Chairman REICHERT. You did awesome. You want to come up
    here and take my place and run the rest of the show?
        Ms. HOVENIER. No thank you.
        Chairman REICHERT. No? Thank you for your testimony and
    thank you for your work.
        [The prepared statement of Ms. Hovenier follows:]

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        Chairman REICHERT. Dr. McGraw, you are recognized for 5
    minutes.

     STATEMENT OF PHIL MCGRAW, PH.D., TALK SHOW HOST, ``DR. PHIL''

        Mr. MCGRAW. Chairman Reichert, Ranking Member Doggett, and
    distinguished Members of the Committee, I wish I didn't have to
    follow this young lady. That is a tough act, to say the least.
        I am honored to be invited here to talk about the possible
    misuse of these psychotropic drugs. They are all too often
    prescribed to America's foster children. Look, these drugs can
    change and even save lives, there is no question about it, but
    when it comes to these vulnerable children, these drugs are
    just too often misused as chemical straitjackets. It is just a
    haphazard attempt to simply control and suppress undesirable
    behavior rather than treat it, nurture it, and develop these
    treasured young people, and simply put, it just makes them less
    inconvenient. It just makes them less inconvenient so they
    don't take as much energy to manage.
        And you have my written statement, and I kind of want to
    begin where it leaves off because I believe that 80 percent of
    all questions are really statements in disguise. And I think
    everybody here already agrees, these drugs are flowing too
    much; there is just no question about that. You know the
    numbers.
        The real question is why? You know, why is this happening?
    I mean, three times as many foster children as their
    counterparts are getting these drugs; 40 percent of them are on
    three classes of drugs, some are on five classes of drugs. This
    is polypharmacy. Is there more psychopathology with these
    foster children? Of course, there is. They have more abuse and
    neglect that they have had to go through. Eighty percent are
    diagnosed with mental illness as opposed to 20 percent in the
    general population, but this is no justification.
        I have been working with this population for 5 years, for
    five decades. Robin and I have been national spokespersons for
    CASA for a number of years. Their budget has been cut, which
    just broke my heart to see. These kids face problems that you
    are not going to fix by throwing drugs at them. And a lot of
    them don't even take the drugs; they sell them. Dr. Charles
    Sophy is with me here today. He is the chief medical director
    for the L.A. County DCFS, the largest in the country. He told
    me within the last month, near a shelter in L.A., some of those
    children tried to sell him their psychotropic drugs, not
    knowing he was the medical director, and more than once in an
    hour trying to sell the drugs. If they do take them, are they
    less inconvenient? Maybe. But it is not convenience without
    consequences.
        They should never be used without evidence-based research.
    There should be proper diagnostics done and appropriate
    monitoring done, and it should always be in conjunction with
    evidence-based therapies, and anything less, we just have to be
    honest, we are sabotaging these kids, we are just flat out
    sabotaging them. And in my view, this is like pulling a thread.
    The entire system is flawed. It is not just the drugs. The
    entire system is flawed. Do we need to turn off the flood of
    drugs? Yes. But the problem is we have got a reverse incentive
    system here. It is a system where the government continues to
    pay for the drugs. We say you shouldn't give them, but yet they
    continue to be compensated for them, and these foster children,
    the more labels they get, the more drugs they are on, the more
    money they get to take care of that child. So they are actually
    paid for pathology. The more scripts, the less treatment, the
    more scripts, the less energy, and so it just becomes an
    assembly line, high volume, move them in, move them out
    process, and these children deserve better than that.
        Real treatment takes high energy, it takes--it is low
    volume. I mean, you have got to have more people, it takes more
    time, but we have got too many doctors with insufficient
    training in these drugs. They don't know what the drugs do. We
    don't--most of us, if we are honest, we have to tell you, we
    don't know why the drugs work when they do work. We don't know
    the agent of action, the agent of change, but we have too many
    doctors with insufficient training about these drugs that are
    prescribing them, and there is no follow up because the foster
    parents change. So there is no long-term follow on this, and
    then the therapists they do get, they change. You have got
    children with detachment problems, attachment disorders,
    detachment problems, and we rotate their therapist in and out.
    As soon as they bond with one, then they are faced with another
    one. So it just becomes a serious problem.
        I have been in this situation, hopefully, fortunately not
    as bad as some of these children, but I was homeless when I was
    15 years old. I was living on the streets in Kansas City. I was
    living in a car. We finally got a room at the YMCA, my dad and
    I, and then ultimately an apartment where we got an apartment,
    but we had no utilities because we didn't have money for the
    deposit. So we froze to death in the dark from 4:30 on, but I
    tell you what happened to me. Nobody ran at me with a handful
    of drugs. I fortunately had a football coach and some others
    who taught me about responsibility, taught me about the things
    to do that were important, and that is what CASAs do with these
    children. That is what therapists involved with evidence-based
    treatments would do with these children. But we have got to
    stop the flow of drugs and we have got to focus on
    reunification. We have just got to try to get these children
    back home.
        This system is broken, and it is flawed, and psychology has
    made great strides. We truly do have alternatives to offer
    these children, and without the side effects that the drugs
    have, but it takes time and it takes money, and it takes a
    completely different model than what we have right now, and so
    I am obviously very passionate about this.
        I just feel so strongly that these children need somebody
    to put an arm around their shoulder, somebody to help them,
    rather than just throw drugs at them, and there is nothing
    better for these children than to be able to look themselves in
    the mirror and say, I did this, I found my way, I got my coping
    skills.
        So I will stop. I want to thank the committee for inviting
    me to participate. A wise man once said--well, actually it was
    me that said it, you can't change what you don't acknowledge.
    And this committee is making a bold acknowledgment of this
    problem, and so I am happy to answer any questions.
        I have Dr. Frank Lawlis, the chairman of my advisory board
    here; Dr. Charles Sophy, who I mentioned earlier, is here; Dr.
    Marty Greenberg, our director of professional affairs, is here.
    We are all here to answer any questions anybody has got. We
    want to change this model. We want to start taking care of
    these kids. They have been through enough.
        Chairman REICHERT. Thank you. Well, we didn't even have to
    hold up an applause card on that one. I wish we had a half hour
    show, Doctor, but that was great testimony. Thank you so much.
    You and I have a couple of things in common. One, I ran away
    and lived in my car. It was a 1956 Mercury for me; I don't know
    what you had.
        Mr. MCGRAW. 1955 Chevy, no reverse. It had no reverse, but
    it did go forward.
        Chairman REICHERT. And it was a football coach that came to
    help me, too, so thank you for your testimony.
        [The prepared statement of Mr. McGraw follows:]

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        Chairman REICHERT. And Dr. Naylor, you are recognized for 5
    minutes.

       STATEMENT OF MICHAEL NAYLOR, M.D., ASSOCIATE PROFESSOR OF
       PSYCHIATRY, SCHOOL OF MEDICINE, UNIVERSITY OF ILLINOIS AT
                             CHICAGO (UIC).

        Dr. NAYLOR. Chairman Reichert, Ranking Member Doggett, and
    Members of the Subcommittee on Human Resources, before I start,
    I really want to lodge a complaint against who seated me here.
    He only had to follow one really incredible testimony. I have
    to follow two. I hope I can live up to it.
        Thank you for inviting me to testify before the committee.
    I am truly honored at the opportunity to address the issue of
    psychotropic medications for kids in the foster care system. We
    have already heard children in foster care, by definition
    Medicaid-eligible, are at higher risk for developing severe
    emotional disturbances and utilize mental health services at
    higher rates than other Medicaid-eligible youth. They are
    prescribed more medications at higher rates and at higher
    doses. In a way, these are not particularly surprising
    findings. As a population, foster children have multiple risk
    factors that predispose them to severe emotional disturbances
    and psychiatric illnesses, including often of genetic
    predisposition to mental illness, in utero exposure to drugs
    and alcohol, the adverse effects of growing up in poverty, a
    history of severe trauma, disrupted early attachments, and
    multiple placement disruptions, to name just a few.
