[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
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COMMITTEE ON WAYS AND MEANS
DAVE CAMP, Michigan, Chairman
SAM JOHNSON, Texas SANDER M. LEVIN, Michigan
KEVIN BRADY, Texas CHARLES B. RANGEL, New York
PAUL RYAN, Wisconsin JIM MCDERMOTT, Washington
DEVIN NUNES, California JOHN LEWIS, Georgia
PATRICK J. TIBERI, Ohio RICHARD E. NEAL, Massachusetts
DAVID G. REICHERT, Washington XAVIER BECERRA, California
CHARLES W. BOUSTANY, JR., Louisiana LLOYD DOGGETT, Texas
PETER J. ROSKAM, Illinois MIKE THOMPSON, California
JIM GERLACH, Pennsylvania JOHN B. LARSON, Connecticut
TOM PRICE, Georgia EARL BLUMENAUER, Oregon
VERN BUCHANAN, Florida RON KIND, Wisconsin
ADRIAN SMITH, Nebraska BILL PASCRELL, JR., New Jersey
AARON SCHOCK, Illinois JOSEPH CROWLEY, New York
LYNN JENKINS, Kansas ALLYSON SCHWARTZ, Pennsylvania
ERIK PAULSEN, Minnesota DANNY DAVIS, Illinois
KENNY MARCHANT, Texas LINDA SANCHEZ, California
DIANE BLACK, Tennessee
TOM REED, New York
TODD YOUNG, Indiana
MIKE KELLY, Pennsylvania
TIM GRIFFIN, Arkansas
JIM RENACCI, Ohio
Jennifer M. Safavian, Staff Director and General Counsel
Janice Mays, Minority Chief Counsel
______
SUBCOMMITTEE ON HUMAN RESOURCES
DAVID G. REICHERT, Washington, Chairman
TODD YOUNG, Indiana LLOYD DOGGETT, Texas
MIKE KELLY, Pennsylvania JOHN LEWIS, Georgia
TIM GRIFFIN, Arkansas JOSEPH CROWLEY, New York
JIM RENACCI, Ohio DANNY DAVIS, Illinois
TOM REED, New York
CHARLES W. BOUSTANY, JR., Louisiana
C O N T E N T S
__________
Page
Advisory of May 29, 2014 announcing the hearing.................. 2
WITNESSES
JooYeun Chang, Associate Commissioner of the Children's Bureau,
Administration for Children and Families, Department of Health
and Human Services (HHS)....................................... 6
Dawna Zender Hovenier, The Mockingbird Society................... 13
Phil McGraw, Ph.D., Talk Show Host, Dr. Phil..................... 18
Michael Naylor, M.D., Associate Professor of Psychiatry, Chicago
School of Medicine, University of Illinois at Chicago (UIC).... 27
Stephen Lord, Director, Forensic Audits and Investigative
Services, Government Accountability Office..................... 38
SUBMISSIONS FOR THE RECORD
Adopt America Network, letter.................................... 77
James Harris, statement.......................................... 84
QUESTIONS FOR THE RECORD
JooYeun Chang.................................................... 76
CARING FOR OUR KIDS: ARE WE
OVERMEDICATING CHILDREN IN
FOSTER CARE?
----------
THURSDAY, MAY 29, 2014
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Human Resources,
Washington, DC.
The subcommittee met, pursuant to call, at 2:30 p.m., in
Room 1100, Longworth House Office Building, the Honorable Dave
Reichert [chairman of the subcommittee] presiding.
[The advisory of the hearing follows:]
HEARING ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
Chairman Reichert Announces Hearing on Caring for Our Kids: Are We
Overmedicating Children in Foster Care?
Washington, May 29, 2014
Congressman Dave Reichert (R-WA), Chairman of the Subcommittee on
Human Resources of the Committee on Ways and Means, today announced
that the Subcommittee will hold a hearing on the use of psychotropic
medications among children in foster care. The hearing will take place
at 2:00 p.m. on Thursday, May 29, 2014, in room 1100 of the Longworth
House Office Building.
In view of the limited time available to hear from witnesses, oral
testimony at this hearing will be from invited witnesses only.
Witnesses will include experts on the prescription and use of
psychotropic drugs by children, and especially children in foster care.
However, any individual or organization not scheduled for an oral
appearance may submit a written statement for consideration by the
Committee and for inclusion in the printed record of the hearing.
BACKGROUND:
Recent reports have highlighted how children in foster care are
prescribed psychotropic drugs at very high rates. According to data
compiled by the Congressional Research Service, between 2008 and 2010,
nearly one out of every four children in foster care was using a
psychotropic medication on any given day--more than four times the rate
among all children. A recent Wall Street Journal story and a multi-part
Denver Post series highlighted how youth in foster care may be
prescribed these powerful, mind-altering drugs because they are
misdiagnosed as having mental health disorders instead of being
recognized as having problems stemming from the abuse and neglect they
have experienced.
Congress has taken a number of steps in recent years designed to
prevent the overuse of psychotropic drugs by children in foster care.
The Child and Family Services Improvement Act of 2006 (P.L. 109-288)
required States to describe how they consult with doctors to assess the
health and well-being of children in foster care and determine
appropriate medical treatment for them. The Fostering Connections to
Success and Increasing Adoptions Act of 2008 (P.L. 110-351) required
States to ensure children in foster care have access to health and
mental health care services and develop strategies for overseeing drugs
prescribed to them. Most recently, the Child and Family Services
Improvement and Innovation Act of 2011 (P.L. 112-34) added that States
must develop protocols covering the use of psychotropic medication for
children in foster care.
States have also taken positive steps to address concerns about the
use of psychotropic medications by children in foster care. These
efforts include reviewing new prescriptions before they are approved,
monitoring existing prescriptions, and examining data on prescription
rates among youth in foster care. For example, in Illinois, board
certified child psychiatric consultants review all psychotropic
medication requests. Connecticut has hired a Chief of Psychiatry to
oversee medications for youth in foster care. Texas has a data system
designed to ensure that psychotropic medications are prescribed within
established guidelines.
In announcing the hearing, Chairman Reichert stated, ``Our future
lies with our nation's children. For kids in foster care, we have an
added responsibility to help them succeed, including helping them
overcome the trauma they experienced before, and in some cases since,
they left their home. Recent news reports have highlighted how powerful
psychotropic drugs are prescribed at high rates to children in foster
care, including by individuals who may misdiagnose the effects of
trauma on these children as a mental health problem. I look forward to
hearing from experts on this issue, learning what States are doing to
ensure the proper use of these medications, and discussing how the
Federal Government can better support efforts to provide youth in
foster care with the help they need to become successful adults.
FOCUS OF THE HEARING:
This hearing will focus on what is known about the use of
psychotropic medications by children in foster care, how States have
implemented recent Federal laws designed to ensure such medications are
used appropriately, and how the Federal Government can continue to work
with States to improve the oversight of these medications to ensure
youth in foster care receive appropriate help.
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Note: All Committee advisories and news releases are available
online at http://waysandmeans.house.gov/.
Chairman REICHERT. The committee will come to order.
Welcome to today's hearing on this very important topic of
whether youth in foster care are being prescribed medications,
whether or not they are being prescribed appropriately. We will
hear from our witnesses that too often the answer is no.
We know from research that foster children are prescribed
mind-altering psychotropic drugs at very high rates, far higher
than other children. CRS found that between 2008 and 2010
nearly one out of every four children in foster care was
overmedicated. That is more than four times the rate among
children overall. In too many cases, government programs may be
trying to medicate away the troubles that these youths have
experienced that will remain with them for many years after the
medications end.
