U.S. GOVERNMENT PUBLISHING OFFICE

35–691 WASHINGTON : 2019

21ST CENTURY CURES IMPLEMENTATION: 

EXAMINING MENTAL HEALTH INITIATIVES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JULY 19, 2018 

Serial No. 115–154 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

JEFF DUNCAN, South Carolina 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

(III) 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MARSHA BLACKBURN, Tennessee 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(V) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Prepared statement .......................................................................................... 5 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 8 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 9 

Prepared statement .......................................................................................... 10 

WITNESSES

Elinore McCance-Katz, Ph.D., Assistant Secretary for Mental Health and 

Substance Use, Substance Abuse and Mental Health Services Administration ........................................................................................................................ 11

Prepared statement .......................................................................................... 14 

Answers to submitted questions 1 ................................................................... 58 

SUBMITTED MATERIAL

Statement of Texas Tech University Health Sciences Center, submitted by 

Mr. Burgess .......................................................................................................... 43 

Statement of the American Academy of Pediatrics, submitted by Mr. Green .... 46 

Statement of the American Psychiatric Association, submitted by Mr. Green .. 47 

Statement of the American Psychological Association, submitted by Mr. 

Green ..................................................................................................................... 48 

Statement of the National Child Traumatic Stress Network, submitted by 

Mr. Green .............................................................................................................. 46 

Article entitled, ‘‘Nazis separated me from my parents as a child. The trauma 

lasts a lifetime,’’ The Guardian, June 18, 2018, submitted by Ms. Schakowsky .................................................................................................................. 51 

Statement of the Anti-Defamation League, submitted by Ms. Schakowsky ....... 54 

1 The committee did not receive a response to Ms. McCance-Katz’s submitted 

questions for the record by the time of printing. 

(1) 

21ST CENTURY CURES IMPLEMENTATION: 

EXAMINING MENTAL HEALTH INITIATIVES 

THURSDAY, JULY 19, 2018 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:03 a.m., in room 

2123, Rayburn House Office Building, Hon. Michael Burgess, M.D. 

(chairman of the subcommittee) presiding. 

Present: Representatives Burgess, Guthrie, Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, Hudson, Carter, 

Walden (ex officio), Green, Schakowsky, Matsui, Castor, Kennedy, 

DeGette, and Pallone (ex officio). 

Staff Present: Jennifer Barblan, Chief Counsel, Oversight and Investigations; Daniel Butler, Legislative Clerk, Health; Karen Christian, General Counsel; Adam Fromm, Director of Outreach and 

Coalitions; Ed Kim, Policy Coordinator, Health; Ryan Long, Deputy 

Staff Director; James Paluskiewicz, Professional Staff Member, 

Health; Kristen Shatynski, Professional Staff Member, Health; Jennifer Sherman, Press Secretary; Austin Stonebreaker, Press Assistant; Josh Trent, Chief Health Counsel, Health; Hamlin Wade, Special Advisor, External Affairs; Jacquelyn Bolen, Minority Professional Staff; Jeff Carrol, Minority Staff Director; Waverly Gordon, 

Minority Health Counsel: Tiffany Guarascio, Minority Deputy Staff 

Director and Chief Health Advisor; Samantha Satchell, Minority 

Senior Policy Analyst; Andrew Souvall, Minority Director of Communications, Outreach and Member Services; and C.J. Young, Minority Press Secretary. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. The Subcommittee on Health will now come to 

order. The chair recognizes himself 5 minutes for the purpose of an 

opening statement. 

So today we convene and hold an oversight hearing on the mental health division of the 21st Century Cures Act which was signed 

into law in December 2016. On the anniversary of the House passage of 21st Century Cures, this subcommittee held a hearing on 

the sections of the law that the National Institute of Health and 

the Food and Drug Administration are implementing. Today we 

have Dr. Elinor McCance-Katz, the assistant secretary for Mental 

Health and Substance Use, here to testify before us about the work 

2 

that the substance abuse and Mental Health Services Administration is doing to address our country’s mental health needs. 

The mental health title of 21st Century Cures was based upon 

the Helping Families and Mental Health Crisis Reform Act of 2016 

which passed the House by a vote of 422 to 2 prior to its inclusion 

in the Cures bill. This legislative effort represents the most significant reforms to the mental health system in more than a decade. 

The first provision within the mental health division strengthened the leadership and the accountability of SAMHSA including 

establishing the position that Dr. McCance-Katz now holds. One of 

her duties as the assistant secretary is to develop a strategic plan 

by the end of this fiscal year. 

Cures also strengthened existing programs, including SAMHSA’s 

two biggest programs, the Community Mental Health Services 

Block Grant and the Substance Abuse Prevention and Treatment 

Block Grant. Given that each State and community is different, 

this law provides flexibility to States to address their unique mental health needs. Additionally, the law authorized the National 

Mental Health Policy Laboratory to carry out existing and new activities under the mental health policy umbrella including awarding grants for promising service delivery models and expanding evidence-based programs. 

Access to mental health and substance use disorder care is vital 

to the overall health of our Nation. According to the National Alliance on Mental Illness, approximately one in five adults in the 

United States experience mental illness per year. Of those adults 

suffering from mental illness, only a little more than 40 percent receive mental health services in the past year. Title 9 of the 21st 

Century Cures Act focused on promoting access to mental health 

and substance use disorder care. 

The programs included in this title authorized and strengthened 

several existing programs that previously had not been in statute. 

Some of these programs provide grants to eligible entries that provide mental health and substance use disorder services to homeless 

individuals and jail diversion programs. Additionally, the title authorized the program to further integrate primary care and behavioral health services through demonstration projects. Notably, the 

21st Century Cures Act expanded the target population of this integration to include additional populations such as certain qualifying children and adolescents. 

The Centers for Disease Control and Prevention recently released 

a vital signs report that showed a rising suicide rate across the 

United States. In 2016, we lost nearly 45,000 lives to suicide. 21st 

Century Cures aimed to provide additional suicide prevention resources by codifying the National Suicide Prevention Hotline and 

authorizing the Garrett Lee Smith Suicide Prevention Resource 

Center and Youth Suicide Prevention State Grants. 

The existence of all of these programs would be far less impactful 

if we did not have an adequate work force to provide services. 

Therefore, there was an entire subtitle directed to strengthening 

the mental and behavioral healthcare workforce through training 

grants, demonstration programs, and other means. 

Cures established several new grant programs to address mental 

health needs in populations such as Mothers and Children. One 

3 

program provides grants to support Statewide or regional pediatric 

mental health care telehealth access programs. Such programs 

could be especially helpful in early identification and treatment of 

mental health issues in school-age children. This is especially critical because 50 percent of all chronic mental illness begins by age 

14. 

21st Century Cures made meaningful long-sought reforms to our 

mental health system and is the result of thoughtful bipartisan legislation created over the course of several years. While this law reflects on our diligence and our commitment to improving America’s 

overall mental health, there is work that remains to be done. 

I will yield back the balance of my time and recognize the ranking member of the subcommittee, Mr. Green, 5 minutes for an 

opening statement, please. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

Good morning. Today we convene to hold an oversight hearing on the mental 

health division of the 21st Century Cures Act, which was signed into law in December 2016. On the anniversary of House passage of 21st Century Cures, this Subcommittee held a hearing on the sections of the law that the National Institutes of 

Health and the Food and Drug Administration are implementing. Today, we have 

Dr. Elinore McCance-Katz, the Assistant Secretary for Mental Health and Substance Use, here to testify before us about the great work that the Substance Abuse 

and Mental Health Services Administration (SAMHSA) is doing to address our 

country’s mental health needs. 

The mental health title of 21st Century Cures was based upon the Helping Families in Mental Health Crisis Reform Act of 2016, whichpassed the House by a vote 

of 422–2 prior to its inclusion in Cures. This legislative effort represents the most 

significant reforms to the mental health system in more than a decade. 

The first provision within the mental health division strengthened the leadership 

and accountability at SAMHSA, including establishing Dr. McCance-Katz’s position. 

One of her duties as the Assistant Secretary is to develop a strategic plan by the 

end of this fiscal year. 

Cures also strengthened existing programs, including SAMHSA’s two biggest programs, the Community Mental Health Services Block Grant and the Substance 

Abuse Prevention and Treatment Block Grant. Given that each state and community is different, the law provides flexibility to states to address their unique mental 

health needs. Additionally, the law authorized the National Mental Health Policy 

Laboratory to carry out existing and new activities under the mental health policy 

umbrella, including awarding grants for promising service delivery models and expanding evidence-based programs. 

Access to mental health and substance use disorder care, especially in the midst 

of an opioid epidemic, is vital to the overall health of our nation. According to the 

National Alliance on Mental Illness, approximately one in five adults in the United 

States experience mental illness per year. Of those adults suffering from mental illness, only 41 percent received mental health services in the past year. Title IX of 

21st Century Cures focused on promoting access to mental health and substance use 

disorder care. 

The programs included in this title authorized and strengthened several existing 

programs that had not been in statute. Some of these programs provide grants to 

eligible entities that provide mental health and substance use disorder services to 

homeless individuals and jail diversion programs. Additionally, the title authorized 

a program to further integrate primary care and behavioral health care services 

through demonstration projects. Notably, 21st Century Cures expanded the target 

population of this integration to include additional populations, such as certain 

qualifying children and adolescents. 

The Centers for Disease Control and Prevention recently released a Vital Signs 

report that showed rising suicide rates across the United States. In 2016, we lost 

nearly 45,000 lives to suicide. 21st Century Cures aimed to provide additional suicide prevention resources by codifying the National Suicide Prevention Hotline and 

authorizing the Garrett Lee Smith Suicide Prevention Resource Center and Youth 

Suicide Prevention State Grants. 

4 

The existence of all of these programs would be far less impactful if we did not 

have an adequate workforce to provide services; therefore there was an entire subtitle dedicated to strengthening the mental and behavioral health care workforce 

through training grants, demonstration programs, and other means. 

Cures established several new grant programs to address mental health needs in 

populations, such as mothers and children. One program provides grants to support 

statewide or regional pediatric mental health care telehealth access programs. Such 

programs could be especially helpful in early identification and treatment of mental 

health issues in our school-aged children. This is especially critical because 50 percent of all chronic mental illness begins by age 14. Another program awards grants 

to states for the purpose of screening and treating depression among women who 

are pregnant or who have given birth in the past year. 

21st Century Cures made meaningful, long-sought reforms to our mental health 

system, and is the result of thoughtful, bipartisan legislation crafted over the course 

of several years. While this law reflects our diligence and our commitment to improving America’s overall mental health, there remains much work to be done. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for holding today’s hearing on the implementation of the 21st Century Cures Act. Today 

we will be examining Division C of the law which focuses on mental health programs and activities administered by the Substance 

Abuse and Mental Health Service Administration, SAMHSA. I 

want to thank Dr. McCance-Katz, the assistant secretary for Mental Health and Substance Use of SAMHSA for joining us this morning. 

The enactment of the 21st Century Cures in December of 2016 

was a great achievement, particularly in a time of sharp partisanship and gridlock. But the work started long before 2016 led by colleagues Fred Upton and Congresswoman Diane DeGette. But all of 

us on the committee were participants. 

In 2014, we set out on a mission to do something positive to 

boost medical research and innovation, accelerate the discovery and 

development of new cures and treatment, and improve public 

health. 

After countless hours devoted to roundtables, white papers, hearings, and drafts, Cures enjoyed bipartisan support and endorsements from over 700 organizations representing a full spectrum of 

the stakeholders. The investment and new authorities created by 

Cures are intended to go far in solving today’s complex scientific 

problems giving new treatments from the lab table to the bedside 

and strengthening our nation’s public health infrastructure. 

The Cures Act made several changes to mental health authorities and programs implemented by SAMHSA reauthorizing several 

existing mental health grant programs and creating new programs. 

For example. The Cures Act Established a chief medical officer 

within SAMHSA to assist in evaluating and organizing programs 

within the agency and promote best practices. 

The law thoroughly requires SAMHSA to develop a strategic plan 

every 4 years to identify priorities and including a strategy for improving the recruitment, training, and retention of a mental health 

workforce. The Cures Act also created a national mental health policy laboratory and an inter-department serious mental illness coordinating committee, which issued a report to Congress last December to address the needs of Americans suffering from serious 

5 

mental illness and suffering emotional disturbance, across Federal 

agencies. One of the most important actions that the Federal Government can take to help Americans suffering from mental illness 

and emotional disturbance is ensuring they have the access to care. 

Medicaid is the single largest payer for mental health services in 

the United States. In 2015, Medicaid covered 21 percent of adults 

with mental illness and 26 percent of adults with series mental 

health. I am concerned that actions taken by the Trump administration to make it more difficult to receive Medicaid and increase 

costs of health coverage more recently by suspending risk adjustment payments to insurers covering high-cost patients will make it 

more difficult for Americans suffering from mental illness and emotional disturbance to receive treatment they need to live in a full 

and healthy life. 

Before I close, I must note that on the ongoing mental health crisis created by the Trump administration regarding the separation 

of children from their parents. The American Academy of Pediatrics has emphasized that highly stressful experiences like family 

separation can cause irreparable harm disrupting a child’s brain, 

architecture, and affecting his or her short- and long-term health. 

This type of prolonged exposure is serious stress known as toxic 

stress can lead to lifelong consequences for these children. 

Currently there are over 3,000 children who are forcibly separated from their parents by Federal authorities. We must hear how 

these family separations are impacting the mental and emotional 

health of these children and what action SAMHSA is taking to help 

these children recover from the trauma of family situation. 

Thank you, Mr. Chairman, and I would be glad to yield my last 

minute to someone who would like a minute. 

Nobody? 

Diane? I will yield to my colleague from Colorado. 

[The prepared statement of Mr. Green follows:] 

PREPARED STATEMENT OF HON. GENE GREEN

Mr. Chairman, thank you for holding today’s hearing on the implementation of 

the 21st Century Cures Act. 

Today, we will be examining Division C of the law, which focuses on mental 

health programs and activities administered by the Substance Abuse and Mental 

Health Services Administration (SAMHSA). 

I would like to thank Dr. McCance-Katz, the Assistant Secretary for Mental 

Health and Substance Use at SAMHSA for joining us this morning. 

The enactment of the 21st Century Cures Act in December 2016 was a great 

achievement, particularly in a time of sharp partisanship and gridlock. 

But the work started long before 2016. In 2014, we set out on a mission: do something positive to boost medical research and innovation, accelerate the discovery, development and of new cures and treatment, and improve public health. 

After countless hours devoted to roundtables, whitepapers, hearings and drafts, 

Cures enjoyed bipartisan support and endorsements from over 700 organizations 

representing the full spectrum of stakeholders. 

The investment and new authorities created by Cures are intended to go far in 

solving today’s complex scientific problems, getting new treatments from the lab 

table to the bedside and strengthening our nation’s public health infrastructure. 

The Cures Act made several changes to mental health authorities and programs 

implemented by SAMHSA, reauthorized several existing mental health grant programs and created new programs. 

For example, the Cures Act established a Chief Medical Officer within SAMHSA 

to assist in evaluating and organizing programs within the agency and promote best 

practices. 