        To complicate matters, there is the fragmented medical and
    psychiatric care system and an absence in the most part of a
    consistent caregiver to provide consent for and longitudinal
    oversight of their ongoing care. Despite all of this, I do
    contend that psychotropic medications are often an important
    component of a comprehensive psychosocial treatment plan that
    really is based on a good biopsychosocial understanding of
    these kids and their situation.
        I will describe how a program designed and implemented by
    the Illinois Department of Children and Family Services to
    provide consent for and oversight of psychotropic medications
    in foster children has resulted in more effective, safer, and
    more cost-effective care.
        In July 2007, I testified in front of the committee under
    Congressman McDermott and to advocate both for the oversight of
    psychotropic medications for foster children and to describe a
    program, the DCFS centralized psychotropic medication consent
    program. Illinois State law prohibits the administration of
    psychotropic medications to foster children without the consent
    of the DCFS guardian. And this is a centralized office compared
    to other consent programs across the Nation. To support the
    consent process, DCFS contracted with UIC to provide an
    independent review of all psychotropic medication consent
    requests to determine the appropriateness of the proposed
    treatment. Utilizing an extensive database consisting of
    consent data, Medicaid pharmacy payment claims, and data from
    the State-wide automated child welfare information system, we
    can monitor an individual's medication history over time,
    across placements, and across providers, and we can monitor
    State-wide patterns of psychotropic medication use. We believe
    that this prospective psychotropic medication consent and
    oversight process has resulted in higher quality and more cost-
    effective care, as evidenced by the implementation of a program
    that provides specialty evaluations of and evidence-based
    psychosocial treatments for preschool aged children in an
    effort to decrease reliance on psychotropic medications,
    improved continuity of care preventing, therefore, on the use
    of medications that have perhaps proven ineffective or been
    associated with significant adverse effects in previous trials,
    increased adherence to evidence-based prescribing for the
    treatment of psychiatric disorders, in the meantime resulting
    in a cost savings, a substantial decrease in the concurrent
    prescription of two or more antipsychotic medications, improved
    monitoring of adverse side effects, for example, documenting
    the weight gain associated with second-generation
    antipsychotics, and devising a policy linking consent for these
    medications to appropriate medication oversight in the doctor's
    office, and finally, improved safety of pharmacotherapy through
    the prevention of potentially serious and even fatal drug-drug
    interactions.
        In conclusion, I will reiterate my 2007 testimony in
    support for the appropriate oversight for the use of
    psychotropic medications in foster children. As shown by the
    Illinois experience, a well designed and implemented medication
    consent and oversight program can improve the quality of care
    and increase cost-effectiveness.
        Again, I want to thank the committee for the opportunity to
    speak with you today, and I will gladly answer any questions
    you may have.
        Chairman REICHERT. Thank you, Dr. Naylor. You did just
    fine.
        Dr. NAYLOR. Thank you.
        Chairman REICHERT. Thank you for your testimony.
        [The prepared statement of Dr. Naylor follows:]

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        Chairman REICHERT. Mr. Lord, you are recognized for 5
    minutes.

       STATEMENT OF STEPHEN LORD, DIRECTOR, FORENSIC AUDITS AND
     INVESTIGATIVE SERVICES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Mr. LORD. Thank you, Chairman Reichert, Ranking Member
    Doggett, and other distinguished Members of the Committee. I am
    really honored to be here on this distinguished panel to
    discuss GAO's work examining the use of psychotropic
    medications in the foster children community. As we have
    already heard today, foster children are an especially
    vulnerable population, and in 2012, there were over 400,000
    children in the foster care system, some of whom had
    experienced neglect and physical abuse.
        Today I would like to focus on two key issues. The first is
    the extent to which children in foster care are prescribed
    psychotropic medications, and secondly, Federal and State
    oversight of these practices. The first key point I would like
    to make is that children in foster care take psychotropic
    medications at higher rates than other children. As we heard
    from the administration witness, 18 percent of foster children
    were taking a psychotropic medication at the time they were
    surveyed, and this compares to about 6 percent for
    noninstitutionalized children in Medicaid nationwide and about
    5 percent for children in private insurance plans.
        It is also important to note that within certain
    populations of foster children, for example, those who lived in
    group homes or residential treatment centers, the rates are
    much higher. The data shows that 48 percent of those living in
    residential homes and treatment centers were taking
    psychotropic medications.
        But another important caveat is these rates do not
    necessarily imply inappropriate prescribing practices based on
    the medical experts we consulted. In some cases, these rates
    could be due to foster children's greater mental health needs
    and perhaps greater exposure to trauma.
        The second key point I would like to make is the Federal
    and State oversight of psychotropic use among foster children
    has improved over the last few years, although we
    wholeheartedly agree additional guidance and attention is
    needed. In 2011, we reported that States monitoring
    psychotropic use among foster children fell short of the best
    practice guidelines espoused by the American Academy of Child
    and Adolescent Psychiatry. Thus we recommended that HHS endorse
    additional best practice guidance to help ensure States were
    properly overseeing the use of these drugs. And the good news
    is that HHS agreed with our recommendation, and ACF has issued
    directives to States to establish better protocols for
    monitoring their youth, and this includes a key April 2012
    program of instruction designed to achieve this goal.
        However, as we highlighted in our new report we issued just
    last week, additional guidance is needed, as some States
    transition away from the so-called fee-for-service arrangement
    to managed care organizations to deliver these prescription
    drug benefits. The need for additional guidance is underscored
    also by our detailed case study reviews, the 24 case studies we
    did as part of our current work. In some instances, the experts
    we consulted, including Dr. Naylor, I should point out, found
    good supporting documentation in the case files for the youth.
    However, in other areas, there was a question. You know, we
    found some supporting documentation, but it raised questions
    about whether some children were receiving the proper therapies
    and treatments, such as evidence-based therapies that might
    have been useful.
        In closing, Federal and State governments have actively
    taken a number of important steps to better oversee the
    prescribing of these drugs. That is the key message of the body
    of work GAO has issued in this area, but as we recently
    highlighted, additional steps are needed to help ensure there
    is good oversight and monitoring of this drug use.
        Mr. Chairman, that concludes my statement. I look forward
    to answering any questions you may have. Thanks.
        Chairman REICHERT. Thank you, Mr. Lord.
        [The prepared statement of Mr. Lord follows:]

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        Chairman REICHERT. Thank you all for your testimony.
        We now move into the question and answer phase of the
    hearing. I will begin.
        My first question is for Ms. Hovenier. I just want to thank
    you again for being here and having courage to tell your story
    and also thank you for all the work that you are doing to help
    other children in foster care.
        You talked a little bit about how you succeeded and what
    helped you, and really you focused on people need love;
    children need love versus drugs. And I wonder if you could just
    tell me a little bit more about--we know your family was there.
    They loved you. Your CASA adviser was there. How did you
    finally get to the point where you were being able to pull
    yourself out of that or have your family pull yourself out of
    that treatment center?
        Ms. HOVENIER. So, on my 18th birthday, I aged out of foster
    care. When I turned 18, they could no longer keep me there.
    However----
        Chairman REICHERT. The drugs.
        Ms. HOVENIER. In the psychiatric facility, they could no
    longer keep me there.
        Chairman REICHERT. Right.
