[House Hearing, 113 Congress] [From the U.S. Government Publishing Office] CARING FOR OUR KIDS: ARE WE OVERMEDICATING CHILDREN IN FOSTER CARE? ======================================================================= HEARING before the SUBCOMMITTEE ON HUMAN RESOURCES of the COMMITTEE ON WAYS AND MEANS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED THIRTEENTH CONGRESS SECOND SESSION __________ MAY 29, 2014 __________ Serial No. 113-HR12 __________ Printed for the use of the Committee on Ways and Means [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] U.S. GOVERNMENT PUBLISHING OFFICE 94-399 WASHINGTON : 2016 ----------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Publishing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC 20402-0001 COMMITTEE ON WAYS AND MEANS DAVE CAMP, Michigan, Chairman SAM JOHNSON, Texas SANDER M. LEVIN, Michigan KEVIN BRADY, Texas CHARLES B. RANGEL, New York PAUL RYAN, Wisconsin JIM MCDERMOTT, Washington DEVIN NUNES, California JOHN LEWIS, Georgia PATRICK J. TIBERI, Ohio RICHARD E. NEAL, Massachusetts DAVID G. REICHERT, Washington XAVIER BECERRA, California CHARLES W. BOUSTANY, JR., Louisiana LLOYD DOGGETT, Texas PETER J. ROSKAM, Illinois MIKE THOMPSON, California JIM GERLACH, Pennsylvania JOHN B. LARSON, Connecticut TOM PRICE, Georgia EARL BLUMENAUER, Oregon VERN BUCHANAN, Florida RON KIND, Wisconsin ADRIAN SMITH, Nebraska BILL PASCRELL, JR., New Jersey AARON SCHOCK, Illinois JOSEPH CROWLEY, New York LYNN JENKINS, Kansas ALLYSON SCHWARTZ, Pennsylvania ERIK PAULSEN, Minnesota DANNY DAVIS, Illinois KENNY MARCHANT, Texas LINDA SANCHEZ, California DIANE BLACK, Tennessee TOM REED, New York TODD YOUNG, Indiana MIKE KELLY, Pennsylvania TIM GRIFFIN, Arkansas JIM RENACCI, Ohio Jennifer M. Safavian, Staff Director and General Counsel Janice Mays, Minority Chief Counsel ______ SUBCOMMITTEE ON HUMAN RESOURCES DAVID G. REICHERT, Washington, Chairman TODD YOUNG, Indiana LLOYD DOGGETT, Texas MIKE KELLY, Pennsylvania JOHN LEWIS, Georgia TIM GRIFFIN, Arkansas JOSEPH CROWLEY, New York JIM RENACCI, Ohio DANNY DAVIS, Illinois TOM REED, New York CHARLES W. BOUSTANY, JR., Louisiana C O N T E N T S __________ Page Advisory of May 29, 2014 announcing the hearing.................. 2 WITNESSES JooYeun Chang, Associate Commissioner of the Children's Bureau, Administration for Children and Families, Department of Health and Human Services (HHS)....................................... 6 Dawna Zender Hovenier, The Mockingbird Society................... 13 Phil McGraw, Ph.D., Talk Show Host, Dr. Phil..................... 18 Michael Naylor, M.D., Associate Professor of Psychiatry, Chicago School of Medicine, University of Illinois at Chicago (UIC).... 27 Stephen Lord, Director, Forensic Audits and Investigative Services, Government Accountability Office..................... 38 SUBMISSIONS FOR THE RECORD Adopt America Network, letter.................................... 77 James Harris, statement.......................................... 84 QUESTIONS FOR THE RECORD JooYeun Chang.................................................... 76 CARING FOR OUR KIDS: ARE WE OVERMEDICATING CHILDREN IN FOSTER CARE? ---------- THURSDAY, MAY 29, 2014 U.S. House of Representatives, Committee on Ways and Means, Subcommittee on Human Resources, Washington, DC. The subcommittee met, pursuant to call, at 2:30 p.m., in Room 1100, Longworth House Office Building, the Honorable Dave Reichert [chairman of the subcommittee] presiding. [The advisory of the hearing follows:] HEARING ADVISORY FROM THE COMMITTEE ON WAYS AND MEANS Chairman Reichert Announces Hearing on Caring for Our Kids: Are We Overmedicating Children in Foster Care? Washington, May 29, 2014 Congressman Dave Reichert (R-WA), Chairman of the Subcommittee on Human Resources of the Committee on Ways and Means, today announced that the Subcommittee will hold a hearing on the use of psychotropic medications among children in foster care. The hearing will take place at 2:00 p.m. on Thursday, May 29, 2014, in room 1100 of the Longworth House Office Building. In view of the limited time available to hear from witnesses, oral testimony at this hearing will be from invited witnesses only. Witnesses will include experts on the prescription and use of psychotropic drugs by children, and especially children in foster care. However, any individual or organization not scheduled for an oral appearance may submit a written statement for consideration by the Committee and for inclusion in the printed record of the hearing. BACKGROUND: Recent reports have highlighted how children in foster care are prescribed psychotropic drugs at very high rates. According to data compiled by the Congressional Research Service, between 2008 and 2010, nearly one out of every four children in foster care was using a psychotropic medication on any given day--more than four times the rate among all children. A recent Wall Street Journal story and a multi-part Denver Post series highlighted how youth in foster care may be prescribed these powerful, mind-altering drugs because they are misdiagnosed as having mental health disorders instead of being recognized as having problems stemming from the abuse and neglect they have experienced. Congress has taken a number of steps in recent years designed to prevent the overuse of psychotropic drugs by children in foster care. The Child and Family Services Improvement Act of 2006 (P.L. 109-288) required States to describe how they consult with doctors to assess the health and well-being of children in foster care and determine appropriate medical treatment for them. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (P.L. 110-351) required States to ensure children in foster care have access to health and mental health care services and develop strategies for overseeing drugs prescribed to them. Most recently, the Child and Family Services Improvement and Innovation Act of 2011 (P.L. 112-34) added that States must develop protocols covering the use of psychotropic medication for children in foster care. States have also taken positive steps to address concerns about the use of psychotropic medications by children in foster care. These efforts include reviewing new prescriptions before they are approved, monitoring existing prescriptions, and examining data on prescription rates among youth in foster care. For example, in Illinois, board certified child psychiatric consultants review all psychotropic medication requests. Connecticut has hired a Chief of Psychiatry to oversee medications for youth in foster care. Texas has a data system designed to ensure that psychotropic medications are prescribed within established guidelines. In announcing the hearing, Chairman Reichert stated, ``Our future lies with our nation's children. For kids in foster care, we have an added responsibility to help them succeed, including helping them overcome the trauma they experienced before, and in some cases since, they left their home. Recent news reports have highlighted how powerful psychotropic drugs are prescribed at high rates to children in foster care, including by individuals who may misdiagnose the effects of trauma on these children as a mental health problem. I look forward to hearing from experts on this issue, learning what States are doing to ensure the proper use of these medications, and discussing how the Federal Government can better support efforts to provide youth in foster care with the help they need to become successful adults. FOCUS OF THE HEARING: This hearing will focus on what is known about the use of psychotropic medications by children in foster care, how States have implemented recent Federal laws designed to ensure such medications are used appropriately, and how the Federal Government can continue to work with States to improve the oversight of these medications to ensure youth in foster care receive appropriate help. DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee website and complete the informational forms. From the Committee homepage, http://waysandmeans.house.gov, select ``Hearings.'' Select the hearing for which you would like to submit, and click on the link entitled, ``Please click here to submit a statement or letter for the record.'' Once you have followed the online instructions, submit all requested information. Attach your submission as a Word document, in compliance with the formatting requirements listed below, by June 12, 2014. Finally, please note that due to the change in House mail policy, the U.S. Capitol Police will refuse sealed-package deliveries to all House Office Buildings. For questions, or if you encounter technical problems, please call (202) 225-1721 or (202) 225-3625. FORMATTING REQUIREMENTS: The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. The Committee will not alter the content of your submission, but we reserve the right to format it according to our guidelines. Any submission provided to the Committee by a witness, any supplementary materials submitted for the printed record, and any written comments in response to a request for written comments must conform to the guidelines listed below. Any submission or supplementary item not in compliance with these guidelines will not be printed, but will be maintained in the Committee files for review and use by the Committee. 1. All submissions and supplementary materials must be provided in Word format and MUST NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official hearing record. 2. Copies of whole documents submitted as exhibit material will not be accepted for printing. Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material not meeting these specifications will be maintained in the Committee files for review and use by the Committee. 3. All submissions must include a list of all clients, persons, and/or organizations on whose behalf the witness appears. A supplemental sheet must accompany each submission listing the name, company, address, telephone, and fax numbers of each witness. The Committee seeks to make its facilities accessible to persons with disabilities. If you are in need of special accommodations, please call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four business days notice is requested). Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. Note: All Committee advisories and news releases are available online at http://waysandmeans.house.gov/.
Chairman REICHERT. The committee will come to order. Welcome to today's hearing on this very important topic of whether youth in foster care are being prescribed medications, whether or not they are being prescribed appropriately. We will hear from our witnesses that too often the answer is no. We know from research that foster children are prescribed mind-altering psychotropic drugs at very high rates, far higher than other children. CRS found that between 2008 and 2010 nearly one out of every four children in foster care was overmedicated. That is more than four times the rate among children overall. In too many cases, government programs may be trying to medicate away the troubles that these youths have experienced that will remain with them for many years after the medications end. Dawna Hovenier is a young woman who was recently in foster care in my home State of Washington. She was unnecessarily medicated with a number of mind-altering drugs and will explain how that helps no one, least of all the youth who need it the most, and Dr. Phil McGraw will second this assertion that one of the most critical reasons to address the problem of overmedication is to ensure children receive proper treatment and not just chemical straitjackets that keep them from acting out. Congress has taken a number of steps in recent years to highlight this issue, and we expect States to continue focusing more attention on prevention as a result of these changes. Federal law passed in 2006, 2008, and 2011 sharpened the focus of States on medical needs of foster youth, including the need to develop protocols preventing the overprescribing of medications. Illinois is a leading example, as we will hear from Dr. Michael Naylor, whose office reviews all medication requests for children in foster care in Illinois. This effort has prevented overmedication of children, likely saving taxpayers money, but more importantly resulting in better care for children. Other States, including Texas and Connecticut, have similar programs, and part of our task is to ensure that all States are taking the necessary steps and learning from each other's best practices. Ultimately the best solution for children is to be in a permanent, loving home with parents who watch out for them each and every day. This subcommittee knows that, and has focused its efforts during the past year in getting more foster youth into those sort of permanent, loving homes. And H.R. 3205, the Promoting Adoption and Legal Guardianship for Children in Foster Care Act, which passed the House last year, incentivizes States to move more children, especially older children, into adoptive homes, and just last week the House