6 

The law further requires SAMHSA to develop a strategic plan every four years 

to identify priorities, including a strategy for improving the recruitment, training, 

and retention of the mental health workforce. 

The Cures Act also created the National Mental Health Policy Laboratory and the 

Inter-Departmental Serious Mental Illness Coordinating Committee, which issued a 

report to Congress last December to address the needs of Americans suffering from 

serious mental illness and serious emotional disturbance across Federal agencies. 

One of the most important actions the Federal Government can take to help 

Americans suffering from mental illness and emotional disturbance is ensuring they 

have access to care. 

Medicaid is the single largest payer for mental health services in the United 

States. In 2015, Medicaid covered 21 percent of adults with mental illness and 26 

percent of adults with serious mental illness. 

I am concerned that actions taken by the Trump Administration to make it more 

difficult to receive Medicaid and the increase the cost of health coverage, most recently by suspending risk adjustment payments to insurers covering high-cost patients, will make it more difficult for Americans suffering from mental illness and 

emotional disturbance to receive the treatment they need to live a full and healthy 

life. 

Before I close, I must note the ongoing mental health crisis created by the Trump 

Administration regarding the separation of children from their parents. 

The American Academy of Pediatrics has emphasized that ‘‘highly stressful experiences, like family separation, can cause irreparable harm, disrupting a child’s 

brain architecture and effecting his or her short- and long-term health. This type 

of prolonged exposure to serious stress—known as toxic stress—can lead to lifelong 

consequences for children.’’ 

Currently, there are over 3,000 children who were forcibly separated from their 

parents by federal authorities. 

We must hear how these family separations are impacting the mental and emotional health of these children and what action SAMHSA is taking to help these 

children recover from the trauma of family separation. 

Thank you, Mr. Chairman, and I yield the remainder of my time. 

Ms. DEGETTE. Thank you very much. 

I just want to thank you, Doctor, for coming today. And I really 

look forward to hearing what SAMHSA is doing to implement the 

reforms in 21st Century Cures. This really, particularly the mental 

health aspects of the bill were issues that this committee worked 

on for many years trying to get it right. And I am not sure we yet 

have it right, but we are certainly working in that direction. So 

thank you. 

And I also want to echo what my colleagues are saying about 

these kids at the border. I think we are making progress reuniting 

them with their families, but we need to double our efforts down, 

and we also need to make sure they get adequate mental health 

counseling. 

I yield back. 

Mr. BURGESS. The gentleman from Texas yields back. 

The chair notes there is a vote on the floor. But with the Committee’s permission, we will finish with our opening statements before adjourning for the vote. 

And I will recognize the gentleman from Oregon, the chairman 

of the full committee, Mr. Walden, for his opening statement. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. Well, thank you very much, Mr. Burgess. We appreciate that. And we appreciate your convening this hearing. It is 

really important that we do oversight on how 21st Century Cures 

and the wonderful bipartisan changes incorporated therein are now 

being implemented. I want to thank our colleagues on the comVerDate Nov 24 2008 10:47 Apr 10, 2019 Jkt 037690 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-154 CHRIS
7 

mittee who are here now, and certainly Dr. Tim Murphy who was 

a real leader in the Congress on mental health reform for his work 

on this as well. These policies were the result of multiyear, multimember bipartisan congressional effort, and they are based largely 

off the Helping Families in Mental Health Crisis Act which passed 

the House in July of 2016 by a sweeping vote of 422 to 2. 

It is also important, as an authorizing committee, that, once we 

pass legislation, we come back and review is it working? Where can 

we improve? What is not working? And that is why we are here 

today. 

These provisions were ultimately folded into Cures which was 

signed into law on December 13 of 2016. Division B of Cures authorized these landmark reforms to our nation’s mental health 

laws, and they were long overdue. 

When our committee first took on this, there were 112 Federal 

programs spread across eight Federal agencies designed to address 

mental illness. And they cost taxpayers $130 billion annually. So 

112 programs, eight agencies, $130 billion. And many of the programs had not been updated or reauthorized in years. 

In Cures, under the leadership of Fred Upton, our chairman of 

the committee at the time, and Ms. DeGette and others, we streamlined these programs and brought them into the 21st century. We 

prioritized access to evidence-based programs and best practices to 

make them available to providers across the Nation. We granted 

States additional flexibility in administering mental health block 

grants to address the specific needs of their patient population. 

And we increased oversight, transparency, and accountability for 

these programs. 

Cures also made important progress in boosting resources for 

suicide prevention. Too many of us have friends who have lost 

loved ones to suicide. My dear friend and colleague, Senator Gordon Smith from Oregon, tragically lost his son Garrett Lee Smith 

to suicide 1 day before his son’s 22nd birthday. I worked hard with 

Senator Smith to authorize the original Garrett Lee Smith Memorial Act which provides information and training for suicide prevention, surveillance, intervention, strategies for all ages. And I was 

proud to see this important program reauthorized in Cures. 

In a March funding bill which is now law, Congress provided 

critical funding for nearly 30 sections of the provisions within 

Cures, and these programs include the National Child Traumatic 

Stress Network, the National Child traumatic Stress Initiative, 

Mental and Behavioral Health Training Grants, Assisted Outpatient Treatment, and the National Suicide Prevention Lifeline. 

In addition, the bill also appropriated more than $2.3 billion in new 

funding for mental health programs and other training. These are 

resources that can mean the difference, literally, between life and 

death. 

It is also worth noting the promotion of integration of primary 

and behavioral health care included in Cures. In Wallowa County 

out the northeast part of my district and other areas across rural 

Oregon, I have heard the success stories of providers who have 

been able now to integrate their community health center and their 

behavioral health services. We know it works, but we also know 

there can be barriers to full integration. So I would appreciate 

8 

hearing from our witness today about what you are seeing at the 

Federal level in this space of integration of service. 

Finally, I would like to note that the sections in Cures devoted 

to substance use disorder. And just last month the House passed 

H.R. 6, the Support for Patients in Communities Act. That is the 

biggest legislative package to address a drug crisis in American 

history. That bill started in this very subcommittee. And our work 

on substance use disorder, however, goes much further back, back 

to the lead up to the Comprehensive Addiction Recovery Acts, 

CARA, and the Cures legislation. 

So this intersection between mental health issues and substance 

abuse disorder is clearer now more than ever, and the grants and 

programs authorized by Cures have set the table for our work to 

combat the opioid crisis. 

So I would like to thank our witness for joining us today and the 

work that you are doing. Your position was created under the very 

law that we are examining today. And I know we are all eager to 

learn more about your work to coordinate critical mental health 

services and programs across the Federal Government. 

Mr. Chairman, I will yield back the balance of my time. 

[The prepared statement of Mr. Walden follows:] 

PREPARED STATEMENT OF HON. GREG WALDEN

I’d like to thank Dr. Burgess for convening this hearing today to examine the 

meaningful mental health reforms enacted into law with the 21st Century Cures 

Act, or Cures. These policies were the result of a multi-year, multi-Congress effort. 

They are based largely off the Helping Families in Mental Health Crisis Act, which 

passed the House in July 2016 by a sweeping vote of 422–2. 

The provisions were ultimately folded into Cures, which was signed into law on 

December 13, 2016. Division B of Cures authorized these landmark reforms to our 

nation’s mental health system that were long overdue. 

When our committee first took this on, there were 112 federal programs spread 

across eight federal agencies designed to address mental illness. They cost $130 billion annually, and many of these programs had not been updated or reauthorized 

in years. 

In Cures, we streamlined these programs and brought them into the 21st century. 

We prioritized access to evidence-based programs and best practices to make them 

available to providers across the country. We granted states additional flexibility in 

administering mental health block grants to address the specific needs of their patient population. And we increased oversight, transparency, and accountability for 

these programs. 

Cures also made important progress in boosting resources for suicide prevention. 

Too many of us have lost loved ones to suicide—my friend and colleague Senator 

Gordon Smith from Oregon tragically lost his son Garrett Lee Smith to suicide, one 

day before his 22nd birthday. I worked hard with Senator Smith to authorize the 

original Garrett Lee Smith Memorial Act, which provides information and training 

for suicide prevention, surveillance, and intervention strategies for all ages. I was 

proud to see this important program reauthorized in Cures. 

In a March funding bill which is now law, Congress provided critical funding for 

nearly 30 sections of provisions within Cures. These programs include: The National 

Child Traumatic Stress Network, The National Child Traumatic Stress Initiative, 

Mental and Behavioral Health Training Grants, Assisted Outpatient Treatment, 

and the National Suicide Prevention Lifeline. In addition, the bill also appropriated 

more than $2.3 billion in new funding for mental health programs and other training. These are resources than can mean the difference between life and death. 

It’s also worth noting the promotion of integration of primary and behavior health 

care included in Cures. In Wallowa County and other areas of my district in Oregon, 

I’ve heard the success stories of providers who have integrated their community 

health center and behavioral health services. We know that works, but we also 

know there can be barriers to full integration and I’d love to hear from our witness 

about what you’re seeing at the federal level in this space. 

9 

Finally, I’d like to note the sections in Cures devoted to substance use disorder. 

Just last month the House passed H.R. 6, the SUPPORT for Patients and Communities Act, the biggest legislative package to address a drug crisis in history. That 

bill started in this very subcommittee. Our work on substance use disorder, however, goes much further back—back to the leadup to the Comprehensive Addiction 

and Recovery Act (CARA) and Cures. 

The intersection between mental health issues and substance use disorder is 

clearer now more than ever, and the grants and programs authorized by Cures have 

set the table for our work to combat the opioid crisis. 

I’d like to thank our witness for joining us today. Her position was created under 

the very law we are examining today, and I know we are all eager to learn more 

about her work to coordinate critical mental health services and programs across 

the Federal Government. 

Mr. BURGESS. The gentleman yields back. The chair thanks the 

gentleman. 

The chair recognizes the gentleman from New Jersey, the ranking member of the full committee, 5 minutes for an opening statement, please. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

It is a critical function of this committee to conduct oversight and 

ensure that the legislation we pass is working as intended, and 

that is why I think it is important to hold hearings like these that 

allow us to learn directly from the administration how policies are 

being implemented. 

In December 2016, President Obama signed the landmark 21st 

Century Cures Act into law which was truly a product of the hard 

work of bipartisan members of this committee. And as we know, 

the Cures Act addressed a wide range of issues facing our 

healthcare system. However, today we will be focusing on the provisions related to mental health. And I would like to thank Dr. 

McCance-Katz for joining us today to testify on the important work 

happening at SAMHSA. 

The Helping Families and Mental Health Crisis Act, which was 

ultimately passed as part of the Cures Act, was an important step 

towards repairing our country’s broken mental health system. And 

I would specifically like to highlight a provision that I worked hard 

with my colleagues to include in this legislation that expanded an 

important set of Medicaid benefits to children receiving inpatient 

psychiatric treatment. But despite what was accomplished through 

this law, I think we all agree our work on this issue is far from 

complete, and more needs to be done to improve access to affordable mental health treatment. 

Unfortunately, in the time since we passed the Cures Act the, 

Republican party has been fixated on repealing the Affordable Care 

Act and cutting Medicaid, which is the single largest payer of mental health services in the country. For many people, Medicaid provides the only chance they have of getting treatment for a mental 

health disorder, and I continue to believe that any progress made 

by the Helping Families and Mental Health Crisis Act would be 

completely reverse if the Republicans ever succeed in their radical 

plans to repeal the Affordable Care Act and drastically cut MedVerDate Nov 24 2008 10:47 Apr 10, 2019 Jkt 037690 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-154 CHRIS
10 

icaid benefits for low-income individuals. These actions could cause 

catastrophic harm to people with mental illness. 

And speaking of helping families in crisis, I am reminded that 

this committee has still not acted to help the thousands of families 

currently in crisis because of the Trump administration’s cruel family separation policy. The administration recklessly moved ahead 

with this inhumane policy with little thought on how to address 

the long-term health implications for the children torn away from 

their parents or how to reunite them with their family. And this 

is a man-made disaster by the Trump administration. 

Public health advocates and healthcare providers have already 

warned how devastating forceable separation can be to a child’s 

mental health and overall development. According to the American 

Academy of Pediatrics, ‘‘highly stressful experiences like family 

separation can cause irreparable harm, disrupting a child’s brain 

architecture, and affecting his or her short and long-term health. 

This type of prolonged exposure to serious stress—known as toxic 

stress—can lead to lifelong consequences for children.’’ 

And as I said at the outset of my remarks, oversight is a critical 

function of this committee. And so far Chairman Walden has not 

been willing to hold an oversight hearing on the family separation 

crisis, which I think we should have before we leave for the August 

recess. And that tells me that the Republican majority are really 

not as troubled by this crisis as some of them claim to be. 

So we must get to the bottom of how this happened so we can 

ensure it never happens again. We must reunite these families immediately. While we can’t undue the trauma that these children 

have already endured, the administration must take every step 

possible to prevent further harm. 

And with that, I yield back, Mr. Chairman. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

It’s a critical function of this committee to conduct oversight and ensure that the 

legislation we pass is working as intended. That’s why I do think it’s important to 

hold hearings like these that allow us to learn directly from the Administration how 

policies are being implemented. 

In December 2016, President Obama signed the landmark 21st Century Cures Act 

into law—which was truly a product of the hard work of bipartisan members of this 

committee. As we know, the Cures Act addressed a wide range of issues facing our 

health care system. However, today we’ll be focusing on the provisions related to 

mental health-and I’d like to thank Dr. McCance-Katz for joining us today to testify 

on the important work happening at the Substance Abuse and Mental Health Services Administration (SAMHSA). 

The Helping Families in Mental Health Crisis Act, which was ultimately passed 

as part of the Cures Act, was an important step towards repairing our country’s broken mental health system. I’d specifically like to highlight a provision I worked hard 

with my colleagues to include in the legislation that expanded an important set of 

Medicaid benefits to children receiving inpatient psychiatric treatment. But despite 

what was accomplished through this law, I think we’d all agree our work on this 

issue is far from complete and more needs to be done to improve access to affordable 

mental health treatment. 

Unfortunately, in the time since we’ve passed the Cures Act the Republican party 

has been fixated on repealing the Affordable Care Act and cutting Medicaid-which 

is the single largest payer of mental health services in the country. For many people, Medicaid provides the only chance they have at getting treatment for a mental 

health disorder. I continue to believe that any progress made by the Helping Families in Mental Health Crisis Act would be completely reversed if the Republicans 

ever succeed in their radical plans to repeal the Affordable Care Act and drastically 

11 

cut Medicaid benefits for low income individuals. These actions would cause catastrophic harm to people with mental illness. 

And speaking of helping families in crisis, I’m reminded that this committee has 

still not acted to help the thousands of families currently in crisis because of the 

Trump Administration’s cruel family separation policy. The Administration recklessly moved ahead with this inhumane policy with little thought on how to address 

the long-term health implications for the children torn away from their parents or 

how to reunite them with their family. This is a man-made disaster by the Trump 

Administration. 