        Ms. HOVENIER. And since I was no longer there, I didn't
    want to take the medications to start out with, so when I left
    the facility, I am like, Okay, I am never taking another
    psychotropic medication because I do not like the way they made
    me feel, and I have never liked it. And so that was when I
    decided I don't need the medication. I already knew I didn't
    need it, but that was the starting point with, Okay, I want to
    get off; how do I do this? And when I moved up to Bellingham,
    we couldn't find a psychiatrist to take me off because they
    looked into my records from the psychiatric facility, and they
    said that they didn't want to take me off because I was a
    liability, that I might do something, but they didn't know me
    before I was on the medication. Before I was on the medication,
    I was a normal teenager, being a normal rebellious teenager,
    but apparently, when you are in foster care and you are
    rebellious, you get medicated. So just having my family, my
    adopted family and my new family just support me, and they are
    like, Okay, we want to do what you want to do. We are here.
    Just let us know anything we can do, and having a private paid
    therapist was a big deal to me because this therapist knew me
    and wanted to support me in getting off. And she wasn't one of
    the therapists that were like, Oh, we are leaving you on this,
    we want to keep you on this. So I think that was a big
    difference.
        Chairman REICHERT. How do you think we can help other
    foster kids?
        Ms. HOVENIER. I believe the government can help other
    foster kids by--I don't know if it is already a thing or not,
    but implementing the foster child no matter what has a right to
    request a second opinion from a doctor or psychiatrist, no
    matter if it is a private paid therapist, private paid
    psychiatrist, and in addition, different forms of therapy
    besides just pharmaceutical therapy, like there is many
    therapies out there. I don't know them all, but those are just
    a couple of my ideas. Thank you.
        Chairman REICHERT. Thank you. Good job.
        Dr. Naylor, Illinois has the fifth largest foster care
    caseload in the country, with about 17,000 children in foster
    care. The program you administer oversees the prescription of
    psychotropic drugs to all of these children in foster care. How
    much does this program cost annually? Do you know what the cost
    is annually?
        Dr. NAYLOR. I write the budget, and it is budget time, so I
    have a pretty good clue. It runs about $1.1 million, that is
    how much we have requested. We typically run it on about
    $900,000.
        Chairman REICHERT. And how is your program funded?
        Dr. NAYLOR. It is funded as a contract through the
    Department of Children and Family Services. The Children and
    Family Services receives funding from the State. In fact, their
    funding from the State is actually quite generous because of a
    consent decree from early 1990s, and some of the money comes
    from various Federal grants. I can't speak to how the money
    from DCFS comes to us, but it is either paid through general
    funds, which would be through the legislature or it comes from
    Children's Services funds, which are specifically earmarked to
    pay quicker. In Illinois, that is a very important factor I
    think, but pays quite a bit quicker than general funds.
        Chairman REICHERT. What are some of the key outcomes that
    sort of tell you that your efforts have been successful, that
    they are making a difference?
        Dr. NAYLOR. Well, I think there is several. One, in the
    written testimony, which I apologize, it didn't translate well
    from the Word document to the PDF, so there is some really
    weird things that happened when it was transferred to PDF, but
    you can see that there was over time a decrease in the use of
    Prozac or fluoxetine, and after the black box warning and after
    the warning regarding Paxil, we made the determination based on
    pretty sound evidence that fluoxetine should be the first drug
    of choice, and by changing our review process, we were able to
    do something that I don't think made the drug companies all
    that happy, which was we increased the rate of generic
    medication, fluoxetine, at the expense of brand name
    medications that were less effective. So one of the things that
    we were able to do was to increase evidence-based prescribing
    at a cost savings because the medication with the greatest
    evidence for it was also the medication that was the cheapest.
        We were able also to show a decline in the use of
    antipsychotic polypharmacy, and these numbers actually are even
    more dramatic than you see in the written testimony because of
    the way we analyze this. We were very conservative.
        Chairman REICHERT. You answered my last question to you.
    You just mentioned cost savings. Okay.
        Dr. McGraw, you have spent your career focusing on mental
    health issues and how to appropriately address them. What do
    you believe is the best way to raise awareness of this issue so
    children are better protected from being prescribed these drugs
    that really aren't going to help them? What is the best way to
    get--one of these of course is today's hearing, with your
    presence that adds to it, but do you have some ideas on that?
        Mr. MCGRAW. Well, I do. I think we need to keep just
    ringing the bell over and over because it is out of sight, out
    of mind, and I think so often these children become invisible,
    and their treatment or their absence of treatment become
    invisible because they are just simply taken out of the
    mainstream, and I think that is why I said a hearing like we
    are having today is so important. We talk about this on the
    ``Dr. Phil'' platform, we talk about it on ``The Doctors,''
    kind of the medical version of our show, and people care about
    this, Chairman Reichert.
        I know when we have had a call to action for CASA
    volunteers, it has just been overwhelming. I mean, we have been
    able to generate close to $90 million in volunteer services
    just from asking people to come forward and get involved.
    People want to get involved. They don't know how. And that is
    why something like a CASA is so important. For you and I, we
    had a football coach that kind of stepped up and jerked a knot
    in our tail and said, you know, get in class and be out here at
    practice, but, you know, you look at all of the psychological
    research, and I don't think there is anything more powerful for
    these children than a caring adult that puts their arm around
    their shoulder and says, I am going to help you navigate this
    maze.
        So I think we just have to tell people about it, and we
    have got to tell them something they can do because if we get
    more adults involved in their lives, then these drugs are going
    to start to go away because there is going to be somebody there
    that says this is just a normal kid, a typical kid that has
    grown up in atypical circumstances. And we need to teach them,
    not medicate them, and I think that only happens when--you
    know, my dad used to say nothing makes the crops grow like the
    shadow of the owner, and it is the same way with your kids.
    Nothing protects your child than their biological parent, but
    if you don't have that, have a caring adult there that will pay
    attention to what is happening, and that is what happened to
    this courageous young woman here. We have got to have a call to
    action to get more people involved, and if you can't be a
    foster parent and bring children into your home, then you can
    be a CASA, which means you just navigate maybe two children a
    year through the process and watch over them, even if you can't
    open your home. If you don't have money to give, you can at
    least do that. So we have just got to tell people what they can
    do to become involved.
        Chairman REICHERT. Thank you.
        Mr. Doggett, you are recognized.
        Mr. DOGGETT. Thank you very much, and thank you for your
    insightful and moving testimony. There is no doubt that
    everyone up here on this dais shares your concern. The question
    is whether or not we will take the action to do something to
    change anything, and that, whether that action will occur in a
    meaningful way is far from certain in this Congress.
        Mr. Chairman, I would ask in that regard unanimous consent
    to enter into the record a letter from over 100 child advocacy
    organizations urging support for the administration's budget
    proposal to reduce the overmedication of foster children
    through a new demonstration project involving both child
    welfare and Medicaid agencies.
        Chairman REICHERT. Without objection.
        Mr. DOGGETT. And, Dr. Phil, I see that your foundation is
    among the organizations that signed that letter, and you have
    already talked about it. All of us are moved when we hear the
    stories from our CASA volunteers. I know I have been in Austin,
    in San Antonio. They do extraordinary work. But we can't solve
    this problem with just volunteers, without resources, as you
    have indicated. You said, and I think I got it down, it takes
    time, and it takes money, and it takes a completely different
    model.
        If you would, just outline why you think it would be
    valuable to have these additional resources and attempt to have
    a demonstration project to help us combat the overprescribing
    of these medications to children in foster care.
        Mr. MCGRAW. Well, Congressman Doggett, thank you for the
    question, and let me say, I think the worst thing we could do
    is throw more money at the model we have now.
        Mr. DOGGETT. Right.