Dawna Hovenier is a young woman who was recently in foster
care in my home State of Washington. She was unnecessarily
medicated with a number of mind-altering drugs and will explain
how that helps no one, least of all the youth who need it the
most, and Dr. Phil McGraw will second this assertion that one
of the most critical reasons to address the problem of
overmedication is to ensure children receive proper treatment
and not just chemical straitjackets that keep them from acting
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:]
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Chairman REICHERT. And Dr. Naylor, you are recognized for 5
minutes.
STATEMENT OF MICHAEL NAYLOR, M.D., ASSOCIATE PROFESSOR OF
PSYCHIATRY, SCHOOL OF MEDICINE, UNIVERSITY OF ILLINOIS AT
CHICAGO (UIC).
Dr. NAYLOR. Chairman Reichert, Ranking Member Doggett, and
Members of the Subcommittee on Human Resources, before I start,
I really want to lodge a complaint against who seated me here.
He only had to follow one really incredible testimony. I have
to follow two. I hope I can live up to it.
Thank you for inviting me to testify before the committee.
I am truly honored at the opportunity to address the issue of
psychotropic medications for kids in the foster care system. We
have already heard children in foster care, by definition
Medicaid-eligible, are at higher risk for developing severe
emotional disturbances and utilize mental health services at
higher rates than other Medicaid-eligible youth. They are
prescribed more medications at higher rates and at higher
doses. In a way, these are not particularly surprising
findings. As a population, foster children have multiple risk
factors that predispose them to severe emotional disturbances
and psychiatric illnesses, including often of genetic
predisposition to mental illness, in utero exposure to drugs
and alcohol, the adverse effects of growing up in poverty, a
history of severe trauma, disrupted early attachments, and
multiple placement disruptions, to name just a few.
To complicate matters, there is the fragmented medical and
psychiatric care system and an absence in the most part of a
consistent caregiver to provide consent for and longitudinal
oversight of their ongoing care. Despite all of this, I do
contend that psychotropic medications are often an important
component of a comprehensive psychosocial treatment plan that
really is based on a good biopsychosocial understanding of
these kids and their situation.
I will describe how a program designed and implemented by
the Illinois Department of Children and Family Services to
provide consent for and oversight of psychotropic medications
in foster children has resulted in more effective, safer, and
more cost-effective care.
In July 2007, I testified in front of the committee under
Congressman McDermott and to advocate both for the oversight of
psychotropic medications for foster children and to describe a
program, the DCFS centralized psychotropic medication consent
program. Illinois State law prohibits the administration of
psychotropic medications to foster children without the consent
of the DCFS guardian. And this is a centralized office compared
to other consent programs across the Nation. To support the
consent process, DCFS contracted with UIC to provide an
independent review of all psychotropic medication consent
requests to determine the appropriateness of the proposed
treatment. Utilizing an extensive database consisting of
consent data, Medicaid pharmacy payment claims, and data from
the State-wide automated child welfare information system, we
can monitor an individual's medication history over time,
across placements, and across providers, and we can monitor
State-wide patterns of psychotropic medication use. We believe
that this prospective psychotropic medication consent and
oversight process has resulted in higher quality and more cost-
effective care, as evidenced by the implementation of a program
that provides specialty evaluations of and evidence-based
psychosocial treatments for preschool aged children in an
effort to decrease reliance on psychotropic medications,
improved continuity of care preventing, therefore, on the use
of medications that have perhaps proven ineffective or been
associated with significant adverse effects in previous trials,
increased adherence to evidence-based prescribing for the
treatment of psychiatric disorders, in the meantime resulting
in a cost savings, a substantial decrease in the concurrent
prescription of two or more antipsychotic medications, improved
monitoring of adverse side effects, for example, documenting
the weight gain associated with second-generation
antipsychotics, and devising a policy linking consent for these
medications to appropriate medication oversight in the doctor's
office, and finally, improved safety of pharmacotherapy through
the prevention of potentially serious and even fatal drug-drug
interactions.
In conclusion, I will reiterate my 2007 testimony in
support for the appropriate oversight for the use of
psychotropic medications in foster children. As shown by the
Illinois experience, a well designed and implemented medication
consent and oversight program can improve the quality of care
and increase cost-effectiveness.
Again, I want to thank the committee for the opportunity to
speak with you today, and I will gladly answer any questions
you may have.
Chairman REICHERT. Thank you, Dr. Naylor. You did just
fine.
Dr. NAYLOR. Thank you.
Chairman REICHERT. Thank you for your testimony.
[The prepared statement of Dr. Naylor follows:]
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Chairman REICHERT. Mr. Lord, you are recognized for 5
minutes.
STATEMENT OF STEPHEN LORD, DIRECTOR, FORENSIC AUDITS AND
INVESTIGATIVE SERVICES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Mr. LORD. Thank you, Chairman Reichert, Ranking Member
Doggett, and other distinguished Members of the Committee. I am
really honored to be here on this distinguished panel to
discuss GAO's work examining the use of psychotropic
medications in the foster children community. As we have
already heard today, foster children are an especially
vulnerable population, and in 2012, there were over 400,000
children in the foster care system, some of whom had
experienced neglect and physical abuse.
Today I would like to focus on two key issues. The first is
the extent to which children in foster care are prescribed
psychotropic medications, and secondly, Federal and State
oversight of these practices. The first key point I would like
to make is that children in foster care take psychotropic
medications at higher rates than other children. As we heard
from the administration witness, 18 percent of foster children
were taking a psychotropic medication at the time they were
surveyed, and this compares to about 6 percent for
noninstitutionalized children in Medicaid nationwide and about
5 percent for children in private insurance plans.
It is also important to note that within certain
populations of foster children, for example, those who lived in
group homes or residential treatment centers, the rates are
much higher. The data shows that 48 percent of those living in
residential homes and treatment centers were taking
psychotropic medications.
But another important caveat is these rates do not
necessarily imply inappropriate prescribing practices based on
the medical experts we consulted. In some cases, these rates
could be due to foster children's greater mental health needs
and perhaps greater exposure to trauma.
The second key point I would like to make is the Federal
and State oversight of psychotropic use among foster children
has improved over the last few years, although we
wholeheartedly agree additional guidance and attention is
needed. In 2011, we reported that States monitoring
psychotropic use among foster children fell short of the best
practice guidelines espoused by the American Academy of Child
and Adolescent Psychiatry. Thus we recommended that HHS endorse
additional best practice guidance to help ensure States were
properly overseeing the use of these drugs. And the good news
is that HHS agreed with our recommendation, and ACF has issued
directives to States to establish better protocols for
monitoring their youth, and this includes a key April 2012
program of instruction designed to achieve this goal.
However, as we highlighted in our new report we issued just
last week, additional guidance is needed, as some States
transition away from the so-called fee-for-service arrangement
to managed care organizations to deliver these prescription
drug benefits. The need for additional guidance is underscored
also by our detailed case study reviews, the 24 case studies we
did as part of our current work. In some instances, the experts
we consulted, including Dr. Naylor, I should point out, found
good supporting documentation in the case files for the youth.
However, in other areas, there was a question. You know, we
found some supporting documentation, but it raised questions
about whether some children were receiving the proper therapies
and treatments, such as evidence-based therapies that might
have been useful.
In closing, Federal and State governments have actively
taken a number of important steps to better oversee the
prescribing of these drugs. That is the key message of the body
of work GAO has issued in this area, but as we recently
highlighted, additional steps are needed to help ensure there
is good oversight and monitoring of this drug use.