Public health advocates and health care providers have already warned how devastating forcible separation can be to a child’s mental health and overall development. According to the American Academy of Pediatrics, ‘‘highly stressful experiences, like family separation, can cause irreparable harm, disrupting a child’s brain 

architecture and effecting his or her short- and long-term health. This type of prolonged exposure to serious stress—known as toxic stress—can lead to lifelong consequences for children.’’ 

As I said at the outset of my remarks, oversight is a critical function of this committee and the fact that Chairman Walden refuses to hold an oversight hearing on 

the family separation crisis tells me that Chairman Walden and the Republican majority are simply not as troubled by this crisis as some of them claim to be—and 

I find that incredibly sad. 

We must get to the bottom of how this happened so we can ensure it never happens again. We must reunite these families immediately—and while we can’t undo 

the trauma that these children have already endured—the Administration must 

take every step possible to prevent further harm. 

I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. 

The chair notes there are under 5 minutes left on this vote series. My understanding is there are four votes in this series. That 

should take us a little less than 1 hour to complete. And the committee will stand in recess until immediately after votes. 

[Recess.] 

Mr. BURGESS. I call the committee back to order. As we recessed 

we had just concluded with member opening statements. 

The chair will remind members that pursuant to committee rules 

all member’s opening statements will be part of the record. And we 

do want to thank our witness for being here today, and staying 

with us through votes, and taking time to testify before the subcommittee. 

Our witness will have the opportunity to give an opening statement followed by questions from members. And today we are going 

to hear from Dr. Elinore McCance-Katz, the Assistant Secretary for 

Mental Health and Substance Use, United States Department of 

Health and Human Services. We appreciate you being here with us 

today Dr. McCance-Katz and you are recognized for 5 minutes for 

an opening statement, please. 

STATEMENT OF ELINORE MCCANCE-KATZ, PHD, ASSISTANT 

SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, 

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION 

Dr. MCCANCE-KATZ. Chairman Burgess, Ranking Member Green 

and members of the House Energy and Commerce Subcommittee 

on Health. Thank you for inviting me to testify at this important 

hearing. 

In December of 2016, the 21st Century Cures Act was signed into 

law. And I want to thank you for your vision and your leadership 

12 

on addressing the needs of Americans living with mental and substance use disorders. We at the Substance Abuse and mental 

Health Services Administration, the Department of Health and 

Human Services have been actively implementing this law since its 

enactment. 

As the first Assistant Secretary for Mental Health and Substance 

Use, a position created by the Cures Act, I take seriously my duties 

outlined in Cures, including leadership and accountability for behavior health, evidence based program promotion and coordination 

across government. Part of strengthening leadership and accountability includes a strong clinical perspective at the agency. Cures 

codifies the role of the chief medical officer. And we have taken this 

further by establishing and expanding the Office of the Chief Medical Officer to include two additional psychiatrists, a clinical psychologist and a nurse practitioner. 

A new component of SAMHSA created by the Cures Act is the 

National Mental Health and Substance Use Policy laboratory. The 

policy lab promotes evidence based practices and service delivery 

through evaluation of models that would benefit from further development, expansion, or replication. The policy laboratory also 

provides leadership in identifying and coordinating policies and 

programs related to mental and substance use disorders, including 

needed policy changes. 

The Interdepartmental Serious Mental Illness Coordinating Committee, or ISMIC, was established by the Cures Act to ensure better coordination across the Federal Government to address the 

needs of adults with serious mental illness and children and youth 

with serious emotional disturbances and their families. 

The ISMIC has been working within five key areas of focus, 

strengthening Federal coordination to improve care, closing the gap 

between what works and what is offered, reducing justice involvement and improving care for those who are just as involved, making it easier to obtain evidence-based healthcare for mental and 

substance use disorders and developing finance strategies to increase availability and affordability of care. 

The Cures Act reauthorized the community mental health services block grant and codified the first episode psychosis set aside. 

If we can intervene early and with needed treatment in psychosocial services, individuals are better able to manage their serious 

mental illnesses similar to other chronic health conditions. 

In 2016, 44,965 Americans died by suicide. And according to 

SAMHSA’s surveys on drug use and health statistics, over 1.3 million Americans attempted suicide. The Cures Act authorized 

SAMHSA’s existing national suicide prevention lifeline. Recent 

evaluation data showed that the majority of individuals served and 

then interview following use of life line purported that the intervention stopped them from completing suicide and helped to keep 

them safe. At the same time, the highest rate of suicide in America 

is among adults, aged 45 to 64 years old. SAMHSA is grateful to 

the authorization of the adult suicide prevention program and 

cures. 

The purpose of this program is to implement suicide prevention 

intervention programs focused on training of healthcare professionals, to ask about suicidal ideations, and to make safety plans 

13 

and to assist people to treatment should they endorse thoughts of 

wanting to end their lives. 

One of SAMHSA’s roles is it to oversee the implementation of 42 

CFR Part 2, the regulation governing confidentiality of substance 

use disorder patient records. SAMHSA made substantive updates 

to these regulations in 2017 and 2018. In compliance with the 

Cures Act, SAMHSA held a listening session attend by over 1,200 

people in January 2018 to obtain input about Part 2 implementation. Themes included the need to align 42 CFR Part 2 in HIPAA, 

the need for technical assistance and training, the importance of 

integrated care, and the use of electronic health records. 

The Cures Act also demonstrates Congress’ commitment to addressing the opioids crisis. Through implementation of CURE’s 

SAMHSA awarded $500 million in each of years 2017 and 2018. 

And the State targeted response grant funding to States and communities around the country. These funds support comprehensive 

approaches to addressing the opioids crisis through prevention, 

treatment and recovery services. 

I feel strongly that we need to ensure that the direction provided 

by Congress in Cures is followed with fidelity and the highest quality service delivery possible. In order to achieve this goal, I have 

reconfigured SAMHSA’s technical assistance approach from a 

grantee-based approach to one which supports a robust national 

and regional technical assistance strategy emphasizing training on 

evidence based and effective practices to communities across the 

country. 

Much work has been undertaken at SAMHSA and across HHS 

to implement the Cures Act, but we know this work is far from 

over. I look forward to continuing a strong partnership with Congress, to help Americans living with mental and substance use disorders and their families. 

I am pleased to answer your questions today. Thank you. 

[The prepared statement of Dr. McCance-Katz follows:] 

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DEPARTMENT OF HEALTH AND HUMAN SERVICES 

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION 

Hearing on 

21" Century Cures Implementation: Examining Mental Health Initiatives 

Witness appearing before the 

House Committee on Energy and Commerce Subcommittee on Health 

Assistant Secretary for Mental Health and Substance Use 

Elinore F. McCance-Katz, M.D., Ph.D. 

July 19, 2018 
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Chairman Burgess, Ranking Member Green, and members of the Subcommittee, thank you for 

inviting me to testify at this important hearing. 

In December 2016, the 21'' Century Cures Act (Cures Act) was signed into law, and the 

Substance Abuse and Mental Health Services Administration (SAMHSA) has been actively 

implementing many of the provisions in coordination with our colleagues at the Department of 

Health and Human Services (HHS), other Federal agencies, state and local governments, tribal 

entities, and other key stakeholders. 

The Cures Act addresses many critical issues including leadership and accountability for 

behavioral health at the federal level, the importance of evidence-based programs for the 

treatment and prevention of mental and substance use disorders, and the imperative need to 

coordinate efforts across government. We at SAMHSA appreciate your leadership and 

dedication in enacting new authorities to reduce the impact of substance abuse and mental illness 

on America's communities. 

In my testimony, I will highlight key ways in which SAMHSA is implementing Cures Act 

provisions and how this implementation is benefiting individuals, families, and communities 

across the country. 

Strengthening Leadership and Accountability 

The Cures Act established the position of Assistant Secretary for Mental Health and Substance 

Use. I am humbled and honored to be the first person to serve in this position and bring my 

experience as a psychiatrist and researcher to this important role. As the Assistant Secretary for 

Mental Health and Substance Use, I take seriously my duties as outlined in the Cures Act such as 

maintaining a system to disseminate research findings and evidence-based programs to improve 

prevention, treatment, and recovery support services; ensuring that grants are subject to 

performance and outcome evaluations; consulting with stakeholders to improve communitybased and other mental health services including for adults with serious mental illness (SMI) and 

children with serious emotional disturbances (SED); collaborating with other departments (such 

as the Departments of Veterans Affairs, Defense, Housing and Urban Development, and Labor); 

and working with stakeholders to improve the recruitment and retention of mental health and 

addiction professionals. SAMHSA has a very important mission and we focus on using our 

resources wisely and addressing the most pressing issues. 

Strengthening leadership and accountability at SAMHSA includes ensuring a strong clinical 

perspective at the agency. The Cures Act codifies the role of the Chief Medical Officer (CMO). 

I believe a clinical perspective at the national level is imperative to sound stewardship and 

implementation of high quality, effective services. As such, I have built upon the codification of 

the CMO in the Cures Act by expanding the Office of the Chief Medical Officer (OCMO) to 

include two additional psychiatrists, a psychologist, and a nurse practitioner. Further, to ensure 

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the elevation ofOCMO within SAMHSA, I have placed it strategically in the Office of the 

Assistant Secretary (OAS). 

OCMO responsibilities include serving as a liaison between SAMHSA and providers, assisting 

the Assistant Secretary in evaluation, organization, integration, and coordination ofSAMHSA 

programs; promoting evidence-based and promising practices; and coordinating internally and 

externally to assess the use and ensure the utilization of appropriate performance metrics. 

The Cures Act also codified the Center for Behavioral Health Statistics and Quality (CBHSQ), 

which serves as the federal government's lead agency for behavioral health statistics. CBHSQ 

conducts national surveys tracking population-level behavioral health issues. These surveys, 

including the National Survey on Drug Use and Health, serve as the national standard for 

behavioral health statistics. The Cures Act places a particular emphasis on program evaluation. 

As such, I have created a new Office of Evaluation, within CBHSQ, which will be responsible 

for conducting SAMHSA's program evaluations. CBHSQ also is responsible for collecting 

standardized performance data from grantees. The Center is currently in the process of 

implementing an innovative, real-time, client-based data-entry and reporting system for the 

streamlined collection of these data. 

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) was required 

by the Cures Act to ensure better coordination across the entire Federal Government related to 

addressing the needs of individuals with SMI and SED and their families. The Committee 

represents collaboration across multiple Departments including: HHS, Justice, Labor, Housing 

and Urban Development, Defense, Veterans Affairs, Education, and the Social Security 

Administration. Fourteen non-federal members representing treatment providers, researchers, 

patients, families, criminal justice systems, and others also participate in the ISMICC. 

Last December, as required in the Cures Act, we released the first ISMICC Report to Congress, 

which was followed by the second public meeting of the ISMICC. The report included 

recommendations from the non-federal members to focus on the following five areas: 

1. Strengthening federal coordination to improve care; 

2. Closing the gap between what works and what is offered; 

3. Reducing justice involvement and improving care for those who are justice 

involved; 

4. Making it easier to obtain evidence-based behavioral healthcare services; and 

5. Developing finance strategies to increase availability and affordability of care. 

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Since that time, the ISMICC formed working groups to address each of these recommendations. 

The groups are working to ensure that recommendations lead to practical and actionable 

activities, which will ultimately benefit those living with mental disorders. For example, the 

development of guidance to communities on universal mental health screening for youth in 

schools is underway. Another key example is the development of a pilot survey to better assess 

the prevalence of mental disorders across America's communities. 

We have also engaged subject matter experts across the country, from academia, hospitals, 

insurers, community providers, state government, consumers, and family members to inform 

SAMHSA and its partners on complex problems such as civil commitment implementation, 

workforce challenges, improving crisis response systems, coordinating federal research agendas, 

screening and treatment of serious emotional disturbance among children, and partnering with 

the faith community. We provide monthly updates to ISMICC members and they have been 

strong advocates to address issues related to serious mental illness in our nation. HHS leadership 

and staff look forward to continued work with the other Federal departments and non-federal 

public members represented on the Committee. 

Ensuring Mental and Substance Use Disorders Prevention, Treatment and Recovery 

Programs Keep Pace with Science and Technology 

The Cures Act created the National Mental Health and Substance Use Policy Laboratory (Policy 

Lab). The Policy Lab is working to promote evidence-based practices and service delivery 

models through evaluating models that would benefit from further development and expansion. 

In particular, the Policy Lab is focusing on schizophrenia and schizoaffective disorder, as well as 

other SMI. It is also focusing on evidence-based practices and services for substance use 

disorders with an emphasis on opioids. 

The responsibilities of the Policy Lab outlined in Cures are: to identify, coordinate, and facilitate 

the implementation of policy changes likely to have a significant effect on mental health and 

mental illness; to work with the Center for Behavioral Health Statistics and Quality to collect 

information from grantees under programs operated by the Administration in order to evaluate 

and disseminate information on evidence-based practices, including culturally and linguistically 

appropriate services and service delivery models; to provide leadership in identifying and 

coordinating policies and programs, including evidence-based programs related to mental illness 

and addiction; to periodically review programs and activities operated by the Administration 

relating to the diagnosis or prevention of, treatment for, and recovery from, mental illness and 

substance use disorders, including identifying any such programs or activities that are duplicative 

and are not evidence-based, effective, or efficient. 

To provide communities, clinicians, policy-makers and others in the field with the information 

and tools they need to incorporate evidence-based practices into their practice, the Policy Lab 

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launched an Evidence-Based Practices Resource Center (Resource Center) in April2018. The 

Resource Center, at www.sarnhsa.gov/ebp-resource-center, contains a collection of sciencebased resources, including Treatment Improvement Protocols, toolkits, resource guides, and 

clinical practice guidelines, for a broad range of audiences. Moving forward, SAMHSA plans to 

develop and to disseminate additional resources, such as new or updated Treatment Improvement 

Protocols, guidance documents, clinical practice policies, toolkits, and other actionable materials 

that incorporate the latest scientific evidence on mental health and substance use. 

Supporting State Activities and Responses to Mental Health and Addiction Needs 

The Cures Act reauthorized the Community Mental Health Services Block Grant and codified a 

set-aside for first episode psychosis. This set-aside is vitally important to ensuring that people 

with SMI receive appropriate treatment. If we can intervene early and provide needed treatment 

and psychosocial services, people are able to manage their SMI and live full, productive lives. 

Through this set-aside, states have been able to address the critical need to intervene as quickly 

and early as possible. States have developed and implemented strategies and programs 

including: statewide coordinated specialty care models, training of peer support specialists, 

expansion of treatment capacity through existing treatment teams, and establishment of quality 

assurance systems. 

Since the enactment of the set-aside in 2015, SAMHSA, in coordination with our colleagues at 

the National Institute of Mental Health (NIMH), a component of the National Institutes of 

Health, has established 250 of these life-saving programs in every state and the District of 

Columbia. 

Promoting Access to Mental Health and Substance Use Disorder Care 

The Cnres Act reauthorized many critical programs at SAMHSA. SAMHSA's Programs of 

Regional and National Significance (PRNS) focus on providing high quality services to myriad 

populations including those involved with the criminal justice system, those living with HIV, 

individuals who are homeless, pregnant and postpartum women, and adolescents. 