        Mr. MCGRAW. If we throw more money to fund Medicaid or
    State agencies to keep writing these prescriptions and
    medicating these children, I think that would be disastrous. It
    would be like throwing gas on a fire. What it takes, and this
    is where money can be spent, is if you now have actual live
    people that will sit down and counsel these folks, give them
    the coping skills, the organizational skills, teach them how to
    talk to themselves about what has happened to them in their
    lives.
        I spoke at a luncheon earlier today with these shadow
    foster kids here. What a great group, by the way, what an
    audience--you want to speak to those kids, let me tell you.
    But, you know, I said to them, sometimes you have to give
    yourself what you wish you could get from someone else. Maybe
    you don't have a parent there to put their arms around you and
    tell you how proud they are of you, but sometimes you have to
    give that to yourself. But they can't do that without having
    someone unravel this emotional ball of yarn for them. They have
    been abandoned. They have been neglected. They have been
    abused. Someone needs to tell them, what do you say to yourself
    about that? Psychology has made just wonderful advances with
    evidence-based therapies that give the kids the coping skills,
    the tools to do that. That is where the money should be spent,
    that is where the money will be spent with the new model, and
    that is why I support that, if it is done in that way, but it
    takes manpower. It takes manpower, and you are right, you can't
    do it with all volunteers, and sometimes the problems are over
    the volunteers' head. I mean, just over their skill set. If you
    have got someone that truly does have a mental illness that
    requires professional intervention, all the love in the world
    is not going to fix that. You need professional intervention to
    do that, and that is why you can't do it with all volunteer,
    and that is why the money would be well spent if it is not
    spent pouring more drugs on the problem.
        Mr. DOGGETT. Ms. Chang, let me ask you to respond on that
    also with specifics because, clearly, we don't want to just
    pour more money into buying drugs. We would like to have some
    cost savings there. But why is it that additional resources are
    needed to get this other model going? Can you expand on what
    Dr. Phil has just told us?
        Ms. CHANG. Sure, I would be happy to do that. I think when
    we think about a system that functions effectively, you need at
    a minimum three core components. You need the ability to screen
    and assess so you can identify what is actually happening in
    that child's life and what their needs are. You need to then be
    able to connect what you have identified to appropriate
    evidence-based interventions, like Dr. Phil was talking about.
    And finally, you have to be able to monitor that child and
    follow them to make sure that that intervention is actually
    working for that individual child.
        We do this in regular medicine all the time, right? If you
    go to your doctor, they are going to prescribe something for
    you. They tell you to come back and follow up, make sure that
    medicine worked. If it didn't, they will try something else.
    Far too often in child welfare, we are missing at a minimum
    those first two components, right? We don't have adequate
    screening and assessment tools that actually can identify what
    trauma that child has experienced and what that has done to
    that child's cognitive, social, emotional, mental health well-
    being, so we miss that first part. And even when we do have the
    capacity to measure what is going on in that child's life, what
    we have learned from the local jurisdictions is that they do
    not have access to the evidence-based interventions, and so
    there are many missing components. And that is why this
    demonstration is really designed to help local jurisdictions
    who want to do the right thing have the resources to either, to
    create for the first time or scale up evidence-based
    interventions. We know what works in the field, and often, as
    folks have said, it really is about family-based care,
    community-based care with mental health professionals who are
    trained in these evidence-based interventions.
        Mr. MCGRAW. Congressman Doggett, I also want to add you are
    not really talking about new money here, by the way. Because
    what hasn't been talked about is these psychotropic drugs have
    addictive elements to them, and these children are at higher
    risk for addiction problems later in life if they have been on
    these drugs or abusing these actual drugs. And you are going to
    have to deal with that down the road if you don't deal with it
    here. If you take the drugs out and you put the right treatment
    and therapies in, you may spend that money doing it now, but
    you are not going to spend that money with lost productivity in
    society with someone that has an addiction problem later in
    life. So pay me now or pay me later, so you would do a whole
    lot better off to do it now and prevent the problems because
    one thing we know is when children get addicted to drugs, their
    development stops, their mental, emotional development stops,
    educational deficits set in.
        Just because these were written with a prescription instead
    of on the street doesn't make their impact any different. The
    educational deficits, the developmental deficits, those things
    become profound, and you are going to pay for those later, and
    it is--that is why it is important to do it now, and whether
    you are--it is with reunification with the family or it is with
    these foster parents, most of which are absolute heros stepping
    up in these kids' lives, so, you know, you are not really
    talking about new money here. It is because just are going to
    spend it here or you are going to spend it there.
        Mr. DOGGETT. Thank you very much.
        Chairman REICHERT. Thank you.
        Mr. Kelly, you are recognized.
        Mr. KELLY. Thank you, Chairman.
        Thank everybody for being here.
        But if I'm listening to you, I may be hearing it
    incorrectly, Ms. Chang you maybe can help me on this. Seems to
    me that because we have had such a human breakdown in the
    family unit, that we have more of these children that are out
    there that cannot be taken care of by a mom and a dad and what
    we would consider a traditional family unit. So,
    overwhelmingly, I was reading the numbers, 400,000 children
    right now in foster care. That is as of 2012. I don't know
    where it is today. So is this--if you were to break it down
    demographically, are these from lower income or lower middle
    income people? Where are these children coming from?
        Ms. CHANG. Sure. So, you are correct. We have a little less
    than 400,000 children in foster care today. I want to note that
    that is a huge mark of progress in the system. That is a
    reduction from over 500,000 children in care just about 10
    years ago, so the system has made a difference. But you are
    right, these are young people who come from often low
    socioeconomic backgrounds. They come from challenging
    neighborhoods, and the abuse and neglect they experience before
    they came into care and then the trauma of coming into care
    even--even if they had to leave an abusive and neglectful
    family, coming into care can be traumatic, but most of these
    kids can be cared for in a foster home with a relative and most
    of them, in fact, are.
        The great majority of our kids are placed with relatives or
    other foster families, and many of them don't have serious
    mental illnesses. Most of our kids have trauma symptoms that
    often are misdiagnosed as mental illness, and because we fail
    to intervene early on, they can escalate into much more serious
    behavior.
        Mr. KELLY. I guess that is where my question comes in. So
    who does the intervention, who determines an intervention is
    necessary? And I think that is the part that bothers me. I have
    got eight grandchildren right now. And 9 and 10 are coming, and
    there is no two of them that are alike.
        Ms. CHANG. That is right.
        Mr. KELLY. Some are more challenging than others.
        Ms. CHANG. That is right.
        Mr. KELLY. The ones that are the most challenging, I
    wouldn't say his problem is he needs medication; I would say
    maybe he needs a little more parenting, but I worry about it.
        Ms. Hovenier, you refer to now you actually have two
    families, two dads and a mom. I think that is interesting
    because you don't say I have two people taking care of them.
    You say the term that most of us have identified as growing up.
    I got a mom. I got a dad. I got people who care about me. I got
    people who love me. I got people who I can go to when I need to
    go to. I keep worrying about this and maybe you can weigh in on
    this. I know your father is with you now. Your dad is with you
    now, but I don't know about your early life. What happened that
    your--your little brother, was a 10-year-old, he was also in a
    foster home. Now, did you say you had a twin sister?
        Ms. HOVENIER. I do, yes.
        Mr. KELLY. Okay. Was your twin sister in a foster home?
        Ms. HOVENIER. Yes.
        Mr. KELLY. Okay. So, your whole family?
        Ms. HOVENIER. Yes.
        Mr. KELLY. Okay. All right. So that has got to be very
    difficult.
        Dr. Phil, you deal with folks all the time. I have watched
    you a couple of times on TV. I don't have the chance to watch
    as maybe I would like to, but I see this breakdown of the
    family is what I see going on, and I think we are--we keep
    looking for government programs that somehow will do the job
    that families no longer do.