passed H.R. 4058, the Preventing Sex Trafficking and Improving Opportunities for Youth in Foster Care Act, which requires States to more quickly move children out of foster care into permanent homes. I am hopeful that we will enact these bills this year. That will help more children move from foster care into loving homes, improving their lives in many ways, vastly decreasing the likelihood of using or needing psychotropic drugs. We welcome all of our witnesses today, and we look forward to their testimony. I was meeting today with one of the foster youth out there in the audience, Courtney is out there. She and I had a chance to talk, and she told her story of moving from foster home to foster home to foster home and even living in a foster home that was not legally a foster home anymore, and State authorities didn't even know that it had been removed from the foster home approved list. So we have a lot of work to do in this area, and this is one of those issues that really tightly is wound into bringing better care to our children across this country. And I now yield time to Mr. Doggett for his opening statement. Mr. DOGGETT. Thank you, Mr. Chairman. I certainly share all the sentiments that you just expressed and appreciate this bipartisan inquiry. I think that while no doubt medication can be one appropriate tool in a treatment plan for some children, it has instead become the first line of consideration for too many children in our foster care system. The Congressional Research Service looked at the year 2010 and found that 40 percent of children in longer-term foster care over the age of 6 were using psychotropic medicines. That is a pretty staggering level. Other studies found the next year, in 2011, that those who are enrolled in Medicaid, children in foster care were prescribed psychotropic medications at rates of 3 to 11 times higher than nonfoster children. The pill is not the answer in many of these situations. Having been abused or neglected and then removed from their homes, every child coming into the foster care system has suffered some degree of trauma. We have heard firsthand in this committee about the problems with psychotropic drugs a couple years ago and continue through our research to see other examples of that, and we have heard firsthand from foster children about the trauma and how it has impacted their lives. This issue was addressed in this committee when our colleague, Chairman McDermott, chaired the committee back in 2008 and required States to develop health oversight plans for children in foster care, including the oversight of prescription medicines. In 2011, Congress strengthened that provision to include specific protocols for reviewing the prescribing of these medications to foster children. I look forward to hearing from each of our witnesses on how child welfare and Medicaid policies have changed in response to these specific laws. My home State of Texas, with the leadership of CASA, the Court-Appointed Special Advocates, recently changed the law there and took a number of steps to prevent unnecessary overmedication of children in foster care including the legislation that will give guardian ad litems a greater role in the oversight of these medications. Improved oversight of medications is only part of the solution. Children in foster care need access to comprehensive treatment for mental and emotional health needs, which requires additional efforts in both Medicaid and the child welfare system. I appreciate the presence here today and the leadership for this hearing from our colleague Karen Bass of California who heads our Foster Care Caucus. The administration's budget calls for $750 million over the next 5 years toward this goal. This is an investment that is equal to about one-quarter of 1 percent of one of the measures that our committee approved earlier today. I believe that we do need to come together with common purpose and hear of any ways we can change the law in this area, but we also have to have the resources present to be able to get the job done effectively and not just respond after some crisis or horrible situation has hit the news media. Thank you, Mr. Chair, and I look forward to hearing from our witnesses. Chairman REICHERT. Thank you, Mr. Doggett. I would like to just mention briefly, I would like to thank Ms. Bass for her work in helping us organize this hearing and her work in helping foster children. It is a pleasure to have you attending our hearing this morning, and also a moment just to thank Mr. McDermott for his hard work as past chairman and past ranking member of this committee and also Mr. Doggett for his support. So, as you can all see, this is a bipartisan effort, rarely seen. We are together on this, and we are going to make a difference and help people. So thank you again, Mr. Doggett. Without objection, each member will have the opportunity to submit a written record and statement and have it included in the record at this point. I want to remind our witnesses to please try and limit your testimony to 5 minutes. However, without objection, all of the written testimony will be made a part of the permanent record, and on our panel this afternoon, we will be hearing from JooYeun Chang, Associate Commissioner of the Children's Bureau Administration for Children and Families, U.S. Department of Health and Human Services; Dawna Zender Hovenier, the Mockingbird Society; Dr. Phil McGraw, talk show host, ``Dr. Phil Show''; Dr. Michael Naylor, M.D., Associate Professor of Psychiatry, School of Medicine, University of Illinois at Chicago; and Stephen Lord, Director of Forensic Audits and Investigative Services, U.S. Government Accountability Office. I would like to mention that we have other experts in the audience who know a thing or two about the foster care system because they have lived it, and as I mentioned just a little bit earlier, a lot of our foster youth are in the audience today, and I think we probably have over 60. And you know what, I am going to do something a little bit unusual, I am going to ask the foster kids, if they want to, to raise your hand or stand because we want to give you a big applause, round of applause for your success. As you can see, they are not shy. We are so happy to have you here. So each of these youth have spent the morning with a Member of Congress, and as I said, Courtney and I got to spend a little time together and talk about my life and her life. We found some similarities as runaways, but I was fortunate enough to make it back to my home and not into a foster home. So thank you for coming today. Ms. Chang, please proceed with your testimony. STATEMENT OF JOOYEUN CHANG, ASSOCIATE COMMISSIONER OF THE CHILDREN'S BUREAU, ADMINISTRATION FOR CHILDREN AND FAMILIES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Ms. CHANG. Thank you. Chairman Reichert, Ranking Member Doggett, and Members of the Subcommittee, thank you for inviting me to testify today. The administration is very concerned about the overmedication of children in the foster care system. We are grateful to you for having this hearing and bringing more attention to the issue. My name is JooYeun Chang, and I am the Associate Commissioner of the Children's Bureau. I have worked as a national advocate on child welfare policies, both as a senior staff attorney at the Children's Defense Fund as well as at Casey Family Programs Foundation, where I worked closely with State and local child welfare agencies. In my current role, I oversee the Federal foster care and adoption assistance programs as well as a range of prevention and post-permanency initiatives. At the Department of Health and Human Services, we are working with State child welfare agencies to ensure that vulnerable children in their care receive appropriate care and services and that they are effectively monitoring for psychotropic medication use. Children who come into foster care often have been exposed to multiple traumas, including abuse and neglect and subsequent removal from their homes. The CDC's Adverse Childhood Experiences Study and other research tells us that the impacts of these negative life experiences affect children in all domains, from brain development to physical health, to how a young person reacts emotionally to various situations and how they are or are not able to interact with others. We know from our research that children who enter foster care are at much higher risk for developing both physical and emotional disorders, especially traumatic stress, and the child welfare system currently struggles to fully meet their needs. If inadequately treated, these experiences can lead to worsening health conditions and may hinder a foster parent's ability to meet the child's needs, potentially resulting in multiple placements for that child. This lack of stability can lead to increasingly restrictive and costly placements and make it more difficult for that child to find a permanent, loving family. These undesired outcomes can negatively impact the well-being of children and youth in foster care and also mean additional cost for the child welfare and other public systems. The need for action in this area is clear. Our own data show that 18 percent of children in foster care are taking one or more psychotropic medications, and the GAO has estimated an even higher rate of 21 to 39 percent. Children in care are prescribed psychotropic medications at far higher rates than other children served by Medicaid and often in amounts that exceed those indicated by FDA approved labeling for such drugs. We appreciate the important role that Congress, led by this committee, has played in bringing attention to these issues, specifically the 2008 enactment of Fostering Connections to Success and Increasing Adoptions Act, which required for the first time ongoing oversight and coordination of health care services for children in foster care, to the more recent enactment of the Child and Family Services Improvement and Innovation Act in 2011 that requires States to report to HHS protocols they have in place for monitoring the use of psychotropic medications. We have worked across the agency and collaboratively across the Department to provide guidance to States on monitoring the use of psychotropic medications for children in foster care, and we have also shared information about evidence-based interventions that address the underlying issues of trauma. We reviewed the progress that had been made and saw that there was a practice gap that needed to be filled. Child welfare agencies often did not have access to adequate research-based nonpharmaceutical mental health treatments and, as a result, often rely on medication as a first line of treatment. If we are serious about reducing the use of psychotropic medication, we must also ensure that child welfare agencies have access to evidence-based interventions. Therefore, along with CMS, we developed the proposal you see in the President's fiscal year 2015 budget, one we hope you will give thoughtful consideration to. This proposal presents a concerted effort to reduce overprescription of psychotropic medications for children by increasing the availability of evidence-based psychosocial treatments that meet the complex needs that children who have experienced maltreatment often have. Increased access to timely and effective screening, assessment, and nonpharmaceutical treatment will reduce overreliance on psychotropic medication, improve child emotional and behavioral health, and increase the likelihood that children in foster care will exit to positive, permanent settings with the life skills and resources they need to be successful. The administration looks forward to working with you to address this crucial issue and improve services to some of our most vulnerable young people. Again, thank you for the opportunity to speak with you today. I would be happy to answer any of your questions. Chairman REICHERT. Thank you, Ms. Chang. [The prepared statement of Ms. Chang follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Chairman REICHERT. And before Ms. Hovenier begins, I would just like to point out that she is quite a remarkable young woman, and as a 21-year-old alumni of Washington's foster care system, she spent 7 years in foster care, primarily in Pierce County in western Washington, just south of Seattle area. She has become a strong advocate for foster care reforms, working with the Mockingbird Society, an advocacy organization for young people impacted by foster care and homelessness in Washington State. And I know she hopes her advocacy will improve the foster care system for young people who come after her, and I believe that you will. Thank you for being with us today, and you can go ahead. She says she is not nervous. I told her I was. But go ahead, you have 5 minutes, Ms. Hovenier. STATEMENT OF DAWNA ZENDER HOVENIER, THE MOCKINGBIRD SOCIETY Ms. HOVENIER. Thank you, Chairman Reichert, Ranking Member Doggett, and committee members for giving me the opportunity to speak. My name is Dawna Zender Hovenier. I