The Cures Act particularly heightened emphasis on serving those living with serious mental 

illness. For example, the Act reauthorized the Assisted Outpatient Treatment program. Assisted 

outpatient treatment programs are court-supervised treatment that take place in the community, 

sometimes referred to as "(involuntary) outpatient commitment." In FY 2016, SAMHSA 

implemented an Assisted Outpatient Treatment grant program and awarded 17 grants through the 

program. A variety of program types receive these grants, including, county and city mental 

health systems, mental health courts, and any other entities with authority under the law of the 

state in which the grantee is located to mandate Assisted Outpatient Treatment. This four-year 

program is intended to implement and evaluate new Assisted Outpatient Treatment programs and 

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identify evidence-based practices in order to reduce the incidence and duration of psychiatric 

hospitalization, homelessness, incarceration, and interactions with the criminal justice system, 

while improving the health and social outcomes of individuals living with SML This program is 

designed to work with families and courts to allow these individuals to obtain treatment while 

continuing to live in the community and in their homes within those communities. SAMHSA 

has partnered with the Assistant Secretary for Planning and Evaluation and NIMH to implement 

a cross-site evaluation that will assess the effectiveness and impact of the Assisted Outpatient 

Treatment grant program. 

SAMHSA is also grateful that the Cures Act recognized and authorized another critical program 

for individuals living with SMI, Assertive Community Treatment (ACT). ACT is an evidencebased practice considered one of the most effective approaches to delivering services to people 

with SMI and has been disseminated by SAMHSA for widespread use through its EvidenceBased Toolkit series beginning in 2008. ACT is designed as a coordinated care approach to 

provide a comprehensive array of services, including medication management and other 

supportive services, directly via a multi-disciplinary team of professionals, rather than through 

referrals. An ACT team is composed of 10-12 transdisciplinary behavioral health staffincluding psychiatrists, nurses, case managers, peer specialists and others - working together to 

deliver a mix of individualized, recovery oriented services to a case load of approximately 100 

people with SMI to help them with integration into the community. The services are provided 24 

hours, seven days a week and as long as needed, wherever they are needed. ACT was developed 

to reduce re-hospitalization and improve outcomes on discharge. I am very pleased that Congress 

appropriated $5 million for SAMHSA's first ever ACT program to be awarded in September 

2018. 

Suicide prevention is another critical component of mental health care which is highlighted in the 

Cures Act. Recent data from the Centers for Disease Control and Prevention (CDC) show that 

suicide deaths tragically continue to rise across the nation in virtually every state and across 

nearly every age group. According to CDC, in 2016,44,965 Americans died by suicide; 

according to the National Survey on Drug Use and Health, there were an estimated 1.3 million 

suicide attempts in the United States. The Cures Act authorized SAMHSA's existing National 

Suicide Prevention Lifeline (Lifeline). In 2017, the Lifeline answered over two million calls, far 

surpassing those recorded for 2016, with over 90 percent of callers reporting that calling the 

crisis hotline helped stop them from completing suicide. 

Suicide remains the second leading cause of death for individuals 15-24 years old. The Cures 

Act reauthorized the Garrett Lee Smith Memorial Act, which provides grants to states and tribes 

to reduce youth suicide and suicide attempts. At the same time, the highest rate of suicide in 

America is among adults 45-64 years old. Prior to the Cures Act, there was no authorized 

suicide prevention program for adults at SAMHSA. SAMHSA is grateful for the authorization 

of the adult suicide prevention program in the Cures Act and for Congress' funding of the first 

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program in FY 2017. In FY 2017, SAMHSA awarded three grants for the Zero Suicide program. 

The purpose of this program is to implement suicide prevention and intervention programs 

within health systems for people who are 25 years of age or older. The comprehensive, multisetting approach will raise awareness of suicide, establish referral processes, and improve care 

and outcomes for individuals who are at risk for suicide. Fourteen additional Zero Suicide grants 

are being awarded in FY 2018. SAMHSA also provided five grants under the Cooperative 

Agreements to Implement the National Strategy for Suicide Prevention program. The purpose of 

this program is to support states in implementing the 2012 National Strategy for Suicide 

Prevention goals and objectives focused on preventing suicide and suicide attempts among 

adults, ages 25 and older, to reduce the overall suicide rate and number of suicides in the United 

States. 

Strengthening Mental and Substance Use Disorder Care for Children and Adolescents 

The Cures Act also addresses the needs of children with mental and substance use disorders 

through reauthorization of the National Child Traumatic Stress Initiative. As one example of the 

work undertaken, the National Child Traumatic Stress Initiative conducted a Psychological First 

Aid Train the Trainer course for the State of Texas in response to Hurricane Harvey. Participants 

were selected from HHS-contracted behavioral health providers, giving priority to those regions 

most impacted by Hurricane Harvey. 

It is estimated that over 7.4 million children and youth in the United States have a serious mental 

disorder. Unfortunately, only 41 percent of those in need of mental health services actually 

receive treatment. Created in 1992, SAMHSA's Children's Mental Health Initiative addresses 

this gap by supporting "systems of care" for children and youth with serious emotional 

disturbance (SED) and their families in order to increase their access to evidence-based treatment 

and supports. The Cures Act reauthorized the Children's Mental Health Initiative which provides 

grants to assist states, local goverrnnents, tribes, and territories in their efforts to deliver services 

and supports to meet the needs of children and youth with SED. 

The Children's Mental Health Initiative supports the development, implementation, expansion, 

and sustainability of comprehensive, community-based services that use the systems of care 

approach. Systems of care is a strategic approach to the delivery of services and supports that 

incorporates family-driven, strength-based, and culturally and linguistically competent care in 

order to meet the physical, intellectual, emotional, cultural, and social needs of children and 

youth throughout the United States. The systems of care approach helps prepare children and 

youth for successful transition to adulthood and assumption of adult roles and responsibilities. 

Services are delivered in the least restrictive environment with evidence-supported treatments 

and interventions. Individualized care management ensures that planned services and supports 

are delivered with an appropriate, effective, and youth-guided approach. This approach has 

demonstrated improved outcomes for children at home, at school, and in their communities. For 

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example, Children's Mental Health Initiative grantee data show that suicide attempt rates fell 

over 38 percent within 12 months after children and youth accessed Children's Mental Health 

Initiative -related systems of care services. In addition, school suspensions/expulsions fell over 

42 percent and unlawful behavior fell over 40 percent within 18 months of children and youth 

beginning systems of care related services and supports. 

As directed in the FY 2018 appropriations, SAMHSA is funding a demonstration within the 

Children's Mental Health Initiative for the first time in FY 2018. The Community Programs for 

Outreach and Intervention with Youth and Young Adults at Clinical High Risk for Psychosis will 

identify youth and young adults, not more than 25 years old, at clinical high risk for psychosis 

and provide evidence-based interventions to prevent the onset of psychosis or lessen the severity 

of psychotic disorder. It is expected that this program will: ( 1) improve symptomatic and 

behavioral functioning; (2) enable youth and young adults to resume age-appropriate social, 

academic, and/or vocational activities; (3) delay or prevent the onset of psychosis; and ( 4) 

minimize the duration of untreated psychosis for those who develop psychotic symptoms. 

Other Key Priority Implementation Activities 

As discussed in the hearing held by this Committee on October 5, 2017 regarding the federal 

response to the opioid crisis, SAMHSA continues to work closely with states on their 

implementation of the $1 billion State Targeted Response (STR) program authorized by section 

1003 of the Cures Act, which enables states to build comprehensive approaches to opioid use 

disorder prevention, treatment, and recovery programs. These funds are supporting state efforts 

to reduce opioid overdose deaths and increase access to treatment. Building on this program, the 

Omnibus Budget for 2018 included an additional $1 billion for the State Opioid Response 

program distributed to states through a formula that considered the number of opioid overdose 

deaths and the treatment gap for those living with opioid use disorders within each state. 

One ofSAMHSA's roles is to oversee implementation of 42 CFR part 2, the regulation 

governing confidentiality of substance use disorder patient records. SAMHSA made substantive 

updates to these regulations in 2017 and 2018; the first such major revisions since 1987. In 

compliance with the Cures Act, SAMHSA held a listening session in January 2018 to obtain 

input about how Part 2 impacts patient care, health outcomes, and patient privacy. More than 

1200 people participated in-person or online and SAMHSA received several written comments 

as welL Major themes included the need to align 42 CFR Part 2 and HIPAA, the need for 

technical assistance and training, and the importance of integrated care and use of Electronic 

Health Records. SAMHSA will continue to diligently review these issues and work to ensure 

that individuals living with substance use disorders have access to practitioners who are fully 

equipped with the knowledge they need to provide the best care possible. Individuals living with 

substance use disorders have a right to privacy; but, we must also not forget their right to high 

quality, effective care for substance use disorders, mental disorders and physical illnesses. 

7 
22 


35691.009

Congress also recognized the critical role behavioral health parity plays in ensuring equitable, 

high-quality health and behavioral healthcare for all Americans. Section 13002 called for the 

convening of a public listening session and the creation of a parity action plan for increased 

enforcement of behavioral health parity. The listening session was held on July 27,2017. More 

than fifteen groups provided public comment in person and a total of 40 comments were received 

via email or in writing. Comments were received from various stakeholder groups including 

insurance representatives, employers, behavioral health providers, and patients or their 

advocates. The most common concerns cited by commenters were the need for more guidance 

from Federal agencies, transparency from insurance companies as to parity analysis and 

coverage decisions, and enforcement of parity protections. The Action Plan includes strategies 

and action steps to address these comments. 

I feel strongly that we need to ensure that the direction provided by Congress in Cures is 

followed with fidelity and the highest quality service delivery possible. In order to achieve this 

goal, I have re-configured SAMHSA's Technical Assistance (TA) approach from a granteebased T A approach to one which supports a robust national and regional strategy that emphasizes 

training on evidence-based and effective practices to communities across the country. 

Conclusion 

I am thankful for the clear and meaningful direction and goals that Congress articulated in the 

Cures Act. I believe that it is my responsibility to ensure that the vision identified in the Cures 

Act is realized. SAMHSA has made great strides in our programming and policies but there is 

more work to do. There are many more people and their families struggling with mental illness 

and addiction that need help. I look forward to continuing a strong partnership with Congress to 

help these Americans. With the Cures Act, Congress has provided an instrumental blueprint for 

addressing these needs, and we at SAMHSA greatly appreciate your efforts. 

8 
23 

Mr. BURGESS. Thank you, Dr. McCance-Katz, and thank you for 

your testimony today. This concludes the witness opening statement portion of the hearing. We will move to member questions. 

I recognize myself 5 minutes for questions. 

And I want to begin by asking unanimous consent to place into 

the record a statement for the record by Dr. Billy Philips from 

Texas Tech University Health Sciences Center, the Hall Professor 

of Family Community Medicine, Professor of Public Health and Executive Vice President for Rural and Community Health at Texas 

Tech University describing their program of Telemedicine, 

Wellness, Intervention, Triage and Referral. 

Without objection so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. BURGESS. And Dr. McCance-Katz, I am submitting the whole 

statement for the record. Let me just pull a couple of pieces out of 

this. Dr. Philips tell us this program provides school based screening assessment and referral services to students that are typically 

struggling with behavioral and mental health issues and is currently active in 10 west Texas independent school districts. 

This project uses telemedicine technology to link remote rural 

schools that are without sufficient counselors, psychiatrists, and 

other mental health service providers. It also provides mental 

health recognition and training services to educators and school resource officers to promote a greater recognition and prompt referral. 

He then goes on to describe in some detail how the program runs 

and the coordination that occurs between their staff and the staff 

of the school. Interesting he provides some statistics. He says the 

impact area has an annual enrollment of 42,000 students in ten 

mostly rural school districts surrounding Lubbock, Texas. They 

have created an environment where students are empowered to 

help create a safe learning environment and better morale. 

Of that number, only a small fraction, 414 total, have been referred by teachers. And we have been trained to recognize those 

who will need to be referred to the larger program, the team has 

screened out and triaged, by telemedicine, 215 students and 25 of 

those have been removed from the school population, most by hospitalizations and a few by arrest. And they believe they have averted tragic outcomes and started others on a path towards healing. 

So a very interesting program that they have developed for 

school safety in their rural school districts in west Texas. And I 

would just be interested in your thoughts as to how this integrates 

with the work we did in Cures, and you are doing now with Cures 

implementation. 

Dr. MCCANCE-KATZ. Thank you for bringing that forward, because this is a very important part of not only of Cures Act but also 

a focus of the President’s Federal school safety commission. And so 

we have had the opportunity to speak to a number of districts 

across the country, Texas being one of them. And these kinds of innovative programs are exactly what we need to better ensure—two 

things, one a safe environment for students, a nurturing environment where they can learn. 

And the second being one where we identify children early who 

may have emotional or mental health issues that need to be adVerDate Nov 24 2008 10:47 Apr 10, 2019 Jkt 037690 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-154 CHRIS
24 

dressed and there are a number of ways to address those kinds of 

mental health service needs via either integration directly within 

the school system or through a close relationship with other types 

of programs. 

Some of the things that the Cures Act do that directly effect 

those kinds of programs is that Cures reauthorized several types 

of mental health programs that are oriented toward children. And 

SAMHSA continues to implement those programs. 

So things like Project Aware which provides for infrastructure of 

these types of services within schools in the States, and programs 

that teach about mental health psychological, mental health, and 

mental health first aid type programs to help to identify youth 

early so that we can get them the care and services that they need, 

Cures reauthorized those programs and we are in the process right 

now of making more awards through our granting system. 

In addition, when we start talking about integration of care, the 

certified community behavioral health centers that Congress established for us represent a model that can be used to provide those 

needed services to children who would be referred from the school 

systems. 

Mr. BURGESS. Well, certainly I think use of that model will be 

important. As I understand this program has been funded entirely 

out of funds within Texas Tech University itself, but they have set 

up the telemedicine portals, and the secure connections, and the 

encrypting and all that is it necessary to have those secure connections. 

But I actually look forward to working with you and your office 

on this and perhaps the White House as well, because I do think 

they are on to something that is very, very important. 

I am going to yield back to you, Mr. Green, and recognize you 

for 5 minutes of questions. 

Mr. GREEN. Thank you, Mr. Chairman. And again welcome, Dr. 

McCance-Katz. 

The 21st Century Cures Act was a landmark law and included 

important provisions to strengthen mental and substance use disorder care for women, children and adolescents. In particular the 

Cures has reauthorized the National Child Traumatic Stress Initiative which supports a national network of child trauma centers and 

focuses on increasing access to affected trauma focused interventions. 

Can you explain how the National Child Traumatic Stress Network operates? And what impact it has on improving the lives of 

children impacted by traumatic stress. 

Dr. MCCANCE-KATZ. Yes, the National Child Traumatic Stress 

initiative is a program that is established in a large number of 

States, it provides national technical assistance services around 

issues of traumatic stress in children. This is a program that not 

only trains practitioners and providers of services, but also will do 

consultation within communities to help them to address traumatic 

issues. So this is a very highly regarded and valuable program. 

Mr. GREEN. Following the chairman, do you know of any grantees in the State of Texas off the top of your head? 

Dr. MCCANCE-KATZ. I don’t have the grantees dedicated to memory. But I will tell you this we can get you that very quickly. 