        I grew up in an all together different time, and I will
    tell you when I talk to my friends, we agree on one thing: We
    grew up in the greatest towns at the greatest times with the
    greatest parents, preachers, teachers, coaches you could ever
    imagine, and a family support system. We didn't have as much of
    a support system government supplied. We had it family
    supplied, and that is the part that bothers me.
        I look at a society that is going more to government for
    answers than it is to internally families making decisions,
    families deciding what to do to help a child, families being
    involved in the final determination of who goes on what or what
    they get prescribed to them. You see it in great numbers. You
    all see it in great numbers, but I keep coming--if our families
    continue to break down the way they are breaking down, there is
    not enough money in the world out there to take care of these
    children that are just out there going around aimlessly.
        Mr. MCGRAW. Well, that is why it is so important to focus
    on reunification. And by the way, I would be happy to get you a
    DVR so you could watch more often.
        Mr. KELLY. No, no, no, that is okay. Thank you. I
    appreciate that
        Mr. MCGRAW. No, that is--the whole reason--and when I say
    the foster system is broken, the goal has to be reunification.
    We have got to restore the American family unit in America. I
    mean, we have become a much more transient society. We used to
    go down and play on the corner and didn't go home, but now we
    go to target schools and different places around. It is a
    different time, but we have got to reinstitute the family unit
    in America, and that is breaking down, and I see it more and
    more every day where parents drop their child off at school and
    expect them to be raised. That can't happen. It has got to
    start at home.
        As parents, we--the same sex parent is the most powerful
    role model in any child's life, and that is where it begins,
    and you cannot advocate that role to anyone, and that is why
    reunification has got to be such a goal in this foster system.
        Mr. KELLY. I agree with you, but it is a socialization
    process we are missing out on today. I got to tell you, the way
    I grew up, there wasn't anybody substituting for my mother and
    my dad.
        And, Ms. Hovenier, I congratulate you in getting through
    what you have gotten through, but I think there is too many
    children out there who do not have the benefit of having a
    strong nuclear family. And I think that is the number one
    problem. If you don't have a strong nuclear family, you don't
    have a strong faith-based folks, you are not going to be able
    to get through it on your own. You just can't learn it by
    yourself through a book or through a program. Thank you.
        Chairman REICHERT. Mr. Griffin, you are recognized.
        Mr. GRIFFIN. Thank you, Mr. Chairman.
        Thank you all for being here. I am from Arkansas, and we
    have had quite a bit of success in Arkansas dealing with this
    particular problem, and you know, there is a lot of--a lot of
    jokes and a lot of things said about Congress, but I will tell
    you that a lot of the progress we have made has been because of
    the laws that we have been able to get in place. And you know,
    I was just looking, reminded of 2011, which was my first year
    of serving here, we had the Child and Family Services
    Improvement Innovation Act, which deals specifically with the
    protocol for prescribing psychotropic medication for children.
    When I look at some of the results of what has gone on in
    Arkansas, it has been incredible, and it, no doubt, has been
    encouraged and in some cases mandated by the Federal
    Government, but the boots on the ground, as we say in the Army,
    has been at the State level.
        And some of the numbers here--well, let me just say, a
    number of--a number of specific edits or, as they are called,
    or changes were put in place. One of them in particular was
    having a child psychiatrist review all requests for
    psychotropic medications for children under 5 and a whole host
    of things, but the numbers are staggering. There was a
    reduction for foster care children under 6 years old, a
    reduction of 86 percent. That is almost elimination. For
    nonfoster care, 92 percent, so there is a gap--there is a gap
    between the nonfoster care children and the foster care
    children. When you get to 6 to 12 years, reduction of 38
    percent for foster care; 49 for nonfoster. So there is
    something that works here, it seems to me, and I think--I think
    the point that, Dr. Phil, you made and some others and some
    folks up here made is a good one, and that is, look, we have
    seen that throwing money at a problem doesn't work. The VA has
    been getting more money for administration after
    administration. I think we tripled the money for the VA in the
    last little over a decade, and it is still a disaster in many
    ways, and so we have got to make sure that we are funding the
    right things and that we are funding things on the ground, not
    more administrators, and I think that is critically important.
        Now, the one thing I would--a couple of things to ask here.
    First of all, Dr. Naylor, in Arkansas, there is still a gap
    between--even though there have been significant reductions and
    great--very effective reforms, still a gap between foster care
    children and nonfoster care children. Dr. Phil mentioned
    earlier that there are certain problems or patterns with foster
    care children. He is--I think you said that there are more
    mental health problems as a percentage than in the general
    population. Maybe that explains the gap.
        Dr. Naylor, could you--I see Dr. Phil shaking his head. Dr.
    Naylor, if you could speak to that, then Dr. McGraw, Dr. Phil,
    whichever one you want to go by, if--apparently, you chosen Dr.
    Phil. But if you all could both speak to that, what is the gap?
    Why is there a gap? So, when we see a reduction, the reduction
    is not as much with the foster care population as it is with
    the nonfoster care.
        Dr. NAYLOR. Well, and I have how many minutes to answer
    that?
        Mr. GRIFFIN. I will give you as much as you want. He may
    not.
        Dr. NAYLOR. Excellent. All right. I think that there is
    several reasons. I summarized some of them in my testimony. I
    really think that these youngsters, you cannot, first of all,
    pathologize kids in foster care or foster children because the
    vast majority of them are able to carry out their roles that
    they are supposed to be carrying out, being part of a foster
    family, being part of a home of a relative, going to school and
    things like that, but there is a subgroup, and I think that
    this is a larger group in foster kids than in the general
    population.
        I was asked by Bryan Samuels, who came from Illinois,
    actually, and he asked me if I really believed that there was a
    higher rate of mental illness in foster kids, and my answer to
    him, was if you really wanted to come up with a model for
    developing mental illness in a population, that is the perfect
    model. You have kids who--a sub-population anyway, are born to
    very impulsive, very aggressive, sometimes mentally ill, very
    often substance abusing and even sociopathic parents, strike
    one. Strike two, in these families, very often there is
    neglect. Neglect is probably worse in some ways even than
    physical abuse is. Physical and sexual abuse. There is often in
    utero exposure to drugs, which you know, between tobacco and
    alcohol, you have got to two biggest risk factors for screwing
    up the kid's brain. And we continue on through disruption of
    the primary attachment.
        And you look at these kids and you think, how can you
    possibly love a mom who treats you like this or a dad who
    treats you like this? But they do, you know, and that is what
    they know. And I think the major trauma in the child welfare
    system actually is when you take the kids and how you take the
    kids into custody.
        In--you know, people talk about the trauma of taking kids
    out of the home, but let me paint a picture for you. You are
    going to school. All of a sudden the police come to you at the
    school. They pick you up, chuck you in the back seat of the
    car, and bring you off to some strange place. Now, if you look
    at this from an evolutionary point of view, abduction equals
    death. And so when you are responding to this as a child, you
    are not responding to just, oh, what a bummer, you were taken
    away from your family. You are responding to a potentially
    life-threatening situation. I mean, that is what your brain is
    telling you.
        And I think that we end up then seeing incredible sadness
    and maybe even more than that, a howling rage for some of these
    kids at being taken out of their families. And then the first
    foster home sometimes stick, but for a lot of these kids, there
    is multiple placement disruptions. And every single disruption
    that you have is accompanied by a decreasing sense of self
    worth and an increase in behavioral problems. And so we have
    the perfect system for developing emotional, behavioral, and
    psychiatric victims.
        Mr. GRIFFIN. Mr. Chairman, I would ask that----
        Chairman REICHERT. I think this is--I think this is an
    important question. The time has gone 2, almost 3 minutes over.