Mr. Chairman, that concludes my statement. I look forward
to answering any questions you may have. Thanks.
Chairman REICHERT. Thank you, Mr. Lord.
[The prepared statement of Mr. Lord follows:]
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Chairman REICHERT. Thank you all for your testimony.
We now move into the question and answer phase of the
hearing. I will begin.
My first question is for Ms. Hovenier. I just want to thank
you again for being here and having courage to tell your story
and also thank you for all the work that you are doing to help
other children in foster care.
You talked a little bit about how you succeeded and what
helped you, and really you focused on people need love;
children need love versus drugs. And I wonder if you could just
tell me a little bit more about--we know your family was there.
They loved you. Your CASA adviser was there. How did you
finally get to the point where you were being able to pull
yourself out of that or have your family pull yourself out of
that treatment center?
Ms. HOVENIER. So, on my 18th birthday, I aged out of foster
care. When I turned 18, they could no longer keep me there.
However----
Chairman REICHERT. The drugs.
Ms. HOVENIER. In the psychiatric facility, they could no
longer keep me there.
Chairman REICHERT. Right.
Ms. HOVENIER. And since I was no longer there, I didn't
want to take the medications to start out with, so when I left
the facility, I am like, Okay, I am never taking another
psychotropic medication because I do not like the way they made
me feel, and I have never liked it. And so that was when I
decided I don't need the medication. I already knew I didn't
need it, but that was the starting point with, Okay, I want to
get off; how do I do this? And when I moved up to Bellingham,
we couldn't find a psychiatrist to take me off because they
looked into my records from the psychiatric facility, and they
said that they didn't want to take me off because I was a
liability, that I might do something, but they didn't know me
before I was on the medication. Before I was on the medication,
I was a normal teenager, being a normal rebellious teenager,
but apparently, when you are in foster care and you are
rebellious, you get medicated. So just having my family, my
adopted family and my new family just support me, and they are
like, Okay, we want to do what you want to do. We are here.
Just let us know anything we can do, and having a private paid
therapist was a big deal to me because this therapist knew me
and wanted to support me in getting off. And she wasn't one of
the therapists that were like, Oh, we are leaving you on this,
we want to keep you on this. So I think that was a big
difference.
Chairman REICHERT. How do you think we can help other
foster kids?
Ms. HOVENIER. I believe the government can help other
foster kids by--I don't know if it is already a thing or not,
but implementing the foster child no matter what has a right to
request a second opinion from a doctor or psychiatrist, no
matter if it is a private paid therapist, private paid
psychiatrist, and in addition, different forms of therapy
besides just pharmaceutical therapy, like there is many
therapies out there. I don't know them all, but those are just
a couple of my ideas. Thank you.
Chairman REICHERT. Thank you. Good job.
Dr. Naylor, Illinois has the fifth largest foster care
caseload in the country, with about 17,000 children in foster
care. The program you administer oversees the prescription of
psychotropic drugs to all of these children in foster care. How
much does this program cost annually? Do you know what the cost
is annually?
Dr. NAYLOR. I write the budget, and it is budget time, so I
have a pretty good clue. It runs about $1.1 million, that is
how much we have requested. We typically run it on about
$900,000.
Chairman REICHERT. And how is your program funded?
Dr. NAYLOR. It is funded as a contract through the
Department of Children and Family Services. The Children and
Family Services receives funding from the State. In fact, their
funding from the State is actually quite generous because of a
consent decree from early 1990s, and some of the money comes
from various Federal grants. I can't speak to how the money
from DCFS comes to us, but it is either paid through general
funds, which would be through the legislature or it comes from
Children's Services funds, which are specifically earmarked to
pay quicker. In Illinois, that is a very important factor I
think, but pays quite a bit quicker than general funds.
Chairman REICHERT. What are some of the key outcomes that
sort of tell you that your efforts have been successful, that
they are making a difference?
Dr. NAYLOR. Well, I think there is several. One, in the
written testimony, which I apologize, it didn't translate well
from the Word document to the PDF, so there is some really
weird things that happened when it was transferred to PDF, but
you can see that there was over time a decrease in the use of
Prozac or fluoxetine, and after the black box warning and after
the warning regarding Paxil, we made the determination based on
pretty sound evidence that fluoxetine should be the first drug
of choice, and by changing our review process, we were able to
do something that I don't think made the drug companies all
that happy, which was we increased the rate of generic
medication, fluoxetine, at the expense of brand name
medications that were less effective. So one of the things that
we were able to do was to increase evidence-based prescribing
at a cost savings because the medication with the greatest
evidence for it was also the medication that was the cheapest.
We were able also to show a decline in the use of
antipsychotic polypharmacy, and these numbers actually are even
more dramatic than you see in the written testimony because of
the way we analyze this. We were very conservative.
Chairman REICHERT. You answered my last question to you.
You just mentioned cost savings. Okay.
Dr. McGraw, you have spent your career focusing on mental
health issues and how to appropriately address them. What do
you believe is the best way to raise awareness of this issue so
children are better protected from being prescribed these drugs
that really aren't going to help them? What is the best way to
get--one of these of course is today's hearing, with your
presence that adds to it, but do you have some ideas on that?
Mr. MCGRAW. Well, I do. I think we need to keep just
ringing the bell over and over because it is out of sight, out
of mind, and I think so often these children become invisible,
and their treatment or their absence of treatment become
invisible because they are just simply taken out of the
mainstream, and I think that is why I said a hearing like we
are having today is so important. We talk about this on the
``Dr. Phil'' platform, we talk about it on ``The Doctors,''
kind of the medical version of our show, and people care about
this, Chairman Reichert.
I know when we have had a call to action for CASA
volunteers, it has just been overwhelming. I mean, we have been
able to generate close to $90 million in volunteer services
just from asking people to come forward and get involved.
People want to get involved. They don't know how. And that is
why something like a CASA is so important. For you and I, we
had a football coach that kind of stepped up and jerked a knot
in our tail and said, you know, get in class and be out here at
practice, but, you know, you look at all of the psychological
research, and I don't think there is anything more powerful for
these children than a caring adult that puts their arm around
their shoulder and says, I am going to help you navigate this
maze.
So I think we just have to tell people about it, and we
have got to tell them something they can do because if we get
more adults involved in their lives, then these drugs are going
to start to go away because there is going to be somebody there
that says this is just a normal kid, a typical kid that has
grown up in atypical circumstances. And we need to teach them,
not medicate them, and I think that only happens when--you
know, my dad used to say nothing makes the crops grow like the
shadow of the owner, and it is the same way with your kids.
Nothing protects your child than their biological parent, but
if you don't have that, have a caring adult there that will pay
attention to what is happening, and that is what happened to
this courageous young woman here. We have got to have a call to
action to get more people involved, and if you can't be a
foster parent and bring children into your home, then you can
be a CASA, which means you just navigate maybe two children a
year through the process and watch over them, even if you can't
open your home. If you don't have money to give, you can at
least do that. So we have just got to tell people what they can
do to become involved.
Chairman REICHERT. Thank you.
Mr. Doggett, you are recognized.
Mr. DOGGETT. Thank you very much, and thank you for your
insightful and moving testimony. There is no doubt that
everyone up here on this dais shares your concern. The question
is whether or not we will take the action to do something to
change anything, and that, whether that action will occur in a
meaningful way is far from certain in this Congress.