25 

Mr. GREEN. OK. Thank you. I appreciate it. 

If children that are impacted by traumatic stress receive early 

interventions and the trauma informed care they need, can the 

long-term health affects of trauma be mitigated in any way? 

Dr. MCCANCE-KATZ. Yes, they can. There is a fair amount of literature on this in terms of how trauma affects children and the 

ability to address those traumatic events in therapeutic environments can mitigate the affects later in life. 

Mr. GREEN. I am interested in how the National Child Traumatic 

Stress Network is responding to the recent events related to the 

family separations at the border as a result of the Trump administration’s zero tolerance. Is the network being utilized to coordinate 

or facilitate services for children that have endured this trauma as 

a result of family separation policy? 

Dr. MCCANCE-KATZ. Well, what I would say, Congressman 

Green, is that SAMHSA itself is not involved in those issues. Those 

issues are being dealt with by a different part of HHS, the Administration for Children and Families and the Office for Refugee Resettlement. Any provider within a jurisdiction can go to a SAMHSA 

national program and ask for resources, but SAMHSA itself is not 

directly involved in that. 

Mr. GREEN. OK. Well, I was wondering, HHS is responsible for 

those children, if you happen to find any information on what is 

being done with HHS in the network for these children—my concern about the National Children Traumatic Stress has a document 

on its website that notes, children can recover from traumatic separation and other traumatic experiences with development of culturally and linguistically appropriate trauma services for these 

children and their families, including evidence based and trauma 

folks treatment. I would hope that would be part of the process and 

obviously SAMHSA in that effort. 

In the interdepartmental serious mental illness coordinating 

committee report that was released by SAMHSA last December it 

listed five areas of focus, including increasing availability and affordability of the care. Could a patient suffering from a serious 

mental illness, and SMI or a serious emotional disturbance, be denied health insurance—insurers as having a preexisting condition? 

Dr. MCCANCE-KATZ. So that is not my area of expertise. I really 

don’t feel comfortable commenting on the details of health insurance. What I would say is that Medicaid is one of the largest providers of mental health services through their insurance program 

and they serve millions of Americans at this very moment. 

Mr. GREEN. Thank you, Mr. Chairman. I would also like to ask 

unanimous consent to place into the record a statement by the 

American Academy of Pediatrics opposing separation of children at 

the border, the American Psychiatric Association, opposing the separation of children from their parents. The American Psychological 

Association regarding the traumatic affects of separating families, 

and again the National Child Traumatic Stress Network and key 

points on the traumatic separation of refugee children and immigrant children. 

I ask unanimous consent to place into the record. 

Mr. BURGESS. Without objection so ordered. 

[The information appears at the conclusion of the hearing.] 

26 

Mr. BURGESS. The gentleman’s time has expired. 

Mr. GREEN. I yield. 

Mr. BURGESS. The gentleman yields back. The chair recognizes 

the gentleman from Kentucky, Mr. Guthrie, 5 minutes for questions. 

Mr. GUTHRIE. Thank you, Mr. Chairman and thanks for being 

here Dr. McCance-Katz. 

I have a question, the CDC has found that less than half of substance use disorder patients with multiple mental health issues 

have ever received treatment for their mental health issue. The 

commission suggests this is due to lack of access, fear of shame, 

and discrimination, and a lack of motivation to seek treatment. 

Would you discuss how you planned to encourage and work with 

States using the State targeted response opioid money to help patients with untreated mental health disorders? 

I am from Kentucky and as you know we have a very large population in need of these services, and the general public who just 

need education and awareness of these services. 

Dr. MCCANCE-KATZ. Yes, yes. Thank you for that question, because we are very much engaged on that issue. And so the State 

targeted response to opioids part of the Cures Act provides funding 

for technical assistance and training within the States. What we 

have now done at SAMHSA, what we have put in place in February was to have a grantee whose requirement was to establish 

teams within every State, multiple teams for States with larger geographic areas, but these teams had to have addiction experts and 

other types of mental health expertise and physical healthcare expertise available so that they could go into communities. Communities and providers within those communities let their States 

know what kinds of services, and training, and technical assistance, and these teams go in and provide that on the spot. 

And so we believe that that is going to be a way that we establish evidence-based practice. We know that the co-occurring rate of 

mental and substance use disorders is quite high. And so if somebody has a substance use disorder, they must be screened for mental health issues. We know that treating one and not treating the 

other and the person who has cooccurring disorders will not solve 

both problems. And these teams are professionals. They are licensed within their States and certified by their various regulatory 

boards to provide that kind of technical assistance and training as 

part of their own clinical practices and they are doing that in our 

communities now. 

Mr. GUTHRIE. OK thanks. And before my next question, I was 

watching I guess a new TV show that is out that Amy Adams the 

actress stars in. And several of the characters seem to have addictions so I can’t really tell where the show is going yet. But at the 

very end of the show they had a public service announcement for 

SAMHSA. I don’t know if you knew that or saw that. At the very 

end it says, if you have any issues or know people who have, please 

call. I don’t know if you are getting any response from that, but I 

was pleased at the end of show they were trying to show people 

how to reach out that have addiction issues. 

So my next question is for guidance issued via the 21st Century 

Cures Act, SAMHSA has released extensive guidance for conVerDate Nov 24 2008 10:47 Apr 10, 2019 Jkt 037690 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-154 CHRIS
27 

sumers on how they can report parity concerns as well as tools for 

health plans. Does SAMHSA have future plans to offer providers 

additional pathways for addressing potential—this is hard to say— 

offer providers additional pathways for addressing potential parity 

violations or concerns? 

Dr. MCCANCE-KATZ. So we are very pleased that we have a portal that consumers can use where they can report what they believe may by parity violations, difficulties they are having with getting coverage for their mental health or substance use problems. 

That portal will get them to the appropriate Federal agency, be it 

labor, be it CMS, be it Treasury, so we are pleased about that. 

We also provide guidance—SAMHSA last summer did a 30-State 

parity policy academy where we trained on issues related to parity 

and MHPAEA and how States can make sure that the appropriate 

attention is being paid so the people of their States can get the 

services that they need. 

Mr. GUTHRIE. Well thank you. And those are my two questions 

and I appreciate you being here. 

And I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair now recognizes the gentleman from New Jersey, ranking member of the full committee, Mr. Pallone 5 minutes 

for questioning. 

Mr. PALLONE. Thank you, Mr. Chairman. 

Doctor, the Cures Act included provisions that specifically addressed child trauma. And as I noted in my opening statement I 

continue to have grave concerns about the children forcibly separated from their parents or guardians as a result of Trump administration’s zero-tolerance policy. 

And I have sought information from the administration on 

whether children in the office of refugee’s care may have experienced trauma. And my resolution of inquiry that was debated by 

the committee last week specifically requested documents on the 

long-term health implications of the family separation policy on the 

children in ORR’s care. 

As HHS’ leader on mental health issue, SAMHSA is uniquely 

qualified to speak to the impacts of trauma and the long-term 

health implications. So my questions are going to focus on this. 

And it is not just me that has raised concern about the health impacts of the family separation policy. This has been echoed by numerous pubic health organizations and child health advocates, including the American Academy of Pediatrics, the American Public 

Health Association, Trust for America’s Health and the National 

Association of County and City Health Officials. 

So in fact the National Child Traumatic Stress Network, which 

is administered by SAMHSA, notes ‘‘that separation from parents 

or primary caregivers is one of the most potent, traumatic stressors 

a child can experience, especially under frightening, sudden, chaotic or prolonged circumstances.’’ What is traumatic or toxic stress 

basically, if you don’t mind? 

Dr. MCCANCE-KATZ. Traumatic or toxic stress can be any of a 

number of things that an individual would experience as emotionally distressing and various individuals will have different types of 

responses to that. In fact, as you mentioned, one of them has been 

28 

reported to be separation. But I would suggest to you that there 

are lots of stressors that these children have probably experienced 

in their travels to the United States. 

So not having seen any of these kids, not being able to attribute 

what their distress might be about, it is hard to say exactly what 

the etiology of any particular individual’s problem might be. 

Mr. PALLONE. So could you comment on how the circumstances 

of separation increase the likelihood of traumatic or toxic stress, 

could you comment on that? 

Dr. MCCANCE-KATZ. Very hard to say. What I will say is that if 

you were to look at the literature on traumatic stress, you would 

see somewhere depending on the study you look at up to 43 percent 

of individuals will experience some type of traumatic stress in their 

lifetime, most of them do not go on to develop major mental disorders. And when you mitigate, when you relieve that stressor, 

they do recover. 

People have an amazing amount of resilience. That’s why all of 

us who are exposed to some type of stress don’t develop mental disorders, some do, we can’t predict with reliability who will. 

Mr. PALLONE. Then all the more reason why if you have had separation to try to get the kids back together with their parents, because then maybe they can recover. 

Dr. MCCANCE-KATZ. And our Department is working very hard 

on that. Our Secretary has spoken to that issue and they are addressing it every single day. 

Mr. PALLONE. Well, I guess the problem that I have is that you 

mention that SAMHSA is not involved in the child separation issue 

that related from the zero-tolerance policy. But the problem is that 

the Cures Bill required SAMHSA to coordinate mental health services across the Federal Government. Do you think that SAMHSA 

as a leader of mental health care for our country should play a role 

in responding to this crisis at the border? 

Dr. MCCANCE-KATZ. SAMHSA has defined responsibilities. One 

of those, as you mentioned in the Cures Act, is the National Traumatic Child Stress Network and we do implement that and we 

work with our grantees to make sure that they are providing the 

services that are needed across this nation to serve Americans who 

may be experienced with traumatic stress and their children. 

It is also a decision by others as to what agencies are specifically 

involved in the day-to-day activities of any particular event. So 

SAMHSA does what it is required to do by the Cures Act and we 

stand ready to provide additional assistance if it were requested. 

Mr. PALLONE. I don’t want to put words in your mouth, but it 

sounds like you would be willing to help but maybe no one at the 

Department is asking you to. But you don’t have to respond to that. 

I just think that it is clear that these families must be reunified 

immediately and ensure that these kids have access to the trauma 

informed prevention and mental health services in order to recover 

and mitigate the harm experienced as a result of this policy. 

And I will leave it at that, because my time has run out. Thank 

you. 

Mr. BURGESS. The gentleman’s time has expired. The gentleman 

yields back. The chair now recognizes the gentleman from Virginia 

5 minutes for questions please. 

29 

Mr. GRIFFITH. Thank you very much. Mr. Chairman, thank you 

for being here today, very important topics, Cures and CARA and 

mental health are all so important. You have touched on a number 

of things. 

I am going to ask some questions that probably are not answerable in the 5 minutes that we have. And so I will give you an opportunity to answer, but recognize that I would like for you to 

think about them and come up with answers if you can and send 

them to us at a later date. 

Dr. MCCANCE-KATZ. Certainly. 

Mr. GRIFFITH. So the first one is, in your testimony you discussed 

concerns brought up about the enforcement of parity protections, 

mental health, and other medicine or treatment. I was in a meeting 

with Secretary Acosta where he brought up similar concerns from 

the Department of Labor about the fact they have enforcement authority under ERISA plans, et cetera, but really have difficulty in 

the enforcement side of that. And so the question is what tools are 

necessary? What suggestions would you have for us about steps 

that we can take in the Federal law to ensure compliance with 

mental health parity and physical health parity? So the two are 

being treated the same in our various plans. And I will give you 

an opportunity, but I recognize that is probably an hour lecture as 

opposed to part of an answer in a 5-minute segment. 

Dr. MCCANCE-KATZ. So my quick answer to that would be that 

the question is quite an important one. It is one that I would want 

to seek legal counsel about. 

Mr. GRIFFITH. Yes. 

Dr. MCCANCE-KATZ. And one that we will be happy to give a 

written answer to. 

Mr. GRIFFITH. I appreciate that. And I would like an extended 

answer because these issues are all complex. 

Dr. MCCANCE-KATZ. Absolutely. 

Mr. GRIFFITH. Switching gears, I am talking to a principal in one 

of my rural schools I represent a mostly rural district. And we are 

talking about school safety and mental health is obviously a major 

component in that. And he says look, we can identify a child that 

has some issues and send them off for evaluation, but because of 

the current state of privacy laws, they can’t tell us what is going 

on. And we don’t need to know everything that is going on in the 

child’s life. But if there are some things that we need to know like 

are they violent, do they have a violent tendency, even if you don’t 

expect them to do something now, is there a violent component in 

their emotional or mental issues. We can at least pay more attention, maybe have them checked by the office so we can look in their 

bookbag every day to see if they are bringing in contraband, guns 

or other weapons or issues that we maybe ought to be aware of. 

So we have got no ability to do that. And so the question is is 

there some way we can expand the knowledge base of folks? And 

we have passed some bills here to try to make it more like HIPAA, 

but that still wouldn’t cover—that would be with drug abuse, but 

it still wouldn’t cover the school personnel who may very well need 

to know what is going on. If you could get my some answers on 

that back, if you have something quick, that is great. 

30 

Dr. MCCANCE-KATZ. So what I will tell you is this is a topic that 

is part of the Federal school safety commission that is one of the 

areas that the President has asked us to look at. And I will just 

go a little bit further, we will give you something in writing as 

well, but part of the big problem here is that providers, teachers, 

administrators don’t understand when they can communicate. And 

if there is a threat already both HIPAA and FERPA allow communication, but this is not well understood. And so one of things that 

we really have to do is we have to work very hard to get that information out as to just what these laws allow and what they don’t 

allow. 

Mr. GRIFFITH. My time is running out, but I do want to jump in 

and say, so here is the dilemma you get, if there is a direct threat, 

yes, that is true or if you think they are going to be harmful to 

somebody else at that moment, but if you just detect that there 

may be a developing problem and that they may be a threat in the 

future I don’t think it covers. 

Now we can certainly sit down and look at this. And so the 

school personnel would like to know what signs should we be looking for if this person might be starting to move further into their 

issues with mental illness that might—right now they are not a 

threat, but they have got some violent tendencies that we need to 

keep an eye on, what should we be looking for? They don’t have 

a clue and they are with the child every day during the week, most 

weeks. And so they are probably the first people who could pick up 

on that. 

I am going to flip to one more, we don’t have time for the answer, 

I apologize for that. And that is we did a lot of work here trying 

to figure out how we could deal with adult children, even if they 

are living in the home, have mental health issues, also medical 

issues, and how do the parents get to be interactive and I would 

love to help on that, I know Ms. DeGette of Colorado struggled 

with this at some time. 

Ms. DEGETTE. Yes. 

Mr. GRIFFITH. If we can be of assistance or if there is something 

that you all have that we need to do in the code, this committee 

on a bipartisan basis wants to help. We want to fix the problem, 

but we don’t want to give up all the privacy rights and balancing 

the two are tough. 

I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair now recognizes the gentlelady from Illinois 

Ms. Schakowsky 5 minutes for questions. 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. 

Dr. McCance-Katz, I was going to—I guess I will ask this question to start, given SAMHSA’s leadership on traumatic informed 

care and practice, has the Office of Refugee Resettlement worked 

with SAMHSA to ensure the children being held in their custody 

are receiving trauma informed care? 