am 21-years old and have spent 7 years in foster care in Washington State. On my 18th birthday, I aged out of foster care and was released after spending 7 months in an adolescent psychiatric hospital. My hope is that the government will quit spending millions of dollars forcing kids like me to take drugs they do not need and give them things they do need, such as a volunteer CASA who believes in them, skilled mental health professionals who they can talk to and, most of all a loving, compassionate family that believes in them. I was ordered into the psychiatric hospital after my social worker told the court I had borderline personality disorder, major depressive disorder, and suicidal ideation. I was forced to take strong doses of psychotropic medication and told I could probably never live on my own. Only my CASA and the man who became my father agreed with me that I did not need the drugs. The 7 months I was locked up and forced to take these drugs felt like being in jail. After reviewing my records, I discovered that the foster care system paid $15,000 a month, about $120,000 total, to lock me up and take these drugs. Last year, I earned my certified nurses aide certificate after successfully completing 2 years of classes at Bellingham Technical College. My GPA? It was a 3.92. I am currently enrolled at Whatcom Community College in Bellingham, Washington. Thanks to Federal and State funding for former foster youth, I was able to complete all my prerequisites required for a nursing degree. I am hoping to be accepted into an RN program to pursue my dreams of becoming a nurse. I have lived independently for more than 2 years. I have been off all psychiatric medications for more than 3 years. I have never felt better or happier. What happened? How did I transition from being diagnosed a mentally disabled foster youth to a model student and productive member of society? I don't have time to tell my whole story. Despite everything I experienced growing up, I know I was lucky. When I was 16, the man who recently became my father and is here with me today adopted my then 10-year-old brother from foster care. My younger brother was also forced to take strong doses of psychiatric drugs. He has been off them since his adoption more than 5 years ago. My dad hired an attorney to fight the State's plan to transfer me to an adult psychiatric facility. He picked me up on my 18th birthday and sent me to live with his friends. They are now my family, too. So today it feels like I have two dads and a mom. The next 6 months were among the most difficult in my life. Because of my diagnosis in foster care, we could not find a psychiatrist willing to take me off the medications, so we had to do it ourselves. This meant battling many intense withdrawal symptoms. One of the medications I was on can cause seizures, resulting in death if not carefully discontinued. My dad wrote a book about adopting my brother from foster care, and some of the professionals who read it advised him on how to get me off these medications. Six months after aging out of foster care I managed to graduate from Mount Baker High School with my class. A few months later, I moved into my own apartment. My new family helped me find an excellent therapist, who supported me in my decision to get off these medications. Today I am able to talk about my feelings, but when I was in the psychiatric hospital, I was so drugged up, I didn't even know how I felt. My twin sister said I was like a zombie. I know some of the kids I was locked up with needed medication. They heard voices that weren't there and got violent sometimes, but I believe many of the foster kids were like me and needed loving parents to guide them. When I think about the government spending over $120,000 locking me up and forcing me to take these drugs, it makes me very angry. I wish that the money could have been spent helping foster youth. Despite all of this, I have been so lucky. A few months ago, on the same day as my brother's adoption 5 years ago, my dad adopted my twin sister and me. What really helped me get off the medication was being surrounded by people who loved me and wanted to help me. I believe what most foster youth need is love, not drugs. Although I can never get back the 7 months that I was locked up and forced to take these drugs, I hope that telling my story here today and continuing to work with the Mockingbird Society will help other youth like me and encourage change. In closing, I want to thank the Mockingbird Society for making it possible for me to come from Seattle to be here today. They are an awesome youth advocacy organization that helps young people share our experiences about foster care and gives us a chance to be heard. Thank you, Chairman Reichert, for inviting me here today. I want to thank you for all the work you do for foster youth. Dr. Phil, I also want to thank you for everything you have done. And I am grateful to my CASA for being the person who knew me and told the court that I did not need these drugs, and for all my family, my twin sister, and my therapist for supporting me to get off these medications. Thank you. Chairman REICHERT. You did awesome. You want to come up here and take my place and run the rest of the show? Ms. HOVENIER. No thank you. Chairman REICHERT. No? Thank you for your testimony and thank you for your work. [The prepared statement of Ms. Hovenier follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Chairman REICHERT. Dr. McGraw, you are recognized for 5 minutes. STATEMENT OF PHIL MCGRAW, PH.D., TALK SHOW HOST, ``DR. PHIL'' Mr. MCGRAW. Chairman Reichert, Ranking Member Doggett, and distinguished Members of the Committee, I wish I didn't have to follow this young lady. That is a tough act, to say the least. I am honored to be invited here to talk about the possible misuse of these psychotropic drugs. They are all too often prescribed to America's foster children. Look, these drugs can change and even save lives, there is no question about it, but when it comes to these vulnerable children, these drugs are just too often misused as chemical straitjackets. It is just a haphazard attempt to simply control and suppress undesirable behavior rather than treat it, nurture it, and develop these treasured young people, and simply put, it just makes them less inconvenient. It just makes them less inconvenient so they don't take as much energy to manage. And you have my written statement, and I kind of want to begin where it leaves off because I believe that 80 percent of all questions are really statements in disguise. And I think everybody here already agrees, these drugs are flowing too much; there is just no question about that. You know the numbers. The real question is why? You know, why is this happening? I mean, three times as many foster children as their counterparts are getting these drugs; 40 percent of them are on three classes of drugs, some are on five classes of drugs. This is polypharmacy. Is there more psychopathology with these foster children? Of course, there is. They have more abuse and neglect that they have had to go through. Eighty percent are diagnosed with mental illness as opposed to 20 percent in the general population, but this is no justification. I have been working with this population for 5 years, for five decades. Robin and I have been national spokespersons for CASA for a number of years. Their budget has been cut, which just broke my heart to see. These kids face problems that you are not going to fix by throwing drugs at them. And a lot of them don't even take the drugs; they sell them. Dr. Charles Sophy is with me here today. He is the chief medical director for the L.A. County DCFS, the largest in the country. He told me within the last month, near a shelter in L.A., some of those children tried to sell him their psychotropic drugs, not knowing he was the medical director, and more than once in an hour trying to sell the drugs. If they do take them, are they less inconvenient? Maybe. But it is not convenience without consequences. They should never be used without evidence-based research. There should be proper diagnostics done and appropriate monitoring done, and it should always be in conjunction with evidence-based therapies, and anything less, we just have to be honest, we are sabotaging these kids, we are just flat out sabotaging them. And in my view, this is like pulling a thread. The entire system is flawed. It is not just the drugs. The entire system is flawed. Do we need to turn off the flood of drugs? Yes. But the problem is we have got a reverse incentive system here. It is a system where the government continues to pay for the drugs. We say you shouldn't give them, but yet they continue to be compensated for them, and these foster children, the more labels they get, the more drugs they are on, the more money they get to take care of that child. So they are actually paid for pathology. The more scripts, the less treatment, the more scripts, the less energy, and so it just becomes an assembly line, high volume, move them in, move them out process, and these children deserve better than that. Real treatment takes high energy, it takes--it is low volume. I mean, you have got to have more people, it takes more time, but we have got too many doctors with insufficient training in these drugs. They don't know what the drugs do. We don't--most of us, if we are honest, we have to tell you, we don't know why the drugs work when they do work. We don't know the agent of action, the agent of change, but we have too many doctors with insufficient training about these drugs that are prescribing them, and there is no follow up because the foster parents change. So there is no long-term follow on this, and then the therapists they do get, they change. You have got children with detachment problems, attachment disorders, detachment problems, and we rotate their therapist in and out. As soon as they bond with one, then they are faced with another one. So it just becomes a serious problem. I have been in this situation, hopefully, fortunately not as bad as some of these children, but I was homeless when I was 15 years old. I was living on the streets in Kansas City. I was living in a car. We finally got a room at the YMCA, my dad and I, and then ultimately an apartment where we got an apartment, but we had no utilities because we didn't have money for the deposit. So we froze to death in the dark from 4:30 on, but I tell you what happened to me. Nobody ran at me with a handful of drugs. I fortunately had a football coach and some others who taught me about responsibility, taught me about the things to do that were important, and that is what CASAs do with these children. That is what therapists involved with evidence-based treatments would do with these children. But we have got to stop the flow of drugs and we have got to focus on reunification. We have just got to try to get these children back home. This system is broken, and it is flawed, and psychology has made great strides. We truly do have alternatives to offer these children, and without the side effects that the drugs have, but it takes time and it takes money, and it takes a completely different model than what we have right now, and so I am obviously very passionate about this. I just feel so strongly that these children need somebody to put an arm around their shoulder, somebody to help them, rather than just throw drugs at them, and there is nothing better for these children than to be able to look themselves in the mirror and say, I did this, I found my way, I got my coping skills. So I will stop. I want to thank the committee for inviting me to participate. A wise man once said--well, actually it was me that said it, you can't change what you don't acknowledge. And this committee is making a bold acknowledgment of this problem, and so I am happy to answer any questions. I have Dr. Frank Lawlis, the chairman of my advisory board here; Dr. Charles Sophy, who I mentioned earlier, is here; Dr. Marty Greenberg, our director of professional affairs, is here. We are all here to answer any questions anybody has got. We want to change this model. We want to start taking care of these kids. They have been through enough. Chairman REICHERT. Thank you. Well, we didn't even have to hold up an applause card on that one. I wish we had a half hour show, Doctor, but that was great testimony. Thank you so much. You and I have a couple of things in common. One, I ran away and lived in my car. It was a 1956 Mercury for me; I don't know what you had. Mr. MCGRAW. 