Mr. Chairman, I would ask in that regard unanimous consent
to enter into the record a letter from over 100 child advocacy
organizations urging support for the administration's budget
proposal to reduce the overmedication of foster children
through a new demonstration project involving both child
welfare and Medicaid agencies.
Chairman REICHERT. Without objection.
Mr. DOGGETT. And, Dr. Phil, I see that your foundation is
among the organizations that signed that letter, and you have
already talked about it. All of us are moved when we hear the
stories from our CASA volunteers. I know I have been in Austin,
in San Antonio. They do extraordinary work. But we can't solve
this problem with just volunteers, without resources, as you
have indicated. You said, and I think I got it down, it takes
time, and it takes money, and it takes a completely different
model.
If you would, just outline why you think it would be
valuable to have these additional resources and attempt to have
a demonstration project to help us combat the overprescribing
of these medications to children in foster care.
Mr. MCGRAW. Well, Congressman Doggett, thank you for the
question, and let me say, I think the worst thing we could do
is throw more money at the model we have now.
Mr. DOGGETT. Right.
Mr. MCGRAW. If we throw more money to fund Medicaid or
State agencies to keep writing these prescriptions and
medicating these children, I think that would be disastrous. It
would be like throwing gas on a fire. What it takes, and this
is where money can be spent, is if you now have actual live
people that will sit down and counsel these folks, give them
the coping skills, the organizational skills, teach them how to
talk to themselves about what has happened to them in their
lives.
I spoke at a luncheon earlier today with these shadow
foster kids here. What a great group, by the way, what an
audience--you want to speak to those kids, let me tell you.
But, you know, I said to them, sometimes you have to give
yourself what you wish you could get from someone else. Maybe
you don't have a parent there to put their arms around you and
tell you how proud they are of you, but sometimes you have to
give that to yourself. But they can't do that without having
someone unravel this emotional ball of yarn for them. They have
been abandoned. They have been neglected. They have been
abused. Someone needs to tell them, what do you say to yourself
about that? Psychology has made just wonderful advances with
evidence-based therapies that give the kids the coping skills,
the tools to do that. That is where the money should be spent,
that is where the money will be spent with the new model, and
that is why I support that, if it is done in that way, but it
takes manpower. It takes manpower, and you are right, you can't
do it with all volunteers, and sometimes the problems are over
the volunteers' head. I mean, just over their skill set. If you
have got someone that truly does have a mental illness that
requires professional intervention, all the love in the world
is not going to fix that. You need professional intervention to
do that, and that is why you can't do it with all volunteer,
and that is why the money would be well spent if it is not
spent pouring more drugs on the problem.
Mr. DOGGETT. Ms. Chang, let me ask you to respond on that
also with specifics because, clearly, we don't want to just
pour more money into buying drugs. We would like to have some
cost savings there. But why is it that additional resources are
needed to get this other model going? Can you expand on what
Dr. Phil has just told us?
Ms. CHANG. Sure, I would be happy to do that. I think when
we think about a system that functions effectively, you need at
a minimum three core components. You need the ability to screen
and assess so you can identify what is actually happening in
that child's life and what their needs are. You need to then be
able to connect what you have identified to appropriate
evidence-based interventions, like Dr. Phil was talking about.
And finally, you have to be able to monitor that child and
follow them to make sure that that intervention is actually
working for that individual child.
We do this in regular medicine all the time, right? If you
go to your doctor, they are going to prescribe something for
you. They tell you to come back and follow up, make sure that
medicine worked. If it didn't, they will try something else.
Far too often in child welfare, we are missing at a minimum
those first two components, right? We don't have adequate
screening and assessment tools that actually can identify what
trauma that child has experienced and what that has done to
that child's cognitive, social, emotional, mental health well-
being, so we miss that first part. And even when we do have the
capacity to measure what is going on in that child's life, what
we have learned from the local jurisdictions is that they do
not have access to the evidence-based interventions, and so
there are many missing components. And that is why this
demonstration is really designed to help local jurisdictions
who want to do the right thing have the resources to either, to
create for the first time or scale up evidence-based
interventions. We know what works in the field, and often, as
folks have said, it really is about family-based care,
community-based care with mental health professionals who are
trained in these evidence-based interventions.
Mr. MCGRAW. Congressman Doggett, I also want to add you are
not really talking about new money here, by the way. Because
what hasn't been talked about is these psychotropic drugs have
addictive elements to them, and these children are at higher
risk for addiction problems later in life if they have been on
these drugs or abusing these actual drugs. And you are going to
have to deal with that down the road if you don't deal with it
here. If you take the drugs out and you put the right treatment
and therapies in, you may spend that money doing it now, but
you are not going to spend that money with lost productivity in
society with someone that has an addiction problem later in
life. So pay me now or pay me later, so you would do a whole
lot better off to do it now and prevent the problems because
one thing we know is when children get addicted to drugs, their
development stops, their mental, emotional development stops,
educational deficits set in.
Just because these were written with a prescription instead
of on the street doesn't make their impact any different. The
educational deficits, the developmental deficits, those things
become profound, and you are going to pay for those later, and
it is--that is why it is important to do it now, and whether
you are--it is with reunification with the family or it is with
these foster parents, most of which are absolute heros stepping
up in these kids' lives, so, you know, you are not really
talking about new money here. It is because just are going to
spend it here or you are going to spend it there.
Mr. DOGGETT. Thank you very much.
Chairman REICHERT. Thank you.
Mr. Kelly, you are recognized.
Mr. KELLY. Thank you, Chairman.
Thank everybody for being here.
But if I'm listening to you, I may be hearing it
incorrectly, Ms. Chang you maybe can help me on this. Seems to
me that because we have had such a human breakdown in the
family unit, that we have more of these children that are out
there that cannot be taken care of by a mom and a dad and what
we would consider a traditional family unit. So,
overwhelmingly, I was reading the numbers, 400,000 children
right now in foster care. That is as of 2012. I don't know
where it is today. So is this--if you were to break it down
demographically, are these from lower income or lower middle
income people? Where are these children coming from?
Ms. CHANG. Sure. So, you are correct. We have a little less
than 400,000 children in foster care today. I want to note that
that is a huge mark of progress in the system. That is a
reduction from over 500,000 children in care just about 10
years ago, so the system has made a difference. But you are
right, these are young people who come from often low
socioeconomic backgrounds. They come from challenging
neighborhoods, and the abuse and neglect they experience before
they came into care and then the trauma of coming into care
even--even if they had to leave an abusive and neglectful
family, coming into care can be traumatic, but most of these
kids can be cared for in a foster home with a relative and most
of them, in fact, are.
The great majority of our kids are placed with relatives or
other foster families, and many of them don't have serious
mental illnesses. Most of our kids have trauma symptoms that
often are misdiagnosed as mental illness, and because we fail
to intervene early on, they can escalate into much more serious
behavior.
Mr. KELLY. I guess that is where my question comes in. So
who does the intervention, who determines an intervention is
necessary? And I think that is the part that bothers me. I have
got eight grandchildren right now. And 9 and 10 are coming, and
there is no two of them that are alike.
Ms. CHANG. That is right.
Mr. KELLY. Some are more challenging than others.
Ms. CHANG. That is right.
Mr. KELLY. The ones that are the most challenging, I
wouldn't say his problem is he needs medication; I would say
maybe he needs a little more parenting, but I worry about it.
Ms. Hovenier, you refer to now you actually have two
families, two dads and a mom. I think that is interesting
because you don't say I have two people taking care of them.
You say the term that most of us have identified as growing up.