        Dr. Naylor, you did an outstanding job. I happen to have
    been one of those police officers years ago that was put in
    those positions, and I will allow Dr. Phil McGraw to respond in
    a sound bite, please.
        Mr. GRIFFIN. Thank you, Mr. Chairman.
        Mr. MCGRAW. I will be as quick as I can. I don't disagree
    with anything Dr. Naylor just said, but I might approach him
    from a different standpoint. Being a foster child is a social
    circumstance. It is not a mental illness. It is a social
    circumstance. You do not treat a social circumstance with a
    drug. You have to fix the underlying problem, and you have got
    to do a differential diagnosis. You have got to say, is the
    etiology here organic? I mean, is there a biochemical imbalance
    that needs to be corrected inside the body, or has someone gone
    through some type of psychological trauma that has threatened
    their safety and their security and their self worth and their
    ability to predict the consequences of their life and their
    action. And if that is the case, I just don't believe that you
    are going to fix that with medication long term.
        Now, it doesn't mean it can't help short term because it
    certainly can, but particularly for these young children, there
    is not one shred of evidence that many of these drugs are
    appropriate to use with 1- and 2-year-old children, certainly
    in a polypharmacy circumstance. And I am not down on
    psychotropics because, let me tell you, they can save and
    change lives when appropriately used, but being a foster child
    is a social circumstance, not a mental illness.
        Now, it can trigger depression and some other things that
    have to be dealt with, but what is the treatment of choice? Is
    the treatment of choice to begin drug therapy? Is the treatment
    of choice to begin some type of evidence-based psychological
    therapy? And I think the former has many more side effects than
    the latter and therefore is much more dangerous.
        Chairman REICHERT. Thank you. Thank you for your answer.
        Mr. Renacci, you are recognized
        Mr. RENACCI. Thank you, Mr. Chairman.
        I want to thank the panel. You know, one thing great about
    being in Congress--I have only been here 3 and a half years--is
    you do get to learn a lot. I was in the business world for 30
    years, and I have always believed in a safety net. There is no
    doubt about that. Coming from Ohio, there are 12,000 Ohio
    children living in foster care each month. You know, when the
    State agrees to take on the responsibility of caring for those
    children and the safety of the vulnerable population, it
    becomes their responsibility, and too many times we set them up
    for failure, not success, which I keep hearing as I am
    listening to this panel. And as I started to read about some of
    the headlines, you know, regarding this issue, ``Out of Sight,
    Out of Mind: Psychotropics and Foster Care,'' ``Mind-Altering
    Psych Drugs for 7-Year Old,'' these are just media stories that
    are--as you start to read and figure out what is going on, and
    you know, when the odds are already really against these
    individuals, that is very concerning.
        So what I am trying to do is get some answers, and I
    listened. One thing I did hear you say, Dr. McGraw, is throwing
    additional money onto this problem is not the answer--the
    current system, I should say. Now, redirecting it might be the
    answer, but before I let you respond to that, I do want to ask
    Dr. McGraw and Dr. Naylor, in each of your opinions, really,
    where is the push for the use of psychotropic drugs coming
    from? You know, is it the child welfare system? Is it the
    medicaid system? Drug companies? Foster parents? Schools? Or
    somewhere else? I would like to get either of your opinions on
    that.
        Dr. NAYLOR. Well, I think that the routes into a
    psychiatrist's office varies. So, very often, as a child
    psychiatrist, I will hear variations of this story. Johnny, who
    is in foster care, has just lost his third preschool, and his
    fourth preschool is going to kick him out. He is running around
    the house, chasing the cat with a knife, and you need to do
    something and you need to do something now. And very often,
    these kids will have had therapy.
        The problem is, is that not all therapies are correct. So
    one of the routes in is because the psychotherapy that is
    provided is not particularly effective and not evidence-based,
    but something needs to be done now. And this can come from
    foster parents. This can come indirectly from schools through
    the foster parents into the office. Very often, it is
    caseworkers who don't necessarily know how to negotiate a
    mental health system. And you would think that mental health
    systems and child welfare systems work together. You would also
    be very wrong if you thought that. I mean, they are very much
    silos. And so I think very often, child welfare workers then
    will say, okay, I know this psychiatrist that treated one of my
    other. I will bring this youngster in.
        I don't--I think that also as a child psychiatrist sitting
    in the office, I look at what is available to make an
    intervention right now that might be able to head off a
    psychotropic medication. And one of the biggest problems is
    access to evidence-based therapies. Like I say, I can get
    somebody to play Chutes and Ladders with them and talk about
    nondescript things, but I can't get good evidence-based
    therapy.
        Mr. RENACCI. So the push is from all of the above?
        Dr. NAYLOR. Yeah.
        Mr. RENACCI. Dr. McGraw?
        Mr. MCGRAW. Well, you can tell you are talking to somebody
    that knows and lives this system, because when he says, I can
    get somebody to play Chutes and Ladders with them, but if you
    have got somebody that truly has a serious self-destructive
    problem, it takes a much higher level of professionalism.
        Here is the problem: Your caseworkers might have 40 files,
    and in those--a given file might have 8 kids in it, so you are
    just talking about being completely overwhelmed, and so what
    you are doing is you are warehousing the problem short term.
    You say, I have got somebody chasing the cat with the knife and
    the school won't let him back in, so you want to take him? What
    are you going to do?
        And so what they do--that is why I use the term chemical
    straightjacket. That is exactly what they do. They put the kid
    in a chemical straightjacket till they can figure something
    out, but the figuring out part never happens. The figuring out
    part never happens.
        Mr. RENACCI. Can you elaborate on your comment earlier
    about throwing more money at this, and just give us here a
    better solution or what your solution would be?
        Mr. MCGRAW. What I am saying is right now, we are overusing
    psychotropic drugs. That is the model. We are overusing them.
    And if you throw more money at it, what you are going to do is
    you are going to spread that problem. That is not the fix. What
    you have got to do is change the model and then finance the
    model.
        You cannot just pour money on the existing model. You have
    got to change the model, and then say, okay, that is all well
    and good there, Dr. Phil, but how are you going to--how are you
    going to give that caseworker access to the professional level
    of intervention that they need? Where are you going to get the
    therapist? How are you going to do that? Where you going do it?
    And that takes manpower, and manpower takes money, and that is
    what I am saying. You have got to change the model to one that
    is intervention based instead of medication based. And that
    takes manpower, and manpower takes money.
        Chairman REICHERT. Time has expired.
        Mr. Boustany, you are recognized.
        Mr. BOUSTANY. Thank you, Mr. Chairman.
        And thank you for holding this hearing. It is a really
    important hearing.
        My wife is a CASA in south Louisiana. I have been hearing
    about all the horror stories and problems that are sort of
    built into the system, as all of you have very, very concisely
    described today, and we were having a conversation not long ago
    over the kitchen table, and she said, you guys have to do
    something about this. It is a huge problem. And then when she
    heard through CASA channels that we were having this hearing,
    she said, thank God that we are doing this, that we need to
    look at this problem. And so I want to thank you. I want to
    thank the panelists for being here.
        I am also a medical doctor and have real concerns on a
    number of issues. One, Dr. Phil, you mentioned the fragmented
    nature of all this, and my wife has really schooled me on this
    whole system and how fragmented decisionmaking is and
    everything else. And you couple that with the psychotropic
    drugs of which, and you correctly said earlier, nobody really
    knows the mechanism of how they really work but they do save a
    lot of lives, but it is even more of a pronounced situation in
    children, adolescents, in understanding what the long-term
    impacts will be, especially if the drugs are used
    inappropriately. I mean, the adolescent in childhood, the
    neurological systems function a whole lot different and they
    respond differently to these drugs.