1955 Chevy, no reverse. It had no reverse, but it did go forward. Chairman REICHERT. And it was a football coach that came to help me, too, so thank you for your testimony. [The prepared statement of Mr. McGraw follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Chairman REICHERT. And Dr. Naylor, you are recognized for 5 minutes. STATEMENT OF MICHAEL NAYLOR, M.D., ASSOCIATE PROFESSOR OF PSYCHIATRY, SCHOOL OF MEDICINE, UNIVERSITY OF ILLINOIS AT CHICAGO (UIC). Dr. NAYLOR. Chairman Reichert, Ranking Member Doggett, and Members of the Subcommittee on Human Resources, before I start, I really want to lodge a complaint against who seated me here. He only had to follow one really incredible testimony. I have to follow two. I hope I can live up to it. Thank you for inviting me to testify before the committee. I am truly honored at the opportunity to address the issue of psychotropic medications for kids in the foster care system. We have already heard children in foster care, by definition Medicaid-eligible, are at higher risk for developing severe emotional disturbances and utilize mental health services at higher rates than other Medicaid-eligible youth. They are prescribed more medications at higher rates and at higher doses. In a way, these are not particularly surprising findings. As a population, foster children have multiple risk factors that predispose them to severe emotional disturbances and psychiatric illnesses, including often of genetic predisposition to mental illness, in utero exposure to drugs and alcohol, the adverse effects of growing up in poverty, a history of severe trauma, disrupted early attachments, and multiple placement disruptions, to name just a few. To complicate matters, there is the fragmented medical and psychiatric care system and an absence in the most part of a consistent caregiver to provide consent for and longitudinal oversight of their ongoing care. Despite all of this, I do contend that psychotropic medications are often an important component of a comprehensive psychosocial treatment plan that really is based on a good biopsychosocial understanding of these kids and their situation. I will describe how a program designed and implemented by the Illinois Department of Children and Family Services to provide consent for and oversight of psychotropic medications in foster children has resulted in more effective, safer, and more cost-effective care. In July 2007, I testified in front of the committee under Congressman McDermott and to advocate both for the oversight of psychotropic medications for foster children and to describe a program, the DCFS centralized psychotropic medication consent program. Illinois State law prohibits the administration of psychotropic medications to foster children without the consent of the DCFS guardian. And this is a centralized office compared to other consent programs across the Nation. To support the consent process, DCFS contracted with UIC to provide an independent review of all psychotropic medication consent requests to determine the appropriateness of the proposed treatment. Utilizing an extensive database consisting of consent data, Medicaid pharmacy payment claims, and data from the State-wide automated child welfare information system, we can monitor an individual's medication history over time, across placements, and across providers, and we can monitor State-wide patterns of psychotropic medication use. We believe that this prospective psychotropic medication consent and oversight process has resulted in higher quality and more cost- effective care, as evidenced by the implementation of a program that provides specialty evaluations of and evidence-based psychosocial treatments for preschool aged children in an effort to decrease reliance on psychotropic medications, improved continuity of care preventing, therefore, on the use of medications that have perhaps proven ineffective or been associated with significant adverse effects in previous trials, increased adherence to evidence-based prescribing for the treatment of psychiatric disorders, in the meantime resulting in a cost savings, a substantial decrease in the concurrent prescription of two or more antipsychotic medications, improved monitoring of adverse side effects, for example, documenting the weight gain associated with second-generation antipsychotics, and devising a policy linking consent for these medications to appropriate medication oversight in the doctor's office, and finally, improved safety of pharmacotherapy through the prevention of potentially serious and even fatal drug-drug interactions. In conclusion, I will reiterate my 2007 testimony in support for the appropriate oversight for the use of psychotropic medications in foster children. As shown by the Illinois experience, a well designed and implemented medication consent and oversight program can improve the quality of care and increase cost-effectiveness. Again, I want to thank the committee for the opportunity to speak with you today, and I will gladly answer any questions you may have. Chairman REICHERT. Thank you, Dr. Naylor. You did just fine. Dr. NAYLOR. Thank you. Chairman REICHERT. Thank you for your testimony. [The prepared statement of Dr. Naylor follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Chairman REICHERT. Mr. Lord, you are recognized for 5 minutes. STATEMENT OF STEPHEN LORD, DIRECTOR, FORENSIC AUDITS AND INVESTIGATIVE SERVICES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE Mr. LORD. Thank you, Chairman Reichert, Ranking Member Doggett, and other distinguished Members of the Committee. I am really honored to be here on this distinguished panel to discuss GAO's work examining the use of psychotropic medications in the foster children community. As we have already heard today, foster children are an especially vulnerable population, and in 2012, there were over 400,000 children in the foster care system, some of whom had experienced neglect and physical abuse. Today I would like to focus on two key issues. The first is the extent to which children in foster care are prescribed psychotropic medications, and secondly, Federal and State oversight of these practices. The first key point I would like to make is that children in foster care take psychotropic medications at higher rates than other children. As we heard from the administration witness, 18 percent of foster children were taking a psychotropic medication at the time they were surveyed, and this compares to about 6 percent for noninstitutionalized children in Medicaid nationwide and about 5 percent for children in private insurance plans. It is also important to note that within certain populations of foster children, for example, those who lived in group homes or residential treatment centers, the rates are much higher. The data shows that 48 percent of those living in residential homes and treatment centers were taking psychotropic medications. But another important caveat is these rates do not necessarily imply inappropriate prescribing practices based on the medical experts we consulted. In some cases, these rates could be due to foster children's greater mental health needs and perhaps greater exposure to trauma. The second key point I would like to make is the Federal and State oversight of psychotropic use among foster children has improved over the last few years, although we wholeheartedly agree additional guidance and attention is needed. In 2011, we reported that States monitoring psychotropic use among foster children fell short of the best practice guidelines espoused by the American Academy of Child and Adolescent Psychiatry. Thus we recommended that HHS endorse additional best practice guidance to help ensure States were properly overseeing the use of these drugs. And the good news is that HHS agreed with our recommendation, and ACF has issued directives to States to establish better protocols for monitoring their youth, and this includes a key April 2012 program of instruction designed to achieve this goal. However, as we highlighted in our new report we issued just last week, additional guidance is needed, as some States transition away from the so-called fee-for-service arrangement to managed care organizations to deliver these prescription drug benefits. The need for additional guidance is underscored also by our detailed case study reviews, the 24 case studies we did as part of our current work. In some instances, the experts we consulted, including Dr. Naylor, I should point out, found good supporting documentation in the case files for the youth. However, in other areas, there was a question. You know, we found some supporting documentation, but it raised questions about whether some children were receiving the proper therapies and treatments, such as evidence-based therapies that might have been useful. In closing, Federal and State governments have actively taken a number of important steps to better oversee the prescribing of these drugs. That is the key message of the body of work GAO has issued in this area, but as we recently highlighted, additional steps are needed to help ensure there is good oversight and monitoring of this drug use. Mr. Chairman, that concludes my statement. I look forward to answering any questions you may have. Thanks. Chairman REICHERT. Thank you, Mr. Lord. [The prepared statement of Mr. Lord follows:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Chairman REICHERT. Thank you all for your testimony. We now move into the question and answer phase of the hearing. I will begin. My first question is for Ms. Hovenier. I just want to thank you again for being here and having courage to tell your story and also thank you for all the work that you are doing to help other children in foster care. You talked a little bit about how you succeeded and what helped you, and really you focused on people need love; children need love versus drugs. And I wonder if you could just tell me a little bit more about--we know your family was there. They loved you. Your CASA adviser was there. How did you finally get to the point where you were being able to pull yourself out of that or have your family pull yourself out of that treatment center? Ms. HOVENIER. So, on my 18th birthday, I aged out of foster care. When I turned 18, they could no longer keep me there. However---- Chairman REICHERT. The drugs. Ms. HOVENIER. In the psychiatric facility, they could no longer keep me there. Chairman REICHERT. Right. Ms. HOVENIER. And since I was no longer there, I didn't want to take the medications to start out with, so when I left the facility, I am like, Okay, I am never taking another psychotropic medication because I do not like the way they made me feel, and I have never liked it. And so that was when I decided I don't need the medication. I already knew I didn't need it, but that was the starting point with, Okay, I want to get off; how do I do this? And when I moved up to Bellingham, we couldn't find a psychiatrist to take me off because they looked into my records from the psychiatric facility, and they said that they didn't want to take me off because I was a liability, that I might do something, but they didn't know me before I was on the medication. Before I was on the medication, I was a normal teenager, being a normal rebellious teenager, but apparently, when you are in foster care and you are rebellious, you get medicated. So just having my family, my adopted family and my new family just support me, and they are like, Okay, we want to do what you want to do. We are here. Just let us know anything we can do, and having a private paid therapist was a big deal to me because this therapist knew me and wanted to support me in getting off. And she wasn't one of the therapists that were like, Oh, we are leaving you on this, we want to keep you on this. So I think that was a big difference. Chairman REICHERT. How do you think we can help other foster kids? Ms. HOVENIER. I believe the government can help other foster kids by--I don't know if it is already a thing or not, but implementing the foster child no matter what has a right to request a second opinion from a doctor or psychiatrist, no matter if it is a private paid therapist, private paid psychiatrist, and in addition, different forms of therapy besides just pharmaceutical therapy, like there is many therapies out there. I don't know them all, but those are just a couple of my ideas. Thank you. Chairman REICHERT. Thank you. Good job. Dr. Naylor, Illinois has the fifth largest foster care caseload in the country, with about 17,000 children in foster care. The program you administer oversees the prescription of psychotropic drugs to all of these children in foster care. How much does this program cost annually? Do you know what the cost is annually? Dr. NAYLOR. I write the budget, and it is budget time, so I have a pretty good clue. It runs about $1.1 million, that is how much we have requested. We typically run it on about $900,000. Chairman REICHERT. And how is your program funded? Dr. NAYLOR. It is funded as a contract through the Department of Children and Family Services. The Children and Family Services receives funding from the State. In fact, their funding from the State is actually quite generous because of a consent decree from early 1990s, and some of the money comes from various Federal grants. I can't speak to how the money from DCFS comes to us, but it is either paid through general funds, which would be through the legislature or it comes from Children's Services funds, which are