I got a mom. I got a dad. I got people who care about me. I got
people who love me. I got people who I can go to when I need to
go to. I keep worrying about this and maybe you can weigh in on
this. I know your father is with you now. Your dad is with you
now, but I don't know about your early life. What happened that
your--your little brother, was a 10-year-old, he was also in a
foster home. Now, did you say you had a twin sister?
Ms. HOVENIER. I do, yes.
Mr. KELLY. Okay. Was your twin sister in a foster home?
Ms. HOVENIER. Yes.
Mr. KELLY. Okay. So, your whole family?
Ms. HOVENIER. Yes.
Mr. KELLY. Okay. All right. So that has got to be very
difficult.
Dr. Phil, you deal with folks all the time. I have watched
you a couple of times on TV. I don't have the chance to watch
as maybe I would like to, but I see this breakdown of the
family is what I see going on, and I think we are--we keep
looking for government programs that somehow will do the job
that families no longer do.
I grew up in an all together different time, and I will
tell you when I talk to my friends, we agree on one thing: We
grew up in the greatest towns at the greatest times with the
greatest parents, preachers, teachers, coaches you could ever
imagine, and a family support system. We didn't have as much of
a support system government supplied. We had it family
supplied, and that is the part that bothers me.
I look at a society that is going more to government for
answers than it is to internally families making decisions,
families deciding what to do to help a child, families being
involved in the final determination of who goes on what or what
they get prescribed to them. You see it in great numbers. You
all see it in great numbers, but I keep coming--if our families
continue to break down the way they are breaking down, there is
not enough money in the world out there to take care of these
children that are just out there going around aimlessly.
Mr. MCGRAW. Well, that is why it is so important to focus
on reunification. And by the way, I would be happy to get you a
DVR so you could watch more often.
Mr. KELLY. No, no, no, that is okay. Thank you. I
appreciate that
Mr. MCGRAW. No, that is--the whole reason--and when I say
the foster system is broken, the goal has to be reunification.
We have got to restore the American family unit in America. I
mean, we have become a much more transient society. We used to
go down and play on the corner and didn't go home, but now we
go to target schools and different places around. It is a
different time, but we have got to reinstitute the family unit
in America, and that is breaking down, and I see it more and
more every day where parents drop their child off at school and
expect them to be raised. That can't happen. It has got to
start at home.
As parents, we--the same sex parent is the most powerful
role model in any child's life, and that is where it begins,
and you cannot advocate that role to anyone, and that is why
reunification has got to be such a goal in this foster system.
Mr. KELLY. I agree with you, but it is a socialization
process we are missing out on today. I got to tell you, the way
I grew up, there wasn't anybody substituting for my mother and
my dad.
And, Ms. Hovenier, I congratulate you in getting through
what you have gotten through, but I think there is too many
children out there who do not have the benefit of having a
strong nuclear family. And I think that is the number one
problem. If you don't have a strong nuclear family, you don't
have a strong faith-based folks, you are not going to be able
to get through it on your own. You just can't learn it by
yourself through a book or through a program. Thank you.
Chairman REICHERT. Mr. Griffin, you are recognized.
Mr. GRIFFIN. Thank you, Mr. Chairman.
Thank you all for being here. I am from Arkansas, and we
have had quite a bit of success in Arkansas dealing with this
particular problem, and you know, there is a lot of--a lot of
jokes and a lot of things said about Congress, but I will tell
you that a lot of the progress we have made has been because of
the laws that we have been able to get in place. And you know,
I was just looking, reminded of 2011, which was my first year
of serving here, we had the Child and Family Services
Improvement Innovation Act, which deals specifically with the
protocol for prescribing psychotropic medication for children.
When I look at some of the results of what has gone on in
Arkansas, it has been incredible, and it, no doubt, has been
encouraged and in some cases mandated by the Federal
Government, but the boots on the ground, as we say in the Army,
has been at the State level.
And some of the numbers here--well, let me just say, a
number of--a number of specific edits or, as they are called,
or changes were put in place. One of them in particular was
having a child psychiatrist review all requests for
psychotropic medications for children under 5 and a whole host
of things, but the numbers are staggering. There was a
reduction for foster care children under 6 years old, a
reduction of 86 percent. That is almost elimination. For
nonfoster care, 92 percent, so there is a gap--there is a gap
between the nonfoster care children and the foster care
children. When you get to 6 to 12 years, reduction of 38
percent for foster care; 49 for nonfoster. So there is
something that works here, it seems to me, and I think--I think
the point that, Dr. Phil, you made and some others and some
folks up here made is a good one, and that is, look, we have
seen that throwing money at a problem doesn't work. The VA has
been getting more money for administration after
administration. I think we tripled the money for the VA in the
last little over a decade, and it is still a disaster in many
ways, and so we have got to make sure that we are funding the
right things and that we are funding things on the ground, not
more administrators, and I think that is critically important.
Now, the one thing I would--a couple of things to ask here.
First of all, Dr. Naylor, in Arkansas, there is still a gap
between--even though there have been significant reductions and
great--very effective reforms, still a gap between foster care
children and nonfoster care children. Dr. Phil mentioned
earlier that there are certain problems or patterns with foster
care children. He is--I think you said that there are more
mental health problems as a percentage than in the general
population. Maybe that explains the gap.
Dr. Naylor, could you--I see Dr. Phil shaking his head. Dr.
Naylor, if you could speak to that, then Dr. McGraw, Dr. Phil,
whichever one you want to go by, if--apparently, you chosen Dr.
Phil. But if you all could both speak to that, what is the gap?
Why is there a gap? So, when we see a reduction, the reduction
is not as much with the foster care population as it is with
the nonfoster care.
Dr. NAYLOR. Well, and I have how many minutes to answer
that?
Mr. GRIFFIN. I will give you as much as you want. He may
not.
Dr. NAYLOR. Excellent. All right. I think that there is
several reasons. I summarized some of them in my testimony. I
really think that these youngsters, you cannot, first of all,
pathologize kids in foster care or foster children because the
vast majority of them are able to carry out their roles that
they are supposed to be carrying out, being part of a foster
family, being part of a home of a relative, going to school and
things like that, but there is a subgroup, and I think that
this is a larger group in foster kids than in the general
population.
I was asked by Bryan Samuels, who came from Illinois,
actually, and he asked me if I really believed that there was a
higher rate of mental illness in foster kids, and my answer to
him, was if you really wanted to come up with a model for
developing mental illness in a population, that is the perfect
model. You have kids who--a sub-population anyway, are born to
very impulsive, very aggressive, sometimes mentally ill, very
often substance abusing and even sociopathic parents, strike
one. Strike two, in these families, very often there is
neglect. Neglect is probably worse in some ways even than
physical abuse is. Physical and sexual abuse. There is often in
utero exposure to drugs, which you know, between tobacco and
alcohol, you have got to two biggest risk factors for screwing
up the kid's brain. And we continue on through disruption of
the primary attachment.
And you look at these kids and you think, how can you
possibly love a mom who treats you like this or a dad who
treats you like this? But they do, you know, and that is what
they know. And I think the major trauma in the child welfare
system actually is when you take the kids and how you take the
kids into custody.
In--you know, people talk about the trauma of taking kids
out of the home, but let me paint a picture for you. You are
going to school. All of a sudden the police come to you at the
school. They pick you up, chuck you in the back seat of the
car, and bring you off to some strange place. Now, if you look
at this from an evolutionary point of view, abduction equals
death. And so when you are responding to this as a child, you
are not responding to just, oh, what a bummer, you were taken
away from your family. You are responding to a potentially
life-threatening situation. I mean, that is what your brain is
telling you.