Dr. MCCANCE-KATZ. So I can say two things about that. One is 

that the Office of Refugee Resettlement assures that these children 

are getting both physical healthcare and mental healthcare and 

they are getting that regularly. That is—— 

31 

Ms. SCHAKOWSKY. OK. And the reason I was going to say I am 

not going to ask you that because quite frankly I was pretty 

shocked by your attitude that well, we all have trauma in our life 

and most of us get over it. And they will probably get over. You 

may have heard Congressman Green enter into the record statements from a number of the professional health organizations, the 

American Psychiatric Association, the American Psychological Association, the American Public Health Association, the American 

Academy of Pediatrics. And the concern about the trauma. 

I want to add into the record too a couple of other articles of people and groups that actually weighed in that were victims of long 

ago atrocities about separation of children. 

So I ask unanimous consent to enter into the record two articles. 

The first from the Guardian: ‘‘Nazis separated me from my parents 

as a child. The trauma lasts a lifetime.’’ That is the one article. 

Mr. BURGESS. Without objection. 

Ms. SCHAKOWSKY. On the second from the Anti-Defamation 

League, ‘‘Hidden children of the Holocaust open up about border 

situation, saying policies separating migrant children from parents 

is unconscionable.’’ And they have in this article talking about the 

lifelong affects which—so maybe it is fine that they didn’t contact 

you about that. 

I wondered if you do have any—— 

Mr. BUCSHON. I object. I have an objection to submitting articles 

about the Nazis and comparing what the Nazis did to what the current U.S. Government’s policy is in the United States. With clarification, I may remove my objection, but to compare Nazis to the 

United States of America is something I will object to and I won’t 

allow those to be submitted to the record. 

Ms. SCHAKOWSKY. Well, then let me just comment on that in defense, particularly of the Anti-Defamation League today issued a 

statement on behalf of a group of hidden children of the Holocaust 

who felt strongly compelled to oppose the Trump administration’s 

expanded ‘‘zero tolerance’’ policies. 

Mr. BUCSHON. I Object, Mr. Chairman. 

Mr. BURGESS. Objection is heard. 

Ms. SCHAKOWSKY. I am going to ask for the yeas and nays. 

Mr. BUCSHON. We can resolve this if the gentlelady would recognize there is no comparison between the current United States 

Government and the Nazis. 

Ms. SCHAKOWSKY. I recognize that there isn’t, but this is about 

a particular issue of separating children from their parents and the 

long-term affect. 

Mr. BUCSHON. OK, I remove my objection thank you. 

[The information appears at the conclusion of the hearing.] 

Ms. SCHAKOWSKY. Thank you, I appreciate that. 

I wanted to ask you about no touching policies. I have had a hard 

time pinning down exactly what that is, if there is a policy, if this 

is being done by the particular staffs at particular places, because—it is unclear exactly if it is a firm policy. But I certainly 

have heard of places for example, and there have been articles, 

that a sister was not able to embrace her younger brother, that 

they were told the children may not touch each other, that staff 

may not come and hold children that are in great distress. I wonVerDate Nov 24 2008 10:47 Apr 10, 2019 Jkt 037690 PO 00000 Frm 00037 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-154 CHRIS
32 

dered what kind of trauma, if those decisions are trauma informed 

care? 

Dr. MCCANCE-KATZ. It is really not possible for me to comment 

on that, because I am not familiar with the details of it. 

Ms. SCHAKOWSKY. The issue of touching, are you not informed 

about the effects of touching or comforting physical touching when 

it comes to mental health? 

Dr. MCCANCE-KATZ. What I am not familiar with is the agency 

and its roles and—— 

Ms. SCHAKOWSKY. No, I am asking a more general question. According to decades of psychological study, positive touch from 

adults cannot only lower stress levels in the most, but can have 

long-term beneficial affects if administered regularly. And relatedly, a consistent lack of positive touch has been shown to have 

detrimental affects on kids as they mature. Do you agree with 

that? 

Dr. MCCANCE-KATZ. I don’t have an opinion on it, it is out of context. 

Ms. SCHAKOWSKY. Really? I am asking generally about an issue 

that you are supposedly an expert on. Trauma informed care. And 

this is not—— 

Dr. MCCANCE-KATZ. Let me just tell you that touching can have 

all sorts of implications, good and bad. And so I—— 

Ms. SCHAKOWSKY. Do you agree with the statement—— 

Mr. BURGESS. I think the witness has answered the question and 

the gentlelady’s time has expired. 

I am going to go to Ms. Brooks from Indiana 5 minutes for questions please. Dr. Bucshon next? Dr. Bucshon 5 minutes for questions. 

Mr. BUCSHON. All right. Thank you. Well first of all thanks for 

being here. I very much appreciate it. 

I just want to say that I am opposed to separating children from 

their families so I think all of us on both sides of the aisle are. But 

I also have serious concerns and I wasn’t going to bring this subject 

up, but since it seems like my colleagues on the other side are staying on message on this and every one of them is going to talk about 

this, I feel that I will also. I am also concerned about the thousands 

children coming unaccompanied from and trekking thousands of 

miles across Mexico, being brought by coyotes and drug cartels, approximately 10,000. 

I have just been down there so this is information I know, many 

of whom have been sexually assaulted and abused. So I am concerned about them also. Just so everyone knows, we have about 

12,000 children under our custody, 10,000 of which approximately 

are unaccompanied that came with no adult, no family member. It 

is a tragic circumstance. 

As well as the families who are coming in currently, adult males 

with children because they know that we don’t have any beds for 

them in the United States and if they come, we are releasing with 

ankle bracelets into the United States, 200 to 300 of these people 

per day. Again, that is not my opinion, that is what we are doing, 

because the cartels and coyotes know our laws and when we don’t 

follow the law they exploit it—or when we do follow our law that 

33 

needs to be changed and it is Congress’ fault, when we need to adjust these things. 

But many of these people are coming in my view from the past 

failed policies most recently of the Obama administration on open 

borders and sanctuary cities and catch and release being encouraged to send their children thousands of miles by themselves. In 

fairness, their countries are in dire circumstances and I can’t say 

what I would do, but I do know that the situation is much more 

complicated than is being portrayed. 

And I am also concerned about the millions of citizen children 

every day who are being abused, neglected and suffering traumatic 

problems. And we all know that that is a difficult circumstance, 

that is all I am going to say on that. 

Section 605 of Cures required SAMHSA to develop a strategic 

plan every 4 years identifying priorities, including a strategy for 

improving the mental health workforce. Additionally, your testimony mentions engaging subject matter experts from across the 

country, from academia hospitals, insurers, community providers, 

State governments consumers, and family to inform SAMHSA on 

the complex problems and it is a complex problem such as workforce challenges among other things. 

Can you expand a little bit on what SAMHSA is doing it address 

the workforce challenges, particularly in rural areas related to 

mental health? And let me just say this, I know because I was a 

healthcare provider before, one of the big challenges is financial 

support for this type of—these type of services. 

But can you expand on that a little bit? 

Dr. MCCANCE-KATZ. I can. And thank you for the question. So we 

have developed a new program that will be in place by September 

30th so the end of this fiscal year that sets up both specialized programs around issues related to mental and substance use disorders. So things like the teens that I mentioned for the opioids crisis, we call it the State targeted response, we have one for veterans, we have the National Child Traumatic Stress initiative. We 

have a number of different types of topic-related special national 

programs. 

We have the new clinical support system for serious mental illness that will address issues around serious mental illness. We 

also are establishing technical assistance and training programs 

within each of the 10 HHS regions. Those again are focused on localized needs of communities because we know every community is 

different. 

We also recently have established a relationship with the Department of Agriculture that does a lot of rural work and so we are expanding our technical assistance through some of their initiatives 

into rural areas. Telehealth is a big issue for the Department of 

Health and Human Services. We have the behavioral health coordinating committee which includes the operating divisions and telehealth is a specific issue that we are working on to provide additional guidance to States to try to expand the reach of the practitioners that we have into rural areas. 

Mr. BUCSHON. Thank you very much for that answer. Mr. Chairman, I yield back. 

34 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. The chair recognizes the gentlelady from California, 

Ms. Matsui for 5 minutes of questions please. 

Ms. MATSUI. Thank you, Mr. Chairman. 

Dr. McCance-Katz, thank you very much it for joining us today. 

I am pleased we are hosting this hearing to discuss the mental 

health provisions in 21st Century Cures. I look forward to having 

oversight hearing of the final section of 21st Century Cures, including health IT and interoperability. 

Before I ask my questions about mental health and Cures, I have 

to make a comment about the mental health of thousands of children who have been separated their families due to President 

Trump’s zero-tolerance policy. Public health, mental health, and 

pediatric experts, including the American Academy of Pediatrics, 

the American Nurses Association have voiced concerns about the 

harm caused through the stress and trauma incurred by children 

who have been forcibly separated from their parents. The stress 

and trauma not only has immediate harmful impact on these children, but is also damaging a long term impact, on a child’s health 

and development. 

Dr. McCance-Katz, SAMHSA notes that the impact of childhood 

traumatic stress can last for far beyond childhood and that child 

trauma survivors are more likely to have long term health problems, including behavior health and substance use disorders. That 

is why this committee must act immediately to ensure that HHS 

is reuniting children with their parents and to ensure that HHS 

has long-term plans to mitigate the impact of trauma on these children. 

Now moving onto my legislative priorities for 21st Century 

Cures. I authored Title 11, the compassionate communication on 

HIPAA’s section of the bill that passed into law, these provisions 

seek to clarify confusion about the HIPAA privacy rule as it applies 

in mental health scenarios. The confusion for patients, families, 

doctors, and even administrators and lawyers about what information can and cannot be shared remains. 

Cures requires that the HHS Office for Civil Rights to coordinate 

with SAMHSA and other relevant agencies to develop, disseminate, 

and periodically update model programs to train healthcare providers, lawyers, patients and the families on the permitted use and 

disclosure of protected health information of individuals seeking 

and receiving treatment from mental health or substance use disorders. 

Dr. McCance-Katz, as you know, HHS released additional guidance on this topic back in December. What progress has it made 

to develop model training programs? 

Dr. MCCANCE-KATZ. Well, I have a few things to tell you. One, 

is that we are working very hard with the office of civil rights to 

coordinate those efforts and one of things that we did just last 

week was to train attorneys, healthcare attorneys, on issues 

around both HIPAA and 42 CFR. In fact I brought a copy of the 

training and I will be happy to leave it if you would like to see it. 

Ms. MATSUI. That would be great. Thank you. 

Dr. MCCANCE-KATZ. We had 1,000 attorneys on that webinar, 

that is the most you can have. And the American Bar Association 

35 

which has possession of this now and is continuing to disseminate 

it, they said that they thought we would have 4,000 could they 

have accommodated everybody that wanted to learn about this 

topic. 

We are also using this to develop something that I will just say 

is going to be in a little more simpler language for people like me, 

who are practitioners, to do special training for practitioners on the 

privacy issues. But the thing that I think is most exciting is that 

yesterday we were able to publish a funding announcement, we 

will have a national center on privacy. HIPAA and 42 CFR and I 

think that is going to make a huge difference. 

Ms. MATSUI. How about the other stakeholders such as clinicians, are you going to be bringing them in too as you develop and 

disseminate these model training programs? 

Dr. MCCANCE-KATZ. Absolutely. So we will have a single grantee 

whose job it will be to train clinicians, to train administrators and 

often these will be lawyers that are involved in healthcare systems. 

But the other requirement that I put in that funding announcement is that we must put out materials for families and for patients. 

Ms. MATSUI. That is really very important because many times 

this is merely misunderstood, even if we set up these programs, if 

we don’t have a communication in essence to even have some patients come in and parents come in to understand what the process 

is, because when the family gets into a certain kind of situation, 

people don’t know what to do. 

And I would hope that we would keep these training sessions 

going too, because just because we have a certain set trained, 

doesn’t mean that it is all done. 

Dr. MCCANCE-KATZ. That is correct. And this will be a multiyear 

initiative. 

Ms. MATSUI. OK well thank you. Yield back. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back. The chair now recognizes the gentlelady from Indiana, 

Mrs. Brooks, for 5 minutes of questions please. 

Mrs. BROOKS. Thank you, Mr. Chairman and thank you Dr. 

McCance-Katz. Thank you so much for being here as the first Assistant Secretary focused on these issues in this way and every answer you have given your portfolio is so large about so many issues 

that our constituents care about, I am having a hard time figuring 

out where to focus. 

I have to tell you as an attorney who practiced criminal defense 

in the courts. As former U.S. attorney, as someone who has been 

very involved in the criminal justice system. We know that 21st 

century Cures reauthorized and added some programs regarding 

revising the jail diversion grant programs for mental health in our 

jails. Our jails are often just overflowing, are often the largest institutions in many ways in counties that have those with mental 

illness. 

Can you give us any updates on these successes you have seen 

in the programs so far that we can help our local county jails and 

State prisons deal with this problem? 

Dr. MCCANCE-KATZ. Yes. And this is really a great benefit of the 

Cures Act that these kinds of resources are being made available. 

36 

What we have done at SAMHSA is to fund mental health courts 

both for adults and for youth who are experiencing mental illness 

sometimes for the first time but it has involved them in the justice 

system. We also are starting programs that divert people prior to 

arrest. This is really very important because people who have serious mental illnesses suffer from a great deal of stigma. And these 

things when have you an arrest it makes it so much more difficult 

for you to be able to navigate in communities without problems. 

It makes it more difficult to get insurance. Makes it more difficult to get a job, makes it more difficult to get housing. So we like 

the idea of prediversion programs and we are funding some of 

those again through the abilities given to us in the Cures Act. 

Mrs. BROOKS. And I applaud you from that, and I also think that 

what you just mentioned the National Center on Privacy and the 

fact that that many lawyers got on a call. I want to applaud the 

American Bar Association for encouraging that. And I believe that 

many, many lawyers will participate in that kind of training. And 

I want to encourage you getting the word out as well as my colleagues across the aisle. 

What is the best way for our constituents to learn about all of 

these grant opportunities? There just seems to be so many new 

grants, so many new programs and quite frankly we are having a 

hard time trying to help direct all of our constituents. We had a 

school shooting in my district on May 25th. And when you talked 

about teachers and educators wanting to learn more, that is the 

one thing that I heard is that our teachers and educators are so 

concerned about learning more about whether it is the mental 

health first aid, whether it is about identifying as Congressman 

Griffith brought up. 

What can you share with us is the best mechanisms we can provide our constituents to be educated or to pursue grant programs, 

particularly for mental health in our schools, mental health in our 

communities, what are the best ways we should be communicating 

this, instead of just going to SAMHSA’s website? And how can we 

have better access to the tools to provide our constituents? 

Dr. MCCANCE-KATZ. And so I would say that SAMHSA’s website 

has that information and it is a resource. 

Mrs. BROOKS. Extensive. 

Dr. MCCANCE-KATZ. It is. And we are working on how to simplify 

that and make it easier to find things. But we also are working on 

developing webinars on specific programs to talk to the public 

about what those programs are and about the funding opportunities that are available. 