specifically earmarked to pay quicker. In Illinois, that is a very important factor I think, but pays quite a bit quicker than general funds. Chairman REICHERT. What are some of the key outcomes that sort of tell you that your efforts have been successful, that they are making a difference? Dr. NAYLOR. Well, I think there is several. One, in the written testimony, which I apologize, it didn't translate well from the Word document to the PDF, so there is some really weird things that happened when it was transferred to PDF, but you can see that there was over time a decrease in the use of Prozac or fluoxetine, and after the black box warning and after the warning regarding Paxil, we made the determination based on pretty sound evidence that fluoxetine should be the first drug of choice, and by changing our review process, we were able to do something that I don't think made the drug companies all that happy, which was we increased the rate of generic medication, fluoxetine, at the expense of brand name medications that were less effective. So one of the things that we were able to do was to increase evidence-based prescribing at a cost savings because the medication with the greatest evidence for it was also the medication that was the cheapest. We were able also to show a decline in the use of antipsychotic polypharmacy, and these numbers actually are even more dramatic than you see in the written testimony because of the way we analyze this. We were very conservative. Chairman REICHERT. You answered my last question to you. You just mentioned cost savings. Okay. Dr. McGraw, you have spent your career focusing on mental health issues and how to appropriately address them. What do you believe is the best way to raise awareness of this issue so children are better protected from being prescribed these drugs that really aren't going to help them? What is the best way to get--one of these of course is today's hearing, with your presence that adds to it, but do you have some ideas on that? Mr. MCGRAW. Well, I do. I think we need to keep just ringing the bell over and over because it is out of sight, out of mind, and I think so often these children become invisible, and their treatment or their absence of treatment become invisible because they are just simply taken out of the mainstream, and I think that is why I said a hearing like we are having today is so important. We talk about this on the ``Dr. Phil'' platform, we talk about it on ``The Doctors,'' kind of the medical version of our show, and people care about this, Chairman Reichert. I know when we have had a call to action for CASA volunteers, it has just been overwhelming. I mean, we have been able to generate close to $90 million in volunteer services just from asking people to come forward and get involved. People want to get involved. They don't know how. And that is why something like a CASA is so important. For you and I, we had a football coach that kind of stepped up and jerked a knot in our tail and said, you know, get in class and be out here at practice, but, you know, you look at all of the psychological research, and I don't think there is anything more powerful for these children than a caring adult that puts their arm around their shoulder and says, I am going to help you navigate this maze. So I think we just have to tell people about it, and we have got to tell them something they can do because if we get more adults involved in their lives, then these drugs are going to start to go away because there is going to be somebody there that says this is just a normal kid, a typical kid that has grown up in atypical circumstances. And we need to teach them, not medicate them, and I think that only happens when--you know, my dad used to say nothing makes the crops grow like the shadow of the owner, and it is the same way with your kids. Nothing protects your child than their biological parent, but if you don't have that, have a caring adult there that will pay attention to what is happening, and that is what happened to this courageous young woman here. We have got to have a call to action to get more people involved, and if you can't be a foster parent and bring children into your home, then you can be a CASA, which means you just navigate maybe two children a year through the process and watch over them, even if you can't open your home. If you don't have money to give, you can at least do that. So we have just got to tell people what they can do to become involved. Chairman REICHERT. Thank you. Mr. Doggett, you are recognized. Mr. DOGGETT. Thank you very much, and thank you for your insightful and moving testimony. There is no doubt that everyone up here on this dais shares your concern. The question is whether or not we will take the action to do something to change anything, and that, whether that action will occur in a meaningful way is far from certain in this Congress. Mr. Chairman, I would ask in that regard unanimous consent to enter into the record a letter from over 100 child advocacy organizations urging support for the administration's budget proposal to reduce the overmedication of foster children through a new demonstration project involving both child welfare and Medicaid agencies. Chairman REICHERT. Without objection. Mr. DOGGETT. And, Dr. Phil, I see that your foundation is among the organizations that signed that letter, and you have already talked about it. All of us are moved when we hear the stories from our CASA volunteers. I know I have been in Austin, in San Antonio. They do extraordinary work. But we can't solve this problem with just volunteers, without resources, as you have indicated. You said, and I think I got it down, it takes time, and it takes money, and it takes a completely different model. If you would, just outline why you think it would be valuable to have these additional resources and attempt to have a demonstration project to help us combat the overprescribing of these medications to children in foster care. Mr. MCGRAW. Well, Congressman Doggett, thank you for the question, and let me say, I think the worst thing we could do is throw more money at the model we have now. Mr. DOGGETT. Right. Mr. MCGRAW. If we throw more money to fund Medicaid or State agencies to keep writing these prescriptions and medicating these children, I think that would be disastrous. It would be like throwing gas on a fire. What it takes, and this is where money can be spent, is if you now have actual live people that will sit down and counsel these folks, give them the coping skills, the organizational skills, teach them how to talk to themselves about what has happened to them in their lives. I spoke at a luncheon earlier today with these shadow foster kids here. What a great group, by the way, what an audience--you want to speak to those kids, let me tell you. But, you know, I said to them, sometimes you have to give yourself what you wish you could get from someone else. Maybe you don't have a parent there to put their arms around you and tell you how proud they are of you, but sometimes you have to give that to yourself. But they can't do that without having someone unravel this emotional ball of yarn for them. They have been abandoned. They have been neglected. They have been abused. Someone needs to tell them, what do you say to yourself about that? Psychology has made just wonderful advances with evidence-based therapies that give the kids the coping skills, the tools to do that. That is where the money should be spent, that is where the money will be spent with the new model, and that is why I support that, if it is done in that way, but it takes manpower. It takes manpower, and you are right, you can't do it with all volunteers, and sometimes the problems are over the volunteers' head. I mean, just over their skill set. If you have got someone that truly does have a mental illness that requires professional intervention, all the love in the world is not going to fix that. You need professional intervention to do that, and that is why you can't do it with all volunteer, and that is why the money would be well spent if it is not spent pouring more drugs on the problem. Mr. DOGGETT. Ms. Chang, let me ask you to respond on that also with specifics because, clearly, we don't want to just pour more money into buying drugs. We would like to have some cost savings there. But why is it that additional resources are needed to get this other model going? Can you expand on what Dr. Phil has just told us? Ms. CHANG. Sure, I would be happy to do that. I think when we think about a system that functions effectively, you need at a minimum three core components. You need the ability to screen and assess so you can identify what is actually happening in that child's life and what their needs are. You need to then be able to connect what you have identified to appropriate evidence-based interventions, like Dr. Phil was talking about. And finally, you have to be able to monitor that child and follow them to make sure that that intervention is actually working for that individual child. We do this in regular medicine all the time, right? If you go to your doctor, they are going to prescribe something for you. They tell you to come back and follow up, make sure that medicine worked. If it didn't, they will try something else. Far too often in child welfare, we are missing at a minimum those first two components, right? We don't have adequate screening and assessment tools that actually can identify what trauma that child has experienced and what that has done to that child's cognitive, social, emotional, mental health well- being, so we miss that first part. And even when we do have the capacity to measure what is going on in that child's life, what we have learned from the local jurisdictions is that they do not have access to the evidence-based interventions, and so there are many missing components. And that is why this demonstration is really designed to help local jurisdictions who want to do the right thing have the resources to either, to create for the first time or scale up evidence-based interventions. We know what works in the field, and often, as folks have said, it really is about family-based care, community-based care with mental health professionals who are trained in these evidence-based interventions. Mr. MCGRAW. Congressman Doggett, I also want to add you are not really talking about new money here, by the way. Because what hasn't been talked about is these psychotropic drugs have addictive elements to them, and these children are at higher risk for addiction problems later in life if they have been on these drugs or abusing these actual drugs. And you are going to have to deal with that down the road if you don't deal with it here. If you take the drugs out and you put the right treatment and therapies in, you may spend that money doing it now, but you are not going to spend that money with lost productivity in society with someone that has an addiction problem later in life. So pay me now or pay me later, so you would do a whole lot better off to do it now and prevent the problems because one thing we know is when children get addicted to drugs, their development stops, their mental, emotional development stops, educational deficits set in. Just because these were written with a prescription instead of on the street doesn't make their impact any different. The educational deficits, the developmental deficits, those things become profound, and you are going to pay for those later, and it is--that is why it is important to do it now, and whether you are--it is with reunification with the family or it is with these foster parents, most of which are absolute heros stepping up in these kids' lives, so, you know, you are not really talking about new money here. It is because just are going to spend it here or you are going to spend it there. Mr. DOGGETT. Thank you very much. Chairman REICHERT. Thank you. Mr. Kelly, you are recognized. Mr. KELLY. Thank you, Chairman. Thank everybody for being here. But if I'm listening to you, I may be hearing it incorrectly, Ms. Chang you maybe can help me on this. Seems to me that because we have had such a human breakdown in the family unit, that we have more of these children that are out there that cannot be taken care of by a mom and a dad and what we would consider a traditional family unit. So, overwhelmingly, I was reading the numbers, 400,000 children right now in foster care. That is as of 2012. I don't know where it is today. So is this--if you were to break it down demographically, are these from lower income or lower middle income people? Where are these children coming from? Ms. CHANG. Sure. So, you are correct. We have a little less than 400,000 children in foster care today. I want to note that that is a huge mark of progress in the system. That is a reduction from over 500,000 children in care just about 10 years ago, so the system has made a difference. But you are right, these are young people who come from often low socioeconomic backgrounds. They come