        But I want to drill down on something. And that is, where
    is the decision made oftentimes or for the most part? Is there
    a pattern? Where are the decisions made to put these children
    on these drugs? I mean, obviously, they see a social worker, a
    CASA will see them. They may be in the court system. They don't
    go straight to a psychiatrist, and the psychiatrist or the
    family doctor or general practitioner is the one who has
    prescribing authority, but somebody is making a decision,
    sending it--then sending him through a psychiatrist or general
    practitioner, the family practitioner who then writes a
    prescription, and I am not convinced in the system that we have
    today that the person prescribing the medicine is actually
    following these cases and applying best practices, you know,
    and appropriate follow up. So I just would like one more
    comment on how this decisionmaking is made at that level to get
    these kids on these drugs.
        Ms. CHANG. So I can begin, and certainly other folks can
    weigh in. I think the question is a good one, and I think that
    is why screening and assessment is so critical. When we don't
    have appropriate screening and assessment tools, we are
    shooting in the dark, right, and so people are not making
    informed decisions, no matter who it is that instigates that
    process, so we need to make sure that that is happening.
        We are really pleased actually that Louisiana is one of our
    grantees who is focused on installing universal trauma-based
    screening and assessment in the State for all children in the
    child welfare system. And they are actually one of our State
    grantees who came to us and said, We do want to do this grant,
    we want to be successful, we have installed screening and
    assessment tools so that we can identify what kids actually
    need. And many of them don't need psychotropic medications.
        The problem they found was they didn't have access to the
    evidence-based interventions the kids do need, and that is the
    real challenge. And as Dr. Phil says, you know, it costs money
    to scale up evidence-based interventions. You have to train
    physicians. You have to train social workers. You have to
    monitor the program itself to make sure it is being implemented
    with fidelity. You have to have data systems that can track the
    outcomes of these kids. That costs money. And so, you are
    right, from the very beginning, we don't have systems in place
    to actually identify what it is these kids need, so many people
    are shooting in the dark.
        And also another challenge is that we have to be realistic.
    A lot of our kids do not have access to providers in a timely
    way that they need them, right. Some of our kids are waiting
    for 6 months to see a physician, and so you can imagine that
    the caseworker knows that that child is not going to see that
    doctor again perhaps for another 6 months, and so they are
    doing what the best that they can with the tools that they have
    available to them, and what we want to do is to expand their
    toolbox so that they have the right instruments they need to
    serve individual children where they are.
        Mr. BOUSTANY. Is there an appropriate review process in
    many of the States? You know, after a child is put on
    psychotropic medication, obviously, you need to, you know,
    track it and monitor it and review the appropriateness of the
    therapy. I mean----
        Ms. CHANG. Well, thanks to Congress, led by this committee
    and through passage of legislation in 2011, we now have a
    Federal mandate that all child welfare system have a process in
    place to oversee the psychotropic medication use of children in
    their care. And what we have heard from researchers, although
    it is still really early because now it has only been a few
    years that these processes have been in place, what researchers
    are finding and they are very excited is that it has made a
    difference.
        So your actions have made an impact in the lives of
    children, and what we want to do is take it to that next step
        Mr. BOUSTANY. Thank you.
        Chairman REICHERT. The gentleman's time has expired.
        We will move on to Mr. Crowley.
        Mr. CROWLEY. Thank you, Mr. Chairman.
        Thank you for holding this hearing today. And to Mr.
    Doggett as well, the ranking member.
        Dr. Phil, I am desperate to try to ask you a profound
    question and hope I might get on your television show, but I
    can't come up with one, but I do want to thank you for the
    attention you are bringing to this issue.
        You mentioned the shadow--the foster youth in the shadows
    today, and I think the real attempt here is to bring them out
    of the shadow and into the light that all of society can better
    understand the circumstances that they are living in, so thank
    you for that.
        I have the opportunity--and I also want to thank my good
    friend and colleague Karen Bass, who is not a member of the
    subcommittee, but I am hopeful, will have an opportunity to say
    a few words as well. She, since coming to Congress, has been an
    incredible leader on the issue of foster care. I dabbled a
    little bit into it, and she has really taken over and really
    ran with it, so I really appreciate all she has done for this
    effort. But I had the opportunity this morning to meet with a
    very impressive young lady named Chanise, who was following me
    this morning, and we had opportunity to share some of her
    experiences and exchanged some ideas and thoughts and to try to
    find some solutions and actions that can take place to
    effectively bring about the changes that are needed within the
    foster care system.
        And that is what our charge here in Congress is to do is to
    try to find ways to bring about change of things that need
    fixing. And certainly I think the foster care system is in need
    of our attention. We have seen the data on how common it is for
    children in foster care to be prescribed these psychotropic
    medications, in some cases, multiple medications at one time,
    and in fact, Chanise shared with me her own experiences in
    terms of medicated--being medicated at a very, very young age.
        And medication is the medication is trying to solve an
    issue that perhaps could be better addressed through
    intervention as has been discussed here earlier today. That is
    something that, as I mentioned, I talked to Chanise about, but
    it is also something in my home State of New York, where I
    think new ground is being broken. And I appreciate the work
    that is taking place there. We need to separate out what is a
    problem generally worthy of medicated treatment and what is
    better served by a social worker or other personal engagement.
    While reducing medication can be a worthy goal in and of
    itself, we want to make sure we are also focusing on a
    comprehensive approach that includes alternative treatments.
        New York has been a leader in trying to address the
    problems of overmedicated--overmedicating foster youth. New
    York is one of five States, including Illinois, as I believe,
    Dr. Naylor, you may be familiar with, participating in a 3-year
    initiative developed by the Center for Health Care Strategies
    and made possible through the Annie E. Casey Foundation. This
    initiative focuses on in collaborative--collaboration among
    State agencies to develop more effective practices for the use
    of these medications in foster care. State experts in New York
    tell me that this initiative has highlighted important areas
    that need to be addressed in order to have successful policies
    on this issue.
        For example, one of the first challenges they had to meet
    was how to share data amongst the various agencies because
    while the Office of Children and Family Services was
    responsible for overseeing the foster care system, the actual
    medical treatment data was under Medicaid within the Department
    of Health, and the Office of Mental Health was also involved as
    well, so even just to survey how widespread the problem is
    required a new level of interagency cooperation. New York was
    fortunate that they honed in on this issue early and were able
    to address it. I know other States may be struggling with
    similar data-sharing problems, so I urge them to look at New
    York as an example.
        Beyond just the data-sharing aspect, it is critical that
    multiple agencies work productively together. You have
    situations where the foster care agency may make
    recommendations or set protocols, but the doctors prescribing
    the medication are under the Department of Health. Everyone
    needs to work together in order to get the best results
    possible.
        One of the lessons New York has learned is to emphatically
    stress collaboration and to ensure that each part of the system
    understands the impact that reaches beyond a single agency.
        Ms. Chang, I see that the ACF has sought to encourage this
    collaboration through their demonstration, so I was wondering
    if you could possibly expound upon that and comment on what is
    taking place.
        Ms. CHANG. Sure. Thank you. We agree with you. We think
    that collaboration is critical. Children in the foster care
    system are not served by one agency. They are served by
    multiple agencies. The Medicaid agencies, the mental health
    agencies, as well as child welfare, and so that is why we are
    really excited that this proposal has both an ACF component as
    well as a CMS component, and that goes to part of what I said
    about having access to providers.
        We know that we have to create incentives so that there are
    physicians who are willing to care for our kids, that we have
    to create incentives to say that the Medicaid offices can also
    get funding to pay for the types of supports that they need so
    that there are providers, and it brings those two groups--major
    groups that serve these people--these children to the table to
    work together.
        Mr. CROWLEY. Thank you.
        Thank you, Mr. Chairman. I yield back.