The other thing that we will be using the system of regionalized 

training for is for these kinds of opportunities as well, to make it 

easier for those who are taking advantage of those regional programs to know more about what the opportunities are. 

So if you have an addiction transfer center for example in region 

one, the Northeast, that technology transfer center also can make 

it easier for the communities and individuals in those communities 

to find out what the resources are as it relates to addiction. We will 

have one for substance abuse prevention and we will also have one 

for mental health issues. 

37 

We also are supplementing those mental health technology transfer centers to specifically work on issues related to schools and our 

children’s needs. That will be happening in the next fiscal year and 

so we hope that by regionalizing the programs that we can get 

down to the community level and communicate better because you 

are so right it is very difficult. 

Mrs. BROOKS. Thank you. I applaud all the work that your office 

is doing. It is so critically important. I look forward to helping you 

with that. I yield back. 

Mr. BURGESS. The chair thanks the gentlelady. The gentlelady 

yields back. 

The chair recognizes the gentlelady from Florida, 5 minutes for 

questions, please. 

Ms. CASTOR. Thank you, Mr. Chairman. 

Dr. McCance-Katz, thank you for being here today. You have a 

very significant responsibility as Assistant Secretary for Mental 

Health and Substance Use, and I want to thank you for taking on 

this very important assignment. I have reviewed your bio. You 

have great experience and a number of degrees from outstanding 

institutions, so I think your expertise is needed here in this area. 

I want to ask you about the long-term mental health implications 

of child traumatic stress caused by the family separation policy. 

You have heard the concern from colleagues here today. And we 

are reflecting the concern that we are hearing back home all across 

the country. 

But I would like to ask you about child traumatic stress caused 

by the family separation policy on those children that have been 

forcibly separated from their families. I know you cannot get into 

specific cases. But based upon your extensive expertise, I would 

like you to comment in general. 

At this point, many public health organizations have stressed 

that ‘‘the practice of separating children from their loved ones and 

caregivers for an extensive period of time is a threat to public 

health, inflicting serious trauma, and threatening long-term irreversible health effects.’’ 

Do you agree? 

Dr. MCCANCE-KATZ. This is a form of trauma. 

Ms. CASTOR. What are some of the serious long-term irreversible 

health effects that could result from family separation? 

Dr. MCCANCE-KATZ. So I can’t speak to family separation per se. 

I don’t know who might develop a mental disorder that will have 

long-term implications for them. None of us do. 

Ms. CASTOR. That kind of runs counter to everything we are 

hearing from organizations, the leading mental health organizations and public health organizations, from across the country. 

Dr. MCCANCE-KATZ. The President has directed that families not 

be separated further. Secretary Azar has made it very clear that 

our job is to reunite these families. We are working very hard at 

HHS to do that. These children are in a safe environment. The 

practitioners there are all licensed within the States that these facilities—— 

Ms. CASTOR. You would not have recommended this policy at the 

outset, would you have? 

38 

If they came to you as the Assistant Secretary, would you have 

recommended this policy? Were you asked? Were you consulted? 

Dr. MCCANCE-KATZ. There are a number of different policy implications there, and—— 

Ms. CASTOR. I am not trying to play gotcha. I am curious. I know 

Secretary Azar, I believe he said he was not consulted. Were you 

asked as the Assistant Secretary for Substance Use Mental Health? 

Dr. MCCANCE-KATZ. Asked what? 

Ms. CASTOR. Before the family separation policy was implemented? 

Dr. MCCANCE-KATZ. I was not consulted about that. 

Ms. CASTOR. OK. We know that there is a significant body of evidence detailing the public health implications of adverse childhood 

experiences. Would you consider the forceable separation of children from their parents to be an adverse childhood experience? 

Dr. MCCANCE-KATZ. I would consider separation from parents to 

be an adverse experience. And I would also remind you that these 

children are getting physical healthcare and mental healthcare, 

and they are getting that very regularly. 

Ms. CASTOR. Thank you. 

It is likely that this forceable separation already compounds 

upon other adverse childhood experiences these children have faced 

in their home countries such as witnessing domestic violence or 

gun violence. 

Do these experiences have a cumulative effect? 

Dr. MCCANCE-KATZ. Depending on the individual, the reality is 

that most people have a great deal of resiliency. And when they 

can get their mental health issues addressed, and these children 

are getting mental healthcare in these facilities, then we hope that 

they will not go on to have any adverse affects. 

Ms. CASTOR. Well, the CDC and Kaiser Permanente adverse 

childhood experiences study found many long-term health impacts 

of adverse childhood experience, including the risk of disrupted 

neural development, social, emotional, and cognitive impairment, 

and heightened risk for disease, disability, and social problems. 

Can you explain some of the specific physical and mental health 

problems that can result from adverse childhood experience? 

Dr. MCCANCE-KATZ. There are a variety of different types of 

mental disorders that can be a result of adverse experiences. 

Ms. CASTOR. And there are risk factors for behavioral health and 

substance use disorders specifically, correct? 

Dr. MCCANCE-KATZ. That is true. 

Ms. CASTOR. There was a recent news report that said—— 

Mr. BURGESS. I believe the gentlelady’s time has expired. 

Ms. CASTOR. Well, I would ask the courtesy most members have 

gotten an additional 30 seconds. I just want to ask about funding 

shifts at HHS, because there is a recent report that HHS has quietly dipped into tens of millions of dollars to pay for what has happened through family separation. The Department has burned 

through at least $40 million in the past 2 months. 

I am just wondering, has that impacted your shop at SAMHSA? 

Have you been asked to shift any moneys out that were previously 

directed towards SAMHSA? 

Dr. MCCANCE-KATZ. SAMHSA has not had any direct effect—— 

39 

Ms. CASTOR. Thank you very much Mr. Chairman. 

Mr. BURGESS. That response is negative, and the gentlelady 

yields back. 

The chair recognizes the gentleman from Florida, 5 minutes, 

please. 

Mr. BILIRAKIS. OK. Thank you very much. I appreciate it, Mr. 

Chairman. 

Dr. McCance-Katz, in accordance with Section 13002 of Cures, I 

understand that SAMHSA last year convened a public listening 

session on mental health parity involving 15 in-person groups with 

an additional 40 comments submitted via email and in writing. 

Can you provide us with a high level summary of those comments? How were these comments addressed through SAMHSA’s 

action plan? And do you plan to host another meeting with industry stakeholders? 

Dr. MCCANCE-KATZ. Yes, we did hold that listening session. And 

the comments that we received were around need for education 

around the Parity Act and how individuals who experience what 

they believe to be pari violations would get assistance that they 

need. And what are the responsibilities of States and insurers 

around these issues. 

SAMHSA is in the process of developing a guidance on that, and 

that should be out before the end of this calendar year is what I 

was told prior to this hearing. So I am giving you the information 

that I have available to me. 

Mr. BILIRAKIS. OK. Thank you very much. 

In your testimony, you mentioned that over 7.4 million children 

and youth in our nation have a serious mental health disorder 

while only 41 percent actually receive treatment leaving the vast 

majority untreated. The 41 percent are the ones that were identified, so it could be even more than that. 

So, as you know, it is a serious issue. And I am glad that the 

chairman is holding this hearing and we are taking this issue very 

seriously. It really is an epidemic. 

And In addition to supporting systems of care, how is SAMHSA 

working with industry to address workforce shortage issues? 

Dr. MCCANCE-KATZ. So when you think about what type of problem we have, we have an urgent problem, we have an urgent need 

to get more services to Americans who are living with these kinds 

of conditions. What is the fastest way to do that? By the way, it 

is not going to be by opening more medical schools. That is going 

to take too long. 

And so when I think about this, I have to think about how can 

I get services to Americans. I can do it by training and providing 

technical assistance that will prepare practitioners to intervene 

and to provide care and treatment for mental and substance use 

disorders. And that is why so much attention, since I have come 

to SAMHSA—— 

Mr. BILIRAKIS. So when you talk about practitioners, are you 

talking about psychologists, psychiatrists, or primary care physicians who would get additional training? 

Dr. MCCANCE-KATZ. All of the above. 

Mr. BILIRAKIS. All of the above. 

40 

Dr. MCCANCE-KATZ. All of the above. And so we are setting up 

programs of regional training and technical assistance. We also 

have speciality programs. We are working very hard to disseminate 

that information so that clinicians and practitioners, psychiatrists, 

psychologists, nurse practitioners, physician assistants, counselors, 

social workers, and primary care doctors would be able to take advantage of these kinds of trainings. That allows them to get specialized kinds of skills and provide that service to their clients. 

Now, the other thing that I would say is that we are working to 

set up programs through our grant-funded organizations that will 

provide ways that practical assistance can be provided. So, for example, in the State targeted response funds that Cures provided, 

the States can contract with providers that provide specialized 

opioid treatment services. We also have a grant program at 

SAMHSA. It is called MAT–PDOA, which just means medication 

assisted—it is a way to implement medication assisted treatment. 

Those programs provide practical experience. So we have the 

ability to provide didactic classroom style webinar, web-based 

training, but then the ability within regions of the country where 

people can go and see this in practice. And we think that that is 

a way to better assure that practitioners will feel confident enough 

and able to use a new skill set to provide care when Americans 

need it. 

We also continue to support programs called SBIRT, Screening, 

Brief Intervention, Referral to Treatment. We also encourage primary care to continue to—— 

Mr. BILIRAKIS. How does that work now in the schools? How are 

we going to identify the kids that have these issues? And is the 

burden going to be always on the teacher? Where do you go next 

once they are diagnosed? 

I know it is very expensive. The treatment centers and a lot of 

the insurance companies do not cover. 

Mr. BURGESS. And the gentlemen—— 

Mr. BILIRAKIS. And even if they do, the co-pays are so very high 

and the deductibles. 

I am sorry, Doctor. 

Mr. BURGESS. The gentleman’s time has expired. 

Mr. BILIRAKIS. OK. All right. 

Mr. BURGESS. The gentleman from Georgia has been waiting 

very, very patiently here all day. Perhaps that question could be 

responded to in writing. 

The gentleman from Georgia is recognized for 5 minutes. 

Mr. CARTER. Thank you, Mr. Chairman. 

Dr. McCance-Katz, thank you for being here. And thank you for 

what you do for the children, particularly of our citizens. We appreciate that very much. I know a lot of this hearing has gotten a little 

bit off base, but I want you to know that we appreciate what you 

are doing for our citizens here. 

I am sorry to have to report to you that Georgia is not doing so 

good with mental health services. In fact, we rate about 47th out 

of 50. And that is one of the things that bothers me. And, in fact, 

it is estimated that we have less than 20 percent of the beds that 

we need for mental health services in the State of Georgia as well. 

Particularly when it comes to childhood mental health, we have got 

41 

159 counties in the State of Georgia, and only 76 of them have a 

licensed—or 76 do not have a licensed psychologist. We have got, 

again, 159 counties, 52 of them have no licensed social worker. 

All of these figures are alarming to us, and alarming to me in 

particular because of the fact that in the State of Georgia, for those 

children between the ages of 15 and 19, the second leading cause 

of death is suicide. And for those between 10 and 14, the third 

leading cause of death is suicide. 

So all of that leads me to ask you, Cures reauthorized the children’s mental health initiative, and that provided a lot of grants 

and a lot of assistance that we are very appreciative for. But I just 

wanted to ask you, particularly in the State of Georgia, we have 

a lot of rural areas, particularly in south Georgia, in my district, 

a lot of rural areas. And I am just wondering how do we get services to those areas? Any suggestions on how we can improve services there? 

Dr. MCCANCE-KATZ. So SAMHSA has supported two types of integrated care programs. One is where behavioral health providers 

would be able to be part of a team in a primary care program such 

as a federally qualified health center. 

The second way is through programs such as our certified community behavioral health clinics that bring primary care directly 

into a behavioral health setting. So that a person can easily access 

all the care and services that they need in one setting. 

SAMHSA, as you know, has limited funds. We do demonstrations. We work closely in terms of establishing those demonstrations and then doing more technical assistance in training and try 

to establish those programs on a national level. We talk with our 

colleagues at the Centers for Medicare and Medicaid Services. 

Mr. CARTER. OK. What about telemedicine? Telehealth, telemedicine. Is that something that we should be focusing more on? 

Dr. MCCANCE-KATZ. Yes. And I was just about to get there. 

Mr. CARTER. I am sorry. 

Dr. MCCANCE-KATZ. So, yes, telehealth is a very important piece 

of it, particularly for areas that have a lot of large rural communities. 

Mr. CARTER. Right. 

Dr. MCCANCE-KATZ. Telehealth can really extend the reach of a 

practitioner who may be in a more urban area but can—and so the 

Department of Health and Human Services has a committee that 

is working on telehealth guidance for the States and, in addition 

to that, is working with, for example, the Drug Enforcement Administration around issues of prescribing so that we can utilize 

those telehealth providers to the very best extent. 

Mr. CARTER. Great. 

Are there grants specifically for that, or are they just included 

in the regular grants that you can use it for that purpose? 

Dr. MCCANCE-KATZ. We have, at SAMHSA, part of a larger grant 

program that our telehealth services come from and I believe that 

other parts of HHS, such as HRSA, have specific funding for telehealth services. 

Mr. CARTER. Great. 

Another thing I want to talk about real quickly is the opioid addiction and the funds that have been going there, the grants that 

42 

have been going there. We have been very fortunate. The Georgia 

Department of Behavioral Health and Developmental Disabilities 

has gotten over almost $12 million. And I want to report back to 

you, because I have been a part of some of these programs. And 

it is working well, and it is been utilized well. In fact, one of the 

cities, and I want to give them a shout-out, the city of Pembroke, 

Georgia, in my district, in Bryan County, has been very active in 

this and has implemented a number of programs that have media 

campaigns, school partnerships. A number of programs that have 

been very successful. 

Can you elaborate just very quickly on what else we might be 

doing with that? 

Dr. MCCANCE-KATZ. So the opioids crisis is one of Secretary 

Azar’s priorities. 

Mr. CARTER. And this committee’s priority. 

Dr. MCCANCE-KATZ. Yes. And we are very grateful to Congress 

for the increase in funding to address these issues. 

So what we have to do is to work very hard to integrate substance abuse treatment, opioid addiction treatment, into primary 

care settings in addition to having speciality care available. We 

know that people find it very difficult to access care, and so we 

want to broaden the number of providers that are willing to engage 

in the care and to use innovative practices, such as telehealth, this 

is why we are working with the Drug Enforcement Administration, 

to make it possible for a clinician to have a greater reach and to 

reach Americans in those rural areas that have such difficulty accessing. 

Mr. CARTER. Great. 

And thank you again for your work. 

And I yield back. 

Mr. BURGESS. The chair thanks the gentleman. The gentleman 

yields back. 

Seeing that all members have had the opportunity to ask questions, I want to again thank our witness for taking time to be here 

with us today. 

Pursuant to committee rules, I remind members they have 10 

business days to submit additional questions for the record. And I 

ask our witness to submit responses within 10 business days upon 

receipt of those questions. 

Without objection, the subcommittee is adjourned. 

[Whereupon, at 12:30 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

43 


35691.010

TEXAS TECH UNIVERSITY 

HEALTH SCIENCES CENTER. 