from challenging neighborhoods, and the abuse and neglect they experience before they came into care and then the trauma of coming into care even--even if they had to leave an abusive and neglectful family, coming into care can be traumatic, but most of these kids can be cared for in a foster home with a relative and most of them, in fact, are. The great majority of our kids are placed with relatives or other foster families, and many of them don't have serious mental illnesses. Most of our kids have trauma symptoms that often are misdiagnosed as mental illness, and because we fail to intervene early on, they can escalate into much more serious behavior. Mr. KELLY. I guess that is where my question comes in. So who does the intervention, who determines an intervention is necessary? And I think that is the part that bothers me. I have got eight grandchildren right now. And 9 and 10 are coming, and there is no two of them that are alike. Ms. CHANG. That is right. Mr. KELLY. Some are more challenging than others. Ms. CHANG. That is right. Mr. KELLY. The ones that are the most challenging, I wouldn't say his problem is he needs medication; I would say maybe he needs a little more parenting, but I worry about it. Ms. Hovenier, you refer to now you actually have two families, two dads and a mom. I think that is interesting because you don't say I have two people taking care of them. You say the term that most of us have identified as growing up. I got a mom. I got a dad. I got people who care about me. I got people who love me. I got people who I can go to when I need to go to. I keep worrying about this and maybe you can weigh in on this. I know your father is with you now. Your dad is with you now, but I don't know about your early life. What happened that your--your little brother, was a 10-year-old, he was also in a foster home. Now, did you say you had a twin sister? Ms. HOVENIER. I do, yes. Mr. KELLY. Okay. Was your twin sister in a foster home? Ms. HOVENIER. Yes. Mr. KELLY. Okay. So, your whole family? Ms. HOVENIER. Yes. Mr. KELLY. Okay. All right. So that has got to be very difficult. Dr. Phil, you deal with folks all the time. I have watched you a couple of times on TV. I don't have the chance to watch as maybe I would like to, but I see this breakdown of the family is what I see going on, and I think we are--we keep looking for government programs that somehow will do the job that families no longer do. I grew up in an all together different time, and I will tell you when I talk to my friends, we agree on one thing: We grew up in the greatest towns at the greatest times with the greatest parents, preachers, teachers, coaches you could ever imagine, and a family support system. We didn't have as much of a support system government supplied. We had it family supplied, and that is the part that bothers me. I look at a society that is going more to government for answers than it is to internally families making decisions, families deciding what to do to help a child, families being involved in the final determination of who goes on what or what they get prescribed to them. You see it in great numbers. You all see it in great numbers, but I keep coming--if our families continue to break down the way they are breaking down, there is not enough money in the world out there to take care of these children that are just out there going around aimlessly. Mr. MCGRAW. Well, that is why it is so important to focus on reunification. And by the way, I would be happy to get you a DVR so you could watch more often. Mr. KELLY. No, no, no, that is okay. Thank you. I appreciate that Mr. MCGRAW. No, that is--the whole reason--and when I say the foster system is broken, the goal has to be reunification. We have got to restore the American family unit in America. I mean, we have become a much more transient society. We used to go down and play on the corner and didn't go home, but now we go to target schools and different places around. It is a different time, but we have got to reinstitute the family unit in America, and that is breaking down, and I see it more and more every day where parents drop their child off at school and expect them to be raised. That can't happen. It has got to start at home. As parents, we--the same sex parent is the most powerful role model in any child's life, and that is where it begins, and you cannot advocate that role to anyone, and that is why reunification has got to be such a goal in this foster system. Mr. KELLY. I agree with you, but it is a socialization process we are missing out on today. I got to tell you, the way I grew up, there wasn't anybody substituting for my mother and my dad. And, Ms. Hovenier, I congratulate you in getting through what you have gotten through, but I think there is too many children out there who do not have the benefit of having a strong nuclear family. And I think that is the number one problem. If you don't have a strong nuclear family, you don't have a strong faith-based folks, you are not going to be able to get through it on your own. You just can't learn it by yourself through a book or through a program. Thank you. Chairman REICHERT. Mr. Griffin, you are recognized. Mr. GRIFFIN. Thank you, Mr. Chairman. Thank you all for being here. I am from Arkansas, and we have had quite a bit of success in Arkansas dealing with this particular problem, and you know, there is a lot of--a lot of jokes and a lot of things said about Congress, but I will tell you that a lot of the progress we have made has been because of the laws that we have been able to get in place. And you know, I was just looking, reminded of 2011, which was my first year of serving here, we had the Child and Family Services Improvement Innovation Act, which deals specifically with the protocol for prescribing psychotropic medication for children. When I look at some of the results of what has gone on in Arkansas, it has been incredible, and it, no doubt, has been encouraged and in some cases mandated by the Federal Government, but the boots on the ground, as we say in the Army, has been at the State level. And some of the numbers here--well, let me just say, a number of--a number of specific edits or, as they are called, or changes were put in place. One of them in particular was having a child psychiatrist review all requests for psychotropic medications for children under 5 and a whole host of things, but the numbers are staggering. There was a reduction for foster care children under 6 years old, a reduction of 86 percent. That is almost elimination. For nonfoster care, 92 percent, so there is a gap--there is a gap between the nonfoster care children and the foster care children. When you get to 6 to 12 years, reduction of 38 percent for foster care; 49 for nonfoster. So there is something that works here, it seems to me, and I think--I think the point that, Dr. Phil, you made and some others and some folks up here made is a good one, and that is, look, we have seen that throwing money at a problem doesn't work. The VA has been getting more money for administration after administration. I think we tripled the money for the VA in the last little over a decade, and it is still a disaster in many ways, and so we have got to make sure that we are funding the right things and that we are funding things on the ground, not more administrators, and I think that is critically important. Now, the one thing I would--a couple of things to ask here. First of all, Dr. Naylor, in Arkansas, there is still a gap between--even though there have been significant reductions and great--very effective reforms, still a gap between foster care children and nonfoster care children. Dr. Phil mentioned earlier that there are certain problems or patterns with foster care children. He is--I think you said that there are more mental health problems as a percentage than in the general population. Maybe that explains the gap. Dr. Naylor, could you--I see Dr. Phil shaking his head. Dr. Naylor, if you could speak to that, then Dr. McGraw, Dr. Phil, whichever one you want to go by, if--apparently, you chosen Dr. Phil. But if you all could both speak to that, what is the gap? Why is there a gap? So, when we see a reduction, the reduction is not as much with the foster care population as it is with the nonfoster care. Dr. NAYLOR. Well, and I have how many minutes to answer that? Mr. GRIFFIN. I will give you as much as you want. He may not. Dr. NAYLOR. Excellent. All right. I think that there is several reasons. I summarized some of them in my testimony. I really think that these youngsters, you cannot, first of all, pathologize kids in foster care or foster children because the vast majority of them are able to carry out their roles that they are supposed to be carrying out, being part of a foster family, being part of a home of a relative, going to school and things like that, but there is a subgroup, and I think that this is a larger group in foster kids than in the general population. I was asked by Bryan Samuels, who came from Illinois, actually, and he asked me if I really believed that there was a higher rate of mental illness in foster kids, and my answer to him, was if you really wanted to come up with a model for developing mental illness in a population, that is the perfect model. You have kids who--a sub-population anyway, are born to very impulsive, very aggressive, sometimes mentally ill, very often substance abusing and even sociopathic parents, strike one. Strike two, in these families, very often there is neglect. Neglect is probably worse in some ways even than physical abuse is. Physical and sexual abuse. There is often in utero exposure to drugs, which you know, between tobacco and alcohol, you have got to two biggest risk factors for screwing up the kid's brain. And we continue on through disruption of the primary attachment. And you look at these kids and you think, how can you possibly love a mom who treats you like this or a dad who treats you like this? But they do, you know, and that is what they know. And I think the major trauma in the child welfare system actually is when you take the kids and how you take the kids into custody. In--you know, people talk about the trauma of taking kids out of the home, but let me paint a picture for you. You are going to school. All of a sudden the police come to you at the school. They pick you up, chuck you in the back seat of the car, and bring you off to some strange place. Now, if you look at this from an evolutionary point of view, abduction equals death. And so when you are responding to this as a child, you are not responding to just, oh, what a bummer, you were taken away from your family. You are responding to a potentially life-threatening situation. I mean, that is what your brain is telling you. And I think that we end up then seeing incredible sadness and maybe even more than that, a howling rage for some of these kids at being taken out of their families. And then the first foster home sometimes stick, but for a lot of these kids, there is multiple placement disruptions. And every single disruption that you have is accompanied by a decreasing sense of self worth and an increase in behavioral problems. And so we have the perfect system for developing emotional, behavioral, and psychiatric victims. Mr. GRIFFIN. Mr. Chairman, I would ask that---- Chairman REICHERT. I think this is--I think this is an important question. The time has gone 2, almost 3 minutes over. Dr. Naylor, you did an outstanding job. I happen to have been one of those police officers years ago that was put in those positions, and I will allow Dr. Phil McGraw to respond in a sound bite, please. Mr. GRIFFIN. Thank you, Mr. Chairman. Mr. MCGRAW. I will be as quick as I can. I don't disagree with anything Dr. Naylor just said, but I might approach him from a different standpoint. Being a foster child is a social circumstance. It is not a mental illness. It is a social circumstance. You do not treat a social circumstance with a drug. You have to fix the underlying problem, and you have got to do a differential diagnosis. You have got to say, is the etiology here organic? I mean, is there a biochemical imbalance that needs to be corrected inside the body, or has someone gone through some type of psychological trauma that has threatened their safety and their security and their self worth and their ability to predict the consequences of their life and their action. And if that is the case, I just don't believe that you are going to fix that with medication long term. Now, it doesn't mean it can't help short term because it certainly can, but particularly for these young children, there is not one shred of evidence that many of these drugs are appropriate to use with 1- and 2-year-old children, certainly in a polypharmacy circumstance. And I am not down on psychotropics because, let me tell you, they can save and change lives when appropriately used, but being a foster child is a social circumstance, not a mental illness. Now, it can trigger depression and some other things that