        Chairman REICHERT. Thank you, Mr. Crowley.
        Mr. McDermott, you are recognized.
        Mr. MCDERMOTT. Thank you, Mr. Chairman. I--full disclosure,
    I was trained at the University of Illinois and worked at
    Allendale School, so I know a little bit about the Illinois
    system.
        My question is really, let's take Dawna. She goes into
    foster care and somebody writes a script for her to have
    medication. And I am talking about today, not 3 or 4 years ago
    when this happened, but today in Illinois. How would that be
    evaluated before she got the medication? Or would it be a
    retrospective evaluation 6 months later? Or when did it happen
    and by whom and did they ever see her? How would that decision
    have been made for her?
        Dr. NAYLOR. That is a good question, and I--there are
    various ways of doing these reviews prospective and
    retrospective being the two major categories. Ours is a
    prospective one, so we review all of the requests before the
    medication is actually prescribed and dispensed.
        Mr. MCDERMOTT. So she is creating havoc in the house as a
    rebellious teenager, which she says she was. Somebody says this
    kid needs to be on drugs, so somebody writes a script, and then
    how long does it take to get to you and your independent agency
    to make a decision about whether she should have them or not?
        Dr. NAYLOR. I hate to use you as an example, but you are
    hospitalized right now, and so the medication request comes to
    DCFS and our program at the very same time, and it has all of
    the diagnostic information, all of the symptom information, all
    medications that she would be on, and our review is not a true
    second opinion. We don't have the resources to be able to send
    somebody out to do an evaluation, and I think we have like
    2,700 kids on medication. That would take a lot of resources to
    have a second opinion on everybody.
        And so the work becomes, there is a diagnosis and the
    symptoms match, if they match, is the treatment something that
    would be recommended or recognized treatment for that
    combination of diagnoses and symptoms. If it is, is the dose
    requested being--an appropriate dosage, and if that is the
    case, we would approve the medication.
        Mr. MCDERMOTT. How often do you reject a request for
    medication for a patient? A thousand scripts come in to you,
    you look at a thousand of them, how many times do you say no?
        Dr. NAYLOR. That is a complicated question, and I will go
    through it as quickly as I can. I don't deny all that many
    requests anymore. And the reason I don't deny all that many
    requests anymore is because I have been doing this now for 15
    years, and initially, when I started the program, people would
    talk to my boss and complain about Dr. Naylor's idiosyncratic
    psychopharmacology, and so they would rant and rave against
    what my recommendations would be. But my boss knew that I was
    arguing science and arguing good clinical care, and so, over
    time, people have changed their prescribing practices, and so
    that is one thing we do.
        Another thing that we do is we ask really embarrassing
    questions like, do you really think it is a good idea to start
    this patient, who is psychotic, on a stimulant, which can cause
    psychosis? And the very act of asking the question will--again,
    because I have been there for 15 years, will lead to the doctor
    withdrawing the request for the medication because they know
    that if they persist, it will be denied.
        So we deny probably 1 percent. There is probably 8 percent
    that are rescinded, but this is down from about 15 percent
    denials and fairly high rescinding rate about 10 years ago.
        Mr. MCDERMOTT. And then 6 months later or a year later, you
    have now put her on the medication, you think it is a good
    idea, what is the possibility it will ever be looked at again
    by someone?
        Dr. NAYLOR. Well, in terms of the consent process, by law,
    I will look at that again in 6 months. We only provide consent
    for every 6 months. And we will ask for a clinical update. If,
    at any point along the way, including with the first time that
    they made a request for the medication, I can request a second
    opinion from another physician, or if it is one of those cases
    that would end up on the front page of the newspaper, I will
    sometimes go out and do these second opinions, so we will
    follow up with getting as much clinical information as we can
    get in order to make a determination whether that medication is
    still indicated or not.
        Mr. MCDERMOTT. If she ran into a CASA worker who said--and
    she said, I don't think I should be on this medication, can I
    get off it, can you help me get off it, and they called you--
    can they call you? Can they appeal to you? Is there any way of
    appeal to you to review what is going on there?
        Dr. NAYLOR. Absolutely. We actually have several different
    ways in where requests for a rereview can be made, and these
    requests can come from guardian ad litems, CASA workers,
    judges, juvenile judges, caseworkers. The nurses in Illinois
    are like another pair of eyes and ears, and they will often
    refer back for additional consultation. And now psychologists
    are also out in the field doing similar kind of monitoring
    work, so we will get consultation requests that way.
        A foster child can go to the guardian ad litem and say I
    would like a second opinion on my medication, and we will find
    a way to get a second opinion done, so yes, there is.
        Mr. MCDERMOTT. Ms. Chang, is this common across the United
    States? The Illinois system is something as comprehensive as
    that?
        Ms. CHANG. This particular model of reauthorization is not
    as common.
        Mr. MCDERMOTT. Not as common. Give me numbers here.
        Ms. CHANG. So I can't give you a 50-State survey. I am
    happy to get back to you, sir, and tell you exactly how all
    States are structuring it. Most States, based on our review, do
    have a monitoring after the fact, and really, the--many of
    those programs are highly successful. Texas is a good example
    of that. They have protocols for when medication can be used,
    and they have a systematic way of reviewing all scripts to make
    sure that they follow the protocol. They also then look at
    individual physicians who break protocol more than once, and so
    they have a very effective way of managing medication, even
    though it doesn't involve preauthorization. And we find that
    most States employ that type of protocol and then making sure
    that doctors are following it.
        There are other models. For example, Massachusetts makes
    sure that there are mental health professionals who specialize
    in medication management who are always available to social
    workers, caseworkers, as well as other physicians who are
    seeing these kids so that whenever questions come up, they can
    immediately get professional assistance because oftentimes, one
    of the problems is that these are folks without the expertise
    in prescribing these types of medications, so there are a
    variety.
        Mr. MCDERMOTT. Thank you.
        Thanks for extending my time.
        Chairman REICHERT. You are welcome.
        Thank you, Mr. McDermott.
        And Ms. Chang, if you can provide that information in
    writing to the committee, I think that was a very good
    question, we would like to have that additional information, if
    you please.
        So, I am just going to repeat a few things that I heard
    today, and then you can leave. We will wrap this up. First of
    all, I heard--I think we are all on agreement--we just don't
    want to pour money into a system that currently is not
    operating at 110 percent, right? So, we recognize there is some
    work there to do. Ms. Chang is working with the States in
    trying to bring States along to develop systems, and Illinois
    is a great example of some great progress that has been made,
    but we all can do better.
        I think, in listening to Ms. Hovenier and her suggestions,
    you know, I really like the idea of no matter what, a second
    opinion. I think coming from you, that has a lot of power
    behind it.
        Choices of therapy, I think Dr. McGraw and Dr. Naylor and
    others have mentioned that sometimes some therapies just don't
    work because it is the wrong therapy. So that was a great point
    that you made.
        And then the mention of tools, the proper tools for
    screening, for assessment and evidence-based, I think is
    really, really critical, and that is when you begin to apply
    the resources and the funding when you know that you have got
    evidence-based information to make decisions on. I think all of
    the panel would agree with that, and I think the members that
    were here today would agree with that.
        And I want to thank, again, all of you for taking time out
    of your busy schedules to be here today. This is such an
    important topic, and all the members here that were here to ask
    questions and listen to your testimony.
        And again, a special thank you to Ms. Bass for her work in
    this arena and helping us schedule this hearing.
        So if members have additional questions, those of us who
    are left, for the witnesses, they will submit them to you in
    writing, and we would appreciate receiving your responses for
    the record within 2 weeks. The committee now stands adjourned.
        [Whereupon, at 4:13 p.m., the subcommittee was adjourned.]
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                      Letter of the Adopt America Network

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