And I think that we end up then seeing incredible sadness
and maybe even more than that, a howling rage for some of these
kids at being taken out of their families. And then the first
foster home sometimes stick, but for a lot of these kids, there
is multiple placement disruptions. And every single disruption
that you have is accompanied by a decreasing sense of self
worth and an increase in behavioral problems. And so we have
the perfect system for developing emotional, behavioral, and
psychiatric victims.
Mr. GRIFFIN. Mr. Chairman, I would ask that----
Chairman REICHERT. I think this is--I think this is an
important question. The time has gone 2, almost 3 minutes over.
Dr. Naylor, you did an outstanding job. I happen to have
been one of those police officers years ago that was put in
those positions, and I will allow Dr. Phil McGraw to respond in
a sound bite, please.
Mr. GRIFFIN. Thank you, Mr. Chairman.
Mr. MCGRAW. I will be as quick as I can. I don't disagree
with anything Dr. Naylor just said, but I might approach him
from a different standpoint. Being a foster child is a social
circumstance. It is not a mental illness. It is a social
circumstance. You do not treat a social circumstance with a
drug. You have to fix the underlying problem, and you have got
to do a differential diagnosis. You have got to say, is the
etiology here organic? I mean, is there a biochemical imbalance
that needs to be corrected inside the body, or has someone gone
through some type of psychological trauma that has threatened
their safety and their security and their self worth and their
ability to predict the consequences of their life and their
action. And if that is the case, I just don't believe that you
are going to fix that with medication long term.
Now, it doesn't mean it can't help short term because it
certainly can, but particularly for these young children, there
is not one shred of evidence that many of these drugs are
appropriate to use with 1- and 2-year-old children, certainly
in a polypharmacy circumstance. And I am not down on
psychotropics because, let me tell you, they can save and
change lives when appropriately used, but being a foster child
is a social circumstance, not a mental illness.
Now, it can trigger depression and some other things that
have to be dealt with, but what is the treatment of choice? Is
the treatment of choice to begin drug therapy? Is the treatment
of choice to begin some type of evidence-based psychological
therapy? And I think the former has many more side effects than
the latter and therefore is much more dangerous.
Chairman REICHERT. Thank you. Thank you for your answer.
Mr. Renacci, you are recognized
Mr. RENACCI. Thank you, Mr. Chairman.
I want to thank the panel. You know, one thing great about
being in Congress--I have only been here 3 and a half years--is
you do get to learn a lot. I was in the business world for 30
years, and I have always believed in a safety net. There is no
doubt about that. Coming from Ohio, there are 12,000 Ohio
children living in foster care each month. You know, when the
State agrees to take on the responsibility of caring for those
children and the safety of the vulnerable population, it
becomes their responsibility, and too many times we set them up
for failure, not success, which I keep hearing as I am
listening to this panel. And as I started to read about some of
the headlines, you know, regarding this issue, ``Out of Sight,
Out of Mind: Psychotropics and Foster Care,'' ``Mind-Altering
Psych Drugs for 7-Year Old,'' these are just media stories that
are--as you start to read and figure out what is going on, and
you know, when the odds are already really against these
individuals, that is very concerning.
So what I am trying to do is get some answers, and I
listened. One thing I did hear you say, Dr. McGraw, is throwing
additional money onto this problem is not the answer--the
current system, I should say. Now, redirecting it might be the
answer, but before I let you respond to that, I do want to ask
Dr. McGraw and Dr. Naylor, in each of your opinions, really,
where is the push for the use of psychotropic drugs coming
from? You know, is it the child welfare system? Is it the
medicaid system? Drug companies? Foster parents? Schools? Or
somewhere else? I would like to get either of your opinions on
that.
Dr. NAYLOR. Well, I think that the routes into a
psychiatrist's office varies. So, very often, as a child
psychiatrist, I will hear variations of this story. Johnny, who
is in foster care, has just lost his third preschool, and his
fourth preschool is going to kick him out. He is running around
the house, chasing the cat with a knife, and you need to do
something and you need to do something now. And very often,
these kids will have had therapy.
The problem is, is that not all therapies are correct. So
one of the routes in is because the psychotherapy that is
provided is not particularly effective and not evidence-based,
but something needs to be done now. And this can come from
foster parents. This can come indirectly from schools through
the foster parents into the office. Very often, it is
caseworkers who don't necessarily know how to negotiate a
mental health system. And you would think that mental health
systems and child welfare systems work together. You would also
be very wrong if you thought that. I mean, they are very much
silos. And so I think very often, child welfare workers then
will say, okay, I know this psychiatrist that treated one of my
other. I will bring this youngster in.
I don't--I think that also as a child psychiatrist sitting
in the office, I look at what is available to make an
intervention right now that might be able to head off a
psychotropic medication. And one of the biggest problems is
access to evidence-based therapies. Like I say, I can get
somebody to play Chutes and Ladders with them and talk about
nondescript things, but I can't get good evidence-based
therapy.
Mr. RENACCI. So the push is from all of the above?
Dr. NAYLOR. Yeah.
Mr. RENACCI. Dr. McGraw?
Mr. MCGRAW. Well, you can tell you are talking to somebody
that knows and lives this system, because when he says, I can
get somebody to play Chutes and Ladders with them, but if you
have got somebody that truly has a serious self-destructive
problem, it takes a much higher level of professionalism.
Here is the problem: Your caseworkers might have 40 files,
and in those--a given file might have 8 kids in it, so you are
just talking about being completely overwhelmed, and so what
you are doing is you are warehousing the problem short term.
You say, I have got somebody chasing the cat with the knife and
the school won't let him back in, so you want to take him? What
are you going to do?
And so what they do--that is why I use the term chemical
straightjacket. That is exactly what they do. They put the kid
in a chemical straightjacket till they can figure something
out, but the figuring out part never happens. The figuring out
part never happens.
Mr. RENACCI. Can you elaborate on your comment earlier
about throwing more money at this, and just give us here a
better solution or what your solution would be?
Mr. MCGRAW. What I am saying is right now, we are overusing
psychotropic drugs. That is the model. We are overusing them.
And if you throw more money at it, what you are going to do is
you are going to spread that problem. That is not the fix. What
you have got to do is change the model and then finance the
model.
You cannot just pour money on the existing model. You have
got to change the model, and then say, okay, that is all well
and good there, Dr. Phil, but how are you going to--how are you
going to give that caseworker access to the professional level
of intervention that they need? Where are you going to get the
therapist? How are you going to do that? Where you going do it?
And that takes manpower, and manpower takes money, and that is
what I am saying. You have got to change the model to one that
is intervention based instead of medication based. And that
takes manpower, and manpower takes money.
Chairman REICHERT. Time has expired.
Mr. Boustany, you are recognized.
Mr. BOUSTANY. Thank you, Mr. Chairman.
And thank you for holding this hearing. It is a really
important hearing.
My wife is a CASA in south Louisiana. I have been hearing
about all the horror stories and problems that are sort of
built into the system, as all of you have very, very concisely
described today, and we were having a conversation not long ago
over the kitchen table, and she said, you guys have to do
something about this. It is a huge problem. And then when she
heard through CASA channels that we were having this hearing,
she said, thank God that we are doing this, that we need to
look at this problem. And so I want to thank you. I want to
thank the panelists for being here.