have to be dealt with, but what is the treatment of choice? Is the treatment of choice to begin drug therapy? Is the treatment of choice to begin some type of evidence-based psychological therapy? And I think the former has many more side effects than the latter and therefore is much more dangerous. Chairman REICHERT. Thank you. Thank you for your answer. Mr. Renacci, you are recognized Mr. RENACCI. Thank you, Mr. Chairman. I want to thank the panel. You know, one thing great about being in Congress--I have only been here 3 and a half years--is you do get to learn a lot. I was in the business world for 30 years, and I have always believed in a safety net. There is no doubt about that. Coming from Ohio, there are 12,000 Ohio children living in foster care each month. You know, when the State agrees to take on the responsibility of caring for those children and the safety of the vulnerable population, it becomes their responsibility, and too many times we set them up for failure, not success, which I keep hearing as I am listening to this panel. And as I started to read about some of the headlines, you know, regarding this issue, ``Out of Sight, Out of Mind: Psychotropics and Foster Care,'' ``Mind-Altering Psych Drugs for 7-Year Old,'' these are just media stories that are--as you start to read and figure out what is going on, and you know, when the odds are already really against these individuals, that is very concerning. So what I am trying to do is get some answers, and I listened. One thing I did hear you say, Dr. McGraw, is throwing additional money onto this problem is not the answer--the current system, I should say. Now, redirecting it might be the answer, but before I let you respond to that, I do want to ask Dr. McGraw and Dr. Naylor, in each of your opinions, really, where is the push for the use of psychotropic drugs coming from? You know, is it the child welfare system? Is it the medicaid system? Drug companies? Foster parents? Schools? Or somewhere else? I would like to get either of your opinions on that. Dr. NAYLOR. Well, I think that the routes into a psychiatrist's office varies. So, very often, as a child psychiatrist, I will hear variations of this story. Johnny, who is in foster care, has just lost his third preschool, and his fourth preschool is going to kick him out. He is running around the house, chasing the cat with a knife, and you need to do something and you need to do something now. And very often, these kids will have had therapy. The problem is, is that not all therapies are correct. So one of the routes in is because the psychotherapy that is provided is not particularly effective and not evidence-based, but something needs to be done now. And this can come from foster parents. This can come indirectly from schools through the foster parents into the office. Very often, it is caseworkers who don't necessarily know how to negotiate a mental health system. And you would think that mental health systems and child welfare systems work together. You would also be very wrong if you thought that. I mean, they are very much silos. And so I think very often, child welfare workers then will say, okay, I know this psychiatrist that treated one of my other. I will bring this youngster in. I don't--I think that also as a child psychiatrist sitting in the office, I look at what is available to make an intervention right now that might be able to head off a psychotropic medication. And one of the biggest problems is access to evidence-based therapies. Like I say, I can get somebody to play Chutes and Ladders with them and talk about nondescript things, but I can't get good evidence-based therapy. Mr. RENACCI. So the push is from all of the above? Dr. NAYLOR. Yeah. Mr. RENACCI. Dr. McGraw? Mr. MCGRAW. Well, you can tell you are talking to somebody that knows and lives this system, because when he says, I can get somebody to play Chutes and Ladders with them, but if you have got somebody that truly has a serious self-destructive problem, it takes a much higher level of professionalism. Here is the problem: Your caseworkers might have 40 files, and in those--a given file might have 8 kids in it, so you are just talking about being completely overwhelmed, and so what you are doing is you are warehousing the problem short term. You say, I have got somebody chasing the cat with the knife and the school won't let him back in, so you want to take him? What are you going to do? And so what they do--that is why I use the term chemical straightjacket. That is exactly what they do. They put the kid in a chemical straightjacket till they can figure something out, but the figuring out part never happens. The figuring out part never happens. Mr. RENACCI. Can you elaborate on your comment earlier about throwing more money at this, and just give us here a better solution or what your solution would be? Mr. MCGRAW. What I am saying is right now, we are overusing psychotropic drugs. That is the model. We are overusing them. And if you throw more money at it, what you are going to do is you are going to spread that problem. That is not the fix. What you have got to do is change the model and then finance the model. You cannot just pour money on the existing model. You have got to change the model, and then say, okay, that is all well and good there, Dr. Phil, but how are you going to--how are you going to give that caseworker access to the professional level of intervention that they need? Where are you going to get the therapist? How are you going to do that? Where you going do it? And that takes manpower, and manpower takes money, and that is what I am saying. You have got to change the model to one that is intervention based instead of medication based. And that takes manpower, and manpower takes money. Chairman REICHERT. Time has expired. Mr. Boustany, you are recognized. Mr. BOUSTANY. Thank you, Mr. Chairman. And thank you for holding this hearing. It is a really important hearing. My wife is a CASA in south Louisiana. I have been hearing about all the horror stories and problems that are sort of built into the system, as all of you have very, very concisely described today, and we were having a conversation not long ago over the kitchen table, and she said, you guys have to do something about this. It is a huge problem. And then when she heard through CASA channels that we were having this hearing, she said, thank God that we are doing this, that we need to look at this problem. And so I want to thank you. I want to thank the panelists for being here. I am also a medical doctor and have real concerns on a number of issues. One, Dr. Phil, you mentioned the fragmented nature of all this, and my wife has really schooled me on this whole system and how fragmented decisionmaking is and everything else. And you couple that with the psychotropic drugs of which, and you correctly said earlier, nobody really knows the mechanism of how they really work but they do save a lot of lives, but it is even more of a pronounced situation in children, adolescents, in understanding what the long-term impacts will be, especially if the drugs are used inappropriately. I mean, the adolescent in childhood, the neurological systems function a whole lot different and they respond differently to these drugs. But I want to drill down on something. And that is, where is the decision made oftentimes or for the most part? Is there a pattern? Where are the decisions made to put these children on these drugs? I mean, obviously, they see a social worker, a CASA will see them. They may be in the court system. They don't go straight to a psychiatrist, and the psychiatrist or the family doctor or general practitioner is the one who has prescribing authority, but somebody is making a decision, sending it--then sending him through a psychiatrist or general practitioner, the family practitioner who then writes a prescription, and I am not convinced in the system that we have today that the person prescribing the medicine is actually following these cases and applying best practices, you know, and appropriate follow up. So I just would like one more comment on how this decisionmaking is made at that level to get these kids on these drugs. Ms. CHANG. So I can begin, and certainly other folks can weigh in. I think the question is a good one, and I think that is why screening and assessment is so critical. When we don't have appropriate screening and assessment tools, we are shooting in the dark, right, and so people are not making informed decisions, no matter who it is that instigates that process, so we need to make sure that that is happening. We are really pleased actually that Louisiana is one of our grantees who is focused on installing universal trauma-based screening and assessment in the State for all children in the child welfare system. And they are actually one of our State grantees who came to us and said, We do want to do this grant, we want to be successful, we have installed screening and assessment tools so that we can identify what kids actually need. And many of them don't need psychotropic medications. The problem they found was they didn't have access to the evidence-based interventions the kids do need, and that is the real challenge. And as Dr. Phil says, you know, it costs money to scale up evidence-based interventions. You have to train physicians. You have to train social workers. You have to monitor the program itself to make sure it is being implemented with fidelity. You have to have data systems that can track the outcomes of these kids. That costs money. And so, you are right, from the very beginning, we don't have systems in place to actually identify what it is these kids need, so many people are shooting in the dark. And also another challenge is that we have to be realistic. A lot of our kids do not have access to providers in a timely way that they need them, right. Some of our kids are waiting for 6 months to see a physician, and so you can imagine that the caseworker knows that that child is not going to see that doctor again perhaps for another 6 months, and so they are doing what the best that they can with the tools that they have available to them, and what we want to do is to expand their toolbox so that they have the right instruments they need to serve individual children where they are. Mr. BOUSTANY. Is there an appropriate review process in many of the States? You know, after a child is put on psychotropic medication, obviously, you need to, you know, track it and monitor it and review the appropriateness of the therapy. I mean---- Ms. CHANG. Well, thanks to Congress, led by this committee and through passage of legislation in 2011, we now have a Federal mandate that all child welfare system have a process in place to oversee the psychotropic medication use of children in their care. And what we have heard from researchers, although it is still really early because now it has only been a few years that these processes have been in place, what researchers are finding and they are very excited is that it has made a difference. So your actions have made an impact in the lives of children, and what we want to do is take it to that next step Mr. BOUSTANY. Thank you. Chairman REICHERT. The gentleman's time has expired. We will move on to Mr. Crowley. Mr. CROWLEY. Thank you, Mr. Chairman. Thank you for holding this hearing today. And to Mr. Doggett as well, the ranking member. Dr. Phil, I am desperate to try to ask you a profound question and hope I might get on your television show, but I can't come up with one, but I do want to thank you for the attention you are bringing to this issue. You mentioned the shadow--the foster youth in the shadows today, and I think the real attempt here is to bring them out of the shadow and into the light that all of society can better understand the circumstances that they are living in, so thank you for that. I have the opportunity--and I also want to thank my good friend and colleague Karen Bass, who is not a member of the subcommittee, but I am hopeful, will have an opportunity to say a few words as well. She, since coming to Congress, has been an incredible leader on the issue of foster care. I dabbled a little bit into it, and she has really taken over and really ran with it, so I really appreciate all she has done for this effort. But I had the opportunity this morning to meet with a very impressive young lady named Chanise, who was following me this morning, and we had opportunity to share some of her experiences and exchanged some ideas and thoughts and to try to find some solutions and actions that can take place to effectively bring about the changes that are needed within the foster care system. And that is what our charge here in Congress is to do is to try to find ways to bring about change of things that need fixing. And certainly I think the foster care system is in need of our attention. We have seen the data on how common it is for children in foster care to be prescribed these psychotropic medications, in some cases, multiple medications