Statement forthe Record 

Submitted to the House Committee on Energy and Commerce Subcommittee on Health 

21'' Century Cures Implementation: Examining Mental Health Initiatives 

July 19, 2018 

Thank you for the opportunity to submit a statement to today's hearing on "21st Century 

Cures Implementation: Examining Mental Health Initiatives." As the Hall Professor of Family 

and Community Medicine, Professor Public Health, and Executive Vice President for Rural and 

Community Health at the Texas Tech University Health Sciences Center in Lubbock, Texas, I 

appreciate this chance to discuss the Mental Health Screening in Schools Telemedicine, 

Wellness, Intervention, Triage and Referral (TWITR) Project. I specifically want to thank 

Chairman Burgess for his support of the TWITR project and his dedication to improving access 

and treatment for mental and behavioral health in the United States. I also want to thank the 

witness for today's hearing, The Honorable Elinore McCance-Katz, who took time to talk with 

me and the Texas Tech University Health Sciences President about the TWITR project just a 

few weeks ago. 

Access to health professionals and services to address the mental and behavioral health 

needs of adolescents remains an important challenge. 215

' Century Cures included important 

provisions and reforms to strengthen our mental health infrastructure in this country, which 

included driving evidence-based programs, and improving mental healthcare for children, 

which is why I am pleased to have this opportunity to discuss the TWITR Project. The TWITR 

Project is a mental health screening program, which provides screening, assessment, and 

referral services to students who are determined to be immediate threats to do harm to 

themselves or others. This program provides school-based screening, assessment, and 

referral services to students that are typically struggling with behavioral and mental health 

issues and is currently active in 10 West Texas independent school districts (ISDs). The TWITR 

Project uses telemedicine technology to link remote rural schools that are without sufficient 

counselors, psychiatrists, and other mental health service providers. It also provides mental 

health recognition and training services to educators and school resource officers to promote 

greater recognition and prompt referral. This is important to areas like West Texas, which is 

very large, rural, and lacks immediate access in many communities to mental health 

professionals. 

36014<h Street STOP 62581 Lubbock, Texas 79430·62581 T 806.743.2900 I F 806.743.2910 
44 


35691.011

The TWITR Project bryuses assessment instruments commonly used in clinical practice and 

the process for the TWITR Project is as follows: 

• The TWITR Project staff will make contact with the referral school administration 

when they arrive at the school. The Telepsychiatry staff will follow the school 

district's procedures for signing in and out of the building. 

• During this visit, the TWITR Project staff can request student records [current 

grades, truancy reports, discipline referrals, and any other pertinent information] 

to assist in understanding the student's academic/social history and to monitor 

changes in the student's behavior throughout the school year. 

• TWITR Project staff will then complete the initial student evaluation, administer 

required TWITR Project assessments to the student, and other applicable parties 

[parent/guardian, teacher/counselor]. TWITR project staff will also obtain 

guardian/parent signatures on required psychiatry forms. This requires training all 

school staff to recognize the signs of behavioral health problems and refer children 

needing immediate care. Evidence-based screening is done by Licensed 

Professional Counselors. If a child exceeds norms they are seen immediately via 

Telemedicine by a Psychiatrist at TIUHSC and emergency measures are taken if 

needed. 

Data for the TWITR Project illustrate effective outcomes. For the 2013-2017 school years, the 

use of TWITR resulted in 25 students being removed from schools, of which about half were 

homicidal and the remainder were actively suicidal. While I cannot share specific details, the 

following two stories illustrate the seriousness of these young people. 

1) Following triage, an individual was detained by the school resource officer, held on 

a mental health warrant, and searches found -a note, a map, names, a date 

certain, and interviews verified the intent to purchase the ammunition and 

handgun. According to the timeframe, this individual was detained on Thursday, 

had planned to buy a firearm on Saturday, and to carry out a plan for harm on 

Monday morning. 

2) Following triage, an individual was ordered to inpatient emergency care by 

psychiatrists, EMS failed to transport, school personnel found subject moments 

before suicide in gym locker room. Subject was hospitalized, stabilized, and is in 

long-term residential treatment facility. 

We have many other examples of how this intervention prevents harm to individuals 

themselves, or others, which I would be pleased to discuss in further details with the 

Committee. Overall, we have impacted an annual enrollment of almost 42,000 students in 10 

mostly rural school districts in and around Lubbock, Texas, by creating an environment where 

students are empowered to help create a safe learning environment and better morale. Of 

that number, only a small fraction (414 total) have been referred by teachers we have trained 

to recognize those who need to be referred to TWITR. The TWITR team has screened and 

36014th Street STOP 62581 Lubbock, Texas 79430-6258 IT 806.743.2900 IF 806.743.2910 

1 f' ~Q"'"~~4.# 
45 


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triaged by telemedicine about 215 and, as previously mentioned, 25 have been removed from 

school, most by hospitalization and a few by arrest. We have averted tragic outcomes and 

started others on a path toward healing. 

It is important to emphasize that we respect the culture of the schools we are invited to work 

in, and the schools appreciate us for it. Our best friends in the schools are often the school 

resource officers, especially when we worry about a particular child. We monitor things like 

grade point averages, truancy rates, disciplinary referrals, and other school climate outcomes 

of TWITR, which often improve in the schools where we work. The schools obtain consent 

from parents and guardians at the beginning of the school year, the TWITR team obtains the 

consent of parents and students before an encounter, and treatment is consented as well. 

We work in places in the school that are private, and we bring our own HIPPA compliant 

telemedicine hotspots and software to encrypt to ensure privacy and security. We are 

purposeful in our activities so that we do not add to the stigma associated with mental 

health, but instead help those who may suffer from a mental health disease. 

Telemedicine is vital to the success ofTWITR. While a virtual visit does not replace an inperson visit, it helps ensure access to timely care, brings care closest to home, saves time and 

distance, and depending on where one lives- rural or urban area- it can impact one or the 

other dynamic more and thus can help avoid health disparities. In mental health applications, 

telemedicine replaces whatever method of care is most convenient and economical at the 

time that care is needed. In many areas we work with, until The TWITR Project, the most 

convenient alternative was to not get any care at all. 

Again, thank you for the opportunity to submit this statement. I hope that as the Committee 

and the Department of Health and Human Services, specifically the Substance Abuse and 

Mental Health Services Administration, continues to implement the mental health provisions 

of 21'' Century Cures, that they will find opportunities to support proven activities such as 

TWITR to help improve mental health access and treatment. 

36014'" Street STOP 62581 Lubbock, Texas 79430-62581 T 806.743.2900 IF 806.743.2910 
46 


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7/19/2018 AAP Statement Opposing Separation of Children and Parents at the Border 

AAP Statement Opposing Separation of Children 

and Parents at the Border 5/8/2018 by: Colleen Kraft, MD, MBA, FAAP, President, American Academy of Pediatrics 

"As a pediatrician, as a parent, as the president of the American Academy of Pediatrics {AAP), I am appalled by a new policy 

reportedly signed by Department of Homeland Security that will forcibly separate children from their parents, a practice that 

this Administration has already been canylng out for months. In fact, during my recent trip to the border, I saw its impact with 

my own eyes, and I am not alone in my outrage and dismay at its sweeping cruelty. The MP is opposed to this policy and 

will continue to urge the Department of Homeland Security and the Department of Justice to reverse it immediately. 

"So many of these parents are fleeing for their lives. So many of these children know no other adult than the parent who 

brought them here. They can be as young as infants and toddlers. 

"Separating children from their parents contradicts everything we stand for as pediatricians -protecting and promoting 

children's health. In fact, highly stressful experiences, like family separation, can cause irreparable harm, disrupting a child's 

brain architecture and affecting his or her short- and long-term health. This type of prolonged exposure to serious stress -

known as toxic stress - can cany lifelong consequences for children. 

'The new policy is the latest example of harmful actions by the Department of Homeland Security against immigrant families, 

hindering their right to seek asylum in our country and denying parents the right to remain with their children. We can and 

must do better for these families. We can and must remember that immigrant children are still children; they need our 

protection, not prosecution." 

II## 

The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical 

subspecialists and pediatric surgical specialists dedicated to the health, safety and ~JVe!l-being of ;ntants, children 

adolescents and young adults. For more information, visit \lli\'\IWaap.org and follow us on Tvitter @AmerAcadPeds. 

Practice Transformation 

Clinical Support 

Quality improvement 

tv>J> Polley 

Research 

Journals & Publications 

Webinars 

Pediatrics as a Profession 

National Conference & Exhibition (NeE} 

Pedfalink/Online Education 

Maintenance of Certification 

Professional Education Publicatio-ns 

Education in Quality Improvement for Pediatric Practice {EQtPP) 

https:/fww.N.aap.org/en-us/about-the-aaplaap-press-room'Pages!StatementOpposingSeparationofChildrenandParants.aspx 213 
47 


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AMERICAN fj PSYCHIATRIC 

ASSOCIATION .. 

News Releases 

May 30,2018 

APA Statement Opposing Separation of 

Children from Parents at the Border 

WASHINGTON, D.C. - The American Psychiatric Association issued the following statement from 

President Altha Stewart, M.D.: 

"As physician experts in mental health, the American Psychiatric Association opposes any policy that 

separates children from their parents at the United States border. Children depend on their parents for 

safety and support. Any forced separation is highly stressful for children and can cause lifelong trauma, as 

well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress 

disorder (PTSD). The evidence is clear that this level of trauma also results in serious medical and health 

consequences for these children and their caregivers. Many families crossing the United States border are 

fleeing war and violence in their home countries and are already coping with the effects of stress and 

trauma. These children deserve our protection and should remain with their families as they seek asylum 

The APA recommends an immediate halt to the policy of separating children from their parents." 

American Psychiatric Association 

The American Psychiatric Association, founded in 1844, is the oldest medical association in the country. 

The APA is also the largest psychiatric association in the world with more than 37,800 physician members 

specializing in the diagnosis, treatment, prevention and research of mental illnesses. APAs vision is to 

ensure access to quality psychiatric diagnosis and treatment For more information please visit 

www R,;ly.cllliliry.mg' 

Media Contacts 

Glenn O'Neal, 202-459-9732 

gress@R,;lY.Ch.org 
48 


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7/19/2018 Statement of APA President Regarding the Traumatic Effects of Separating Immigrant Families 

0 AMERICAN PSYCHOLOGICAL ASSOCIATION 

ABOUT APATOPICSPUBLICATIONS & DATABASESPSYCHOLOGY HELP CENTER NEWS & EVENTSSCIENCE 

EDUCATIONCAREERSMEMBERSHIP 

May29. 2018 

Statement of APA President Regarding the Traumatic 

Effects of Separating Immigrant Families 

WASHINGTON Following is the statement of APA President Jessica Henderson Daniel, PhD, regarding 

the deleterious impact on the health and well-being of children and families who are separated as they 

seek to enter the United States without proper documentation: 

"The administration's policy of separating children from their families as they attempt to cross into the 

United States without documentation is not only needless and cruel, it threatens the mental and physical 

health of both the children and their caregivers. Psychological research shows that immigrants 

experience unique stressors related to the conditions that led them to flee their home countries in the 

first place. The longer that children and parents are separated, the greater the reported symptoms of 

anxiely and depression for the children. Negative outcomes for children include psychological distress, 

academic difficulties and disruptions in their development. 

"The American Psychological Association calls on the administration to rescind this policy and keep 

immigrant families intact (/advocacy/immigration/index.aspx). We support practical, humane immigration 

policies that consider the needs of immigrants. and particularly immigrant families. We must adopt 

policies that take into account what we know about the harmful, long-term psychological effects of 

separation on children and their families. This is not an acceptable policy to counter unlawful 

immigration." 

The American Psychological Association, in Washington, D. C., is the largest scientific and professional 

organization representing psychology in the United States. APA's membership includes nearly 115,700 

researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of 

psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to 

advance the creation, communication and application of psychological knowledge to benefit society 

and improve people's lives. 

http:/l'lv\IM'.apa.org/newslpressfreleases/2018105/separating~immigrant~fami!ies.aspx 

Contact 

Kim I. Mills 

(202) 336-6048 

113 
49 


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KEY POINTS: 

e The relationship with a loving parent or primary caregiver is critical to a child's sense of self, safety, 

trust and ability to thrive. 

e Separations from parents or primary caregivers is one of the most potent traumatic stressors a child can experience, 

especially under frightening, sudden, chaotic, or prolonged circumstances. Such separations may increase children's 

risk for developing depression, anxiety, separation-related posttraumatic stress disorder symptoms ("traumatic 

separation"}, or other trauma reactions. 

o For young children, separation from their primary attachment figure affects their emotional and physical wellbeing in 

several ways, including: 

Inability to trust, soothe themselves, or develop foundations for meaningful relationships due to the disruption 

in the single most important relationship they have. 

Terror on the face of their attachment figure triggers a fear response in children that may affect them cognitively, 

emotionally, and physiologically for the rest of their lives, 

e; This risk ls greater for children who experienced previous traumas !n their home countries, such as domestic or gang 

violence, due to the cumulative impact of such stressors on child development. 

e Children who experience traumatic separation may have a variety of trauma symptoms including: 

Intrusion: nightmares, scary images, or thoughts about the separation or past traumas 

Avoidance: trying not to remember or ta!k about people, places, things, or situations associated with the 

separation or past traumas 

Negative trauma~related beliefs: blaming oneself or others for the separation; be!levlng the world is extremely 

dangerous; loss of trust 

Negative trauma-related emotions: extreme anger, sadness, guilt, fear, shame, etc. 

Negative behaviors: aggression, withdrawal, irritability, oppositional bet'lavior 

Hyperarousal: trouble sleeping, not listening, trouble paying attention, stomachaches, headaches, Increased 

vigilance to danger 

e Children with traumatic separation often do not understand why the separation occurred and may blame themselves 

for the separation. Providing honest, age-appropriate information to the child about the reason for the separation is 

criticaL 
50 


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13 After a long period of traumatic separation, a chHd who had initially been inconsolable may eventually become 

more withdrawn and quiet. This change could be misinterpreted as an indication that the child has adjusted to 

the separation. Instead, the change may occur because the child's stress hormone levels are depressed and their 

emotions are dulled. 

o During refugee and immigration processes, children may also experience concern about the parent's safety. 

Facilitating direct parent-child communication can help to diminish the child's sense of danger. 

e The negative impact of traumatic separation from parents is potentially long lasting and may continue even after 

children are reunited with their parents. Without early recognition and effective intervention, chlldren may have 

serious medical and mental health problems throughout their lives. 

0 Such long-term consequences may include: struggling with behavioral issues; dropping out of school; turning to 

damaging coping strategies, leading to issues with drugs and alcohol; or being diagnosed with chronic illnesses, 

such as diabetes or heart disease. 

e The presence of a supportive parent !s a protective factor that helps children regulate negative emotional states 

and promotes connections in the brain that protect children from developing PTSD and depression and help chlldren 

recover from traumatic stress. Younger children are particularly vulnerable due to their attachment needs, 

dependence on caregivers, and less developed cognitive and coping abilities. 

e Chlldren can recover from traumatic separation and other traumatic experiences with developmentally, cultura!!y, 

and