I am also a medical doctor and have real concerns on a
number of issues. One, Dr. Phil, you mentioned the fragmented
nature of all this, and my wife has really schooled me on this
whole system and how fragmented decisionmaking is and
everything else. And you couple that with the psychotropic
drugs of which, and you correctly said earlier, nobody really
knows the mechanism of how they really work but they do save a
lot of lives, but it is even more of a pronounced situation in
children, adolescents, in understanding what the long-term
impacts will be, especially if the drugs are used
inappropriately. I mean, the adolescent in childhood, the
neurological systems function a whole lot different and they
respond differently to these drugs.
But I want to drill down on something. And that is, where
is the decision made oftentimes or for the most part? Is there
a pattern? Where are the decisions made to put these children
on these drugs? I mean, obviously, they see a social worker, a
CASA will see them. They may be in the court system. They don't
go straight to a psychiatrist, and the psychiatrist or the
family doctor or general practitioner is the one who has
prescribing authority, but somebody is making a decision,
sending it--then sending him through a psychiatrist or general
practitioner, the family practitioner who then writes a
prescription, and I am not convinced in the system that we have
today that the person prescribing the medicine is actually
following these cases and applying best practices, you know,
and appropriate follow up. So I just would like one more
comment on how this decisionmaking is made at that level to get
these kids on these drugs.
Ms. CHANG. So I can begin, and certainly other folks can
weigh in. I think the question is a good one, and I think that
is why screening and assessment is so critical. When we don't
have appropriate screening and assessment tools, we are
shooting in the dark, right, and so people are not making
informed decisions, no matter who it is that instigates that
process, so we need to make sure that that is happening.
We are really pleased actually that Louisiana is one of our
grantees who is focused on installing universal trauma-based
screening and assessment in the State for all children in the
child welfare system. And they are actually one of our State
grantees who came to us and said, We do want to do this grant,
we want to be successful, we have installed screening and
assessment tools so that we can identify what kids actually
need. And many of them don't need psychotropic medications.
The problem they found was they didn't have access to the
evidence-based interventions the kids do need, and that is the
real challenge. And as Dr. Phil says, you know, it costs money
to scale up evidence-based interventions. You have to train
physicians. You have to train social workers. You have to
monitor the program itself to make sure it is being implemented
with fidelity. You have to have data systems that can track the
outcomes of these kids. That costs money. And so, you are
right, from the very beginning, we don't have systems in place
to actually identify what it is these kids need, so many people
are shooting in the dark.
And also another challenge is that we have to be realistic.
A lot of our kids do not have access to providers in a timely
way that they need them, right. Some of our kids are waiting
for 6 months to see a physician, and so you can imagine that
the caseworker knows that that child is not going to see that
doctor again perhaps for another 6 months, and so they are
doing what the best that they can with the tools that they have
available to them, and what we want to do is to expand their
toolbox so that they have the right instruments they need to
serve individual children where they are.
Mr. BOUSTANY. Is there an appropriate review process in
many of the States? You know, after a child is put on
psychotropic medication, obviously, you need to, you know,
track it and monitor it and review the appropriateness of the
therapy. I mean----
Ms. CHANG. Well, thanks to Congress, led by this committee
and through passage of legislation in 2011, we now have a
Federal mandate that all child welfare system have a process in
place to oversee the psychotropic medication use of children in
their care. And what we have heard from researchers, although
it is still really early because now it has only been a few
years that these processes have been in place, what researchers
are finding and they are very excited is that it has made a
difference.
So your actions have made an impact in the lives of
children, and what we want to do is take it to that next step
Mr. BOUSTANY. Thank you.
Chairman REICHERT. The gentleman's time has expired.
We will move on to Mr. Crowley.
Mr. CROWLEY. Thank you, Mr. Chairman.
Thank you for holding this hearing today. And to Mr.
Doggett as well, the ranking member.
Dr. Phil, I am desperate to try to ask you a profound
question and hope I might get on your television show, but I
can't come up with one, but I do want to thank you for the
attention you are bringing to this issue.
You mentioned the shadow--the foster youth in the shadows
today, and I think the real attempt here is to bring them out
of the shadow and into the light that all of society can better
understand the circumstances that they are living in, so thank
you for that.
I have the opportunity--and I also want to thank my good
friend and colleague Karen Bass, who is not a member of the
subcommittee, but I am hopeful, will have an opportunity to say
a few words as well. She, since coming to Congress, has been an
incredible leader on the issue of foster care. I dabbled a
little bit into it, and she has really taken over and really
ran with it, so I really appreciate all she has done for this
effort. But I had the opportunity this morning to meet with a
very impressive young lady named Chanise, who was following me
this morning, and we had opportunity to share some of her
experiences and exchanged some ideas and thoughts and to try to
find some solutions and actions that can take place to
effectively bring about the changes that are needed within the
foster care system.
And that is what our charge here in Congress is to do is to
try to find ways to bring about change of things that need
fixing. And certainly I think the foster care system is in need
of our attention. We have seen the data on how common it is for
children in foster care to be prescribed these psychotropic
medications, in some cases, multiple medications at one time,
and in fact, Chanise shared with me her own experiences in
terms of medicated--being medicated at a very, very young age.
And medication is the medication is trying to solve an
issue that perhaps could be better addressed through
intervention as has been discussed here earlier today. That is
something that, as I mentioned, I talked to Chanise about, but
it is also something in my home State of New York, where I
think new ground is being broken. And I appreciate the work
that is taking place there. We need to separate out what is a
problem generally worthy of medicated treatment and what is
better served by a social worker or other personal engagement.
While reducing medication can be a worthy goal in and of
itself, we want to make sure we are also focusing on a
comprehensive approach that includes alternative treatments.
New York has been a leader in trying to address the
problems of overmedicated--overmedicating foster youth. New
York is one of five States, including Illinois, as I believe,
Dr. Naylor, you may be familiar with, participating in a 3-year
initiative developed by the Center for Health Care Strategies
and made possible through the Annie E. Casey Foundation. This
initiative focuses on in collaborative--collaboration among
State agencies to develop more effective practices for the use
of these medications in foster care. State experts in New York
tell me that this initiative has highlighted important areas
that need to be addressed in order to have successful policies
on this issue.
For example, one of the first challenges they had to meet
was how to share data amongst the various agencies because
while the Office of Children and Family Services was
responsible for overseeing the foster care system, the actual
medical treatment data was under Medicaid within the Department
of Health, and the Office of Mental Health was also involved as
well, so even just to survey how widespread the problem is
required a new level of interagency cooperation. New York was
fortunate that they honed in on this issue early and were able
to address it. I know other States may be struggling with
similar data-sharing problems, so I urge them to look at New
York as an example.
Beyond just the data-sharing aspect, it is critical that
multiple agencies work productively together. You have
situations where the foster care agency may make
recommendations or set protocols, but the doctors prescribing
the medication are under the Department of Health. Everyone
needs to work together in order to get the best results
possible.
One of the lessons New York has learned is to emphatically
stress collaboration and to ensure that each part of the system
understands the impact that reaches beyond a single agency.
Ms. Chang, I see that the ACF has sought to encourage this
collaboration through their demonstration, so I was wondering
if you could possibly expound upon that and comment on what is
taking place.
Ms. CHANG. Sure. Thank you. We agree with you. We think
that collaboration is critical. Children in the foster care
system are not served by one agency. They are served by
multiple agencies. The Medicaid agencies, the mental health
agencies, as well as child welfare, and so that is why we are
really excited that this proposal has both an ACF component as
well as a CMS component, and that goes to part of what I said
about having access to providers.
We know that we have to create incentives so that there are
physicians who are willing to care for our kids, that we have
to create incentives to say that the Medicaid offices can also
get funding to pay for the types of supports that they need so
that there are providers, and it brings those two groups--major
groups that serve these people--these children to the table to
work together.
