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




                               before the


                                 of the

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


                             SECOND SESSION


                              MAY 29, 2014


                          Serial No. 113-HR12


         Printed for the use of the Committee on Ways and Means


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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
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
MIKE KELLY, Pennsylvania

        Jennifer M. Safavian, Staff Director and General Counsel

                  Janice Mays, Minority Chief Counsel



                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

                            C O N T E N T S


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


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:]



  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.


    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.


    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.


    Please Note: Any person(s) and/or organization(s) wishing to submit 
for the hearing record must follow the appropriate link on the hearing 
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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 
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    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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:]

    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.


    Ms. HOVENIER. Thank you, Chairman Reichert, Ranking Member 
Doggett, and committee members for giving me the opportunity to 
    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 
    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 
    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:]

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


    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 
    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 
    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 
    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:]

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

                         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 
    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 
    Dr. NAYLOR. Thank you.
    Chairman REICHERT. Thank you for your testimony.
    [The prepared statement of Dr. Naylor follows:]


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


    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:]
    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. 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Mr. GRIFFIN. I will give you as much as you want. He may 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.]
    [Questions for the record follow:]
    [Submissions for the record follow:]
                  Letter of the Adopt America Network