at one time, and in fact, Chanise shared with me her own experiences in terms of medicated--being medicated at a very, very young age. And medication is the medication is trying to solve an issue that perhaps could be better addressed through intervention as has been discussed here earlier today. That is something that, as I mentioned, I talked to Chanise about, but it is also something in my home State of New York, where I think new ground is being broken. And I appreciate the work that is taking place there. We need to separate out what is a problem generally worthy of medicated treatment and what is better served by a social worker or other personal engagement. While reducing medication can be a worthy goal in and of itself, we want to make sure we are also focusing on a comprehensive approach that includes alternative treatments. New York has been a leader in trying to address the problems of overmedicated--overmedicating foster youth. New York is one of five States, including Illinois, as I believe, Dr. Naylor, you may be familiar with, participating in a 3-year initiative developed by the Center for Health Care Strategies and made possible through the Annie E. Casey Foundation. This initiative focuses on in collaborative--collaboration among State agencies to develop more effective practices for the use of these medications in foster care. State experts in New York tell me that this initiative has highlighted important areas that need to be addressed in order to have successful policies on this issue. For example, one of the first challenges they had to meet was how to share data amongst the various agencies because while the Office of Children and Family Services was responsible for overseeing the foster care system, the actual medical treatment data was under Medicaid within the Department of Health, and the Office of Mental Health was also involved as well, so even just to survey how widespread the problem is required a new level of interagency cooperation. New York was fortunate that they honed in on this issue early and were able to address it. I know other States may be struggling with similar data-sharing problems, so I urge them to look at New York as an example. Beyond just the data-sharing aspect, it is critical that multiple agencies work productively together. You have situations where the foster care agency may make recommendations or set protocols, but the doctors prescribing the medication are under the Department of Health. Everyone needs to work together in order to get the best results possible. One of the lessons New York has learned is to emphatically stress collaboration and to ensure that each part of the system understands the impact that reaches beyond a single agency. Ms. Chang, I see that the ACF has sought to encourage this collaboration through their demonstration, so I was wondering if you could possibly expound upon that and comment on what is taking place. Ms. CHANG. Sure. Thank you. We agree with you. We think that collaboration is critical. Children in the foster care system are not served by one agency. They are served by multiple agencies. The Medicaid agencies, the mental health agencies, as well as child welfare, and so that is why we are really excited that this proposal has both an ACF component as well as a CMS component, and that goes to part of what I said about having access to providers. We know that we have to create incentives so that there are physicians who are willing to care for our kids, that we have to create incentives to say that the Medicaid offices can also get funding to pay for the types of supports that they need so that there are providers, and it brings those two groups--major groups that serve these people--these children to the table to work together. Mr. CROWLEY. Thank you. Thank you, Mr. Chairman. I yield back. Chairman REICHERT. Thank you, Mr. Crowley. Mr. McDermott, you are recognized. Mr. MCDERMOTT. Thank you, Mr. Chairman. I--full disclosure, I was trained at the University of Illinois and worked at Allendale School, so I know a little bit about the Illinois system. My question is really, let's take Dawna. She goes into foster care and somebody writes a script for her to have medication. And I am talking about today, not 3 or 4 years ago when this happened, but today in Illinois. How would that be evaluated before she got the medication? Or would it be a retrospective evaluation 6 months later? Or when did it happen and by whom and did they ever see her? How would that decision have been made for her? Dr. NAYLOR. That is a good question, and I--there are various ways of doing these reviews prospective and retrospective being the two major categories. Ours is a prospective one, so we review all of the requests before the medication is actually prescribed and dispensed. Mr. MCDERMOTT. So she is creating havoc in the house as a rebellious teenager, which she says she was. Somebody says this kid needs to be on drugs, so somebody writes a script, and then how long does it take to get to you and your independent agency to make a decision about whether she should have them or not? Dr. NAYLOR. I hate to use you as an example, but you are hospitalized right now, and so the medication request comes to DCFS and our program at the very same time, and it has all of the diagnostic information, all of the symptom information, all medications that she would be on, and our review is not a true second opinion. We don't have the resources to be able to send somebody out to do an evaluation, and I think we have like 2,700 kids on medication. That would take a lot of resources to have a second opinion on everybody. And so the work becomes, there is a diagnosis and the symptoms match, if they match, is the treatment something that would be recommended or recognized treatment for that combination of diagnoses and symptoms. If it is, is the dose requested being--an appropriate dosage, and if that is the case, we would approve the medication. Mr. MCDERMOTT. How often do you reject a request for medication for a patient? A thousand scripts come in to you, you look at a thousand of them, how many times do you say no? Dr. NAYLOR. That is a complicated question, and I will go through it as quickly as I can. I don't deny all that many requests anymore. And the reason I don't deny all that many requests anymore is because I have been doing this now for 15 years, and initially, when I started the program, people would talk to my boss and complain about Dr. Naylor's idiosyncratic psychopharmacology, and so they would rant and rave against what my recommendations would be. But my boss knew that I was arguing science and arguing good clinical care, and so, over time, people have changed their prescribing practices, and so that is one thing we do. Another thing that we do is we ask really embarrassing questions like, do you really think it is a good idea to start this patient, who is psychotic, on a stimulant, which can cause psychosis? And the very act of asking the question will--again, because I have been there for 15 years, will lead to the doctor withdrawing the request for the medication because they know that if they persist, it will be denied. So we deny probably 1 percent. There is probably 8 percent that are rescinded, but this is down from about 15 percent denials and fairly high rescinding rate about 10 years ago. Mr. MCDERMOTT. And then 6 months later or a year later, you have now put her on the medication, you think it is a good idea, what is the possibility it will ever be looked at again by someone? Dr. NAYLOR. Well, in terms of the consent process, by law, I will look at that again in 6 months. We only provide consent for every 6 months. And we will ask for a clinical update. If, at any point along the way, including with the first time that they made a request for the medication, I can request a second opinion from another physician, or if it is one of those cases that would end up on the front page of the newspaper, I will sometimes go out and do these second opinions, so we will follow up with getting as much clinical information as we can get in order to make a determination whether that medication is still indicated or not. Mr. MCDERMOTT. If she ran into a CASA worker who said--and she said, I don't think I should be on this medication, can I get off it, can you help me get off it, and they called you-- can they call you? Can they appeal to you? Is there any way of appeal to you to review what is going on there? Dr. NAYLOR. Absolutely. We actually have several different ways in where requests for a rereview can be made, and these requests can come from guardian ad litems, CASA workers, judges, juvenile judges, caseworkers. The nurses in Illinois are like another pair of eyes and ears, and they will often refer back for additional consultation. And now psychologists are also out in the field doing similar kind of monitoring work, so we will get consultation requests that way. A foster child can go to the guardian ad litem and say I would like a second opinion on my medication, and we will find a way to get a second opinion done, so yes, there is. Mr. MCDERMOTT. Ms. Chang, is this common across the United States? The Illinois system is something as comprehensive as that? Ms. CHANG. This particular model of reauthorization is not as common. Mr. MCDERMOTT. Not as common. Give me numbers here. Ms. CHANG. So I can't give you a 50-State survey. I am happy to get back to you, sir, and tell you exactly how all States are structuring it. Most States, based on our review, do have a monitoring after the fact, and really, the--many of those programs are highly successful. Texas is a good example of that. They have protocols for when medication can be used, and they have a systematic way of reviewing all scripts to make sure that they follow the protocol. They also then look at individual physicians who break protocol more than once, and so they have a very effective way of managing medication, even though it doesn't involve preauthorization. And we find that most States employ that type of protocol and then making sure that doctors are following it. There are other models. For example, Massachusetts makes sure that there are mental health professionals who specialize in medication management who are always available to social workers, caseworkers, as well as other physicians who are seeing these kids so that whenever questions come up, they can immediately get professional assistance because oftentimes, one of the problems is that these are folks without the expertise in prescribing these types of medications, so there are a variety. Mr. MCDERMOTT. Thank you. Thanks for extending my time. Chairman REICHERT. You are welcome. Thank you, Mr. McDermott. And Ms. Chang, if you can provide that information in writing to the committee, I think that was a very good question, we would like to have that additional information, if you please. So, I am just going to repeat a few things that I heard today, and then you can leave. We will wrap this up. First of all, I heard--I think we are all on agreement--we just don't want to pour money into a system that currently is not operating at 110 percent, right? So, we recognize there is some work there to do. Ms. Chang is working with the States in trying to bring States along to develop systems, and Illinois is a great example of some great progress that has been made, but we all can do better. I think, in listening to Ms. Hovenier and her suggestions, you know, I really like the idea of no matter what, a second opinion. I think coming from you, that has a lot of power behind it. Choices of therapy, I think Dr. McGraw and Dr. Naylor and others have mentioned that sometimes some therapies just don't work because it is the wrong therapy. So that was a great point that you made. And then the mention of tools, the proper tools for screening, for assessment and evidence-based, I think is really, really critical, and that is when you begin to apply the resources and the funding when you know that you have got evidence-based information to make decisions on. I think all of the panel would agree with that, and I think the members that were here today would agree with that. And I want to thank, again, all of you for taking time out of your busy schedules to be here today. This is such an important topic, and all the members here that were here to ask questions and listen to your testimony. And again, a special thank you to Ms. Bass for her work in this arena and helping us schedule this hearing. So if members have additional questions, those of us who are left, for the witnesses, they will submit them to you in writing, and we would appreciate receiving your responses for the record within 2 weeks. The committee now stands adjourned. [Whereupon, at 4:13 p.m., the subcommittee was adjourned.] [Questions for the record follow:] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] [Submissions for the record follow:] Letter of the Adopt America Network [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] [all]