Mr. CROWLEY. Thank you.
Thank you, Mr. Chairman. I yield back.
Chairman REICHERT. Thank you, Mr. Crowley.
Mr. McDermott, you are recognized.
Mr. MCDERMOTT. Thank you, Mr. Chairman. I--full disclosure,
I was trained at the University of Illinois and worked at
Allendale School, so I know a little bit about the Illinois
system.
My question is really, let's take Dawna. She goes into
foster care and somebody writes a script for her to have
medication. And I am talking about today, not 3 or 4 years ago
when this happened, but today in Illinois. How would that be
evaluated before she got the medication? Or would it be a
retrospective evaluation 6 months later? Or when did it happen
and by whom and did they ever see her? How would that decision
have been made for her?
Dr. NAYLOR. That is a good question, and I--there are
various ways of doing these reviews prospective and
retrospective being the two major categories. Ours is a
prospective one, so we review all of the requests before the
medication is actually prescribed and dispensed.
Mr. MCDERMOTT. So she is creating havoc in the house as a
rebellious teenager, which she says she was. Somebody says this
kid needs to be on drugs, so somebody writes a script, and then
how long does it take to get to you and your independent agency
to make a decision about whether she should have them or not?
Dr. NAYLOR. I hate to use you as an example, but you are
hospitalized right now, and so the medication request comes to
DCFS and our program at the very same time, and it has all of
the diagnostic information, all of the symptom information, all
medications that she would be on, and our review is not a true
second opinion. We don't have the resources to be able to send
somebody out to do an evaluation, and I think we have like
2,700 kids on medication. That would take a lot of resources to
have a second opinion on everybody.
And so the work becomes, there is a diagnosis and the
symptoms match, if they match, is the treatment something that
would be recommended or recognized treatment for that
combination of diagnoses and symptoms. If it is, is the dose
requested being--an appropriate dosage, and if that is the
case, we would approve the medication.
Mr. MCDERMOTT. How often do you reject a request for
medication for a patient? A thousand scripts come in to you,
you look at a thousand of them, how many times do you say no?
Dr. NAYLOR. That is a complicated question, and I will go
through it as quickly as I can. I don't deny all that many
requests anymore. And the reason I don't deny all that many
requests anymore is because I have been doing this now for 15
years, and initially, when I started the program, people would
talk to my boss and complain about Dr. Naylor's idiosyncratic
psychopharmacology, and so they would rant and rave against
what my recommendations would be. But my boss knew that I was
arguing science and arguing good clinical care, and so, over
time, people have changed their prescribing practices, and so
that is one thing we do.
Another thing that we do is we ask really embarrassing
questions like, do you really think it is a good idea to start
this patient, who is psychotic, on a stimulant, which can cause
psychosis? And the very act of asking the question will--again,
because I have been there for 15 years, will lead to the doctor
withdrawing the request for the medication because they know
that if they persist, it will be denied.
So we deny probably 1 percent. There is probably 8 percent
that are rescinded, but this is down from about 15 percent
denials and fairly high rescinding rate about 10 years ago.
Mr. MCDERMOTT. And then 6 months later or a year later, you
have now put her on the medication, you think it is a good
idea, what is the possibility it will ever be looked at again
by someone?
Dr. NAYLOR. Well, in terms of the consent process, by law,
I will look at that again in 6 months. We only provide consent
for every 6 months. And we will ask for a clinical update. If,
at any point along the way, including with the first time that
they made a request for the medication, I can request a second
opinion from another physician, or if it is one of those cases
that would end up on the front page of the newspaper, I will
sometimes go out and do these second opinions, so we will
follow up with getting as much clinical information as we can
get in order to make a determination whether that medication is
still indicated or not.
Mr. MCDERMOTT. If she ran into a CASA worker who said--and
she said, I don't think I should be on this medication, can I
get off it, can you help me get off it, and they called you--
can they call you? Can they appeal to you? Is there any way of
appeal to you to review what is going on there?
Dr. NAYLOR. Absolutely. We actually have several different
ways in where requests for a rereview can be made, and these
requests can come from guardian ad litems, CASA workers,
judges, juvenile judges, caseworkers. The nurses in Illinois
are like another pair of eyes and ears, and they will often
refer back for additional consultation. And now psychologists
are also out in the field doing similar kind of monitoring
work, so we will get consultation requests that way.
A foster child can go to the guardian ad litem and say I
would like a second opinion on my medication, and we will find
a way to get a second opinion done, so yes, there is.
Mr. MCDERMOTT. Ms. Chang, is this common across the United
States? The Illinois system is something as comprehensive as
that?
Ms. CHANG. This particular model of reauthorization is not
as common.
Mr. MCDERMOTT. Not as common. Give me numbers here.
Ms. CHANG. So I can't give you a 50-State survey. I am
happy to get back to you, sir, and tell you exactly how all
States are structuring it. Most States, based on our review, do
have a monitoring after the fact, and really, the--many of
those programs are highly successful. Texas is a good example
of that. They have protocols for when medication can be used,
and they have a systematic way of reviewing all scripts to make
sure that they follow the protocol. They also then look at
individual physicians who break protocol more than once, and so
they have a very effective way of managing medication, even
though it doesn't involve preauthorization. And we find that
most States employ that type of protocol and then making sure
that doctors are following it.
There are other models. For example, Massachusetts makes
sure that there are mental health professionals who specialize
in medication management who are always available to social
workers, caseworkers, as well as other physicians who are
seeing these kids so that whenever questions come up, they can
immediately get professional assistance because oftentimes, one
of the problems is that these are folks without the expertise
in prescribing these types of medications, so there are a
variety.
Mr. MCDERMOTT. Thank you.
Thanks for extending my time.
Chairman REICHERT. You are welcome.
Thank you, Mr. McDermott.
And Ms. Chang, if you can provide that information in
writing to the committee, I think that was a very good
question, we would like to have that additional information, if
you please.
So, I am just going to repeat a few things that I heard
today, and then you can leave. We will wrap this up. First of
all, I heard--I think we are all on agreement--we just don't
want to pour money into a system that currently is not
operating at 110 percent, right? So, we recognize there is some
work there to do. Ms. Chang is working with the States in
trying to bring States along to develop systems, and Illinois
is a great example of some great progress that has been made,
but we all can do better.
I think, in listening to Ms. Hovenier and her suggestions,
you know, I really like the idea of no matter what, a second
opinion. I think coming from you, that has a lot of power
behind it.
Choices of therapy, I think Dr. McGraw and Dr. Naylor and
others have mentioned that sometimes some therapies just don't
work because it is the wrong therapy. So that was a great point
that you made.
And then the mention of tools, the proper tools for
screening, for assessment and evidence-based, I think is
really, really critical, and that is when you begin to apply
the resources and the funding when you know that you have got
evidence-based information to make decisions on. I think all of
the panel would agree with that, and I think the members that
were here today would agree with that.
And I want to thank, again, all of you for taking time out
of your busy schedules to be here today. This is such an
important topic, and all the members here that were here to ask
questions and listen to your testimony.
And again, a special thank you to Ms. Bass for her work in
this arena and helping us schedule this hearing.
So if members have additional questions, those of us who
are left, for the witnesses, they will submit them to you in
writing, and we would appreciate receiving your responses for
the record within 2 weeks. The committee now stands adjourned.
[Whereupon, at 4:13 p.m., the subcommittee was adjourned.]
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Letter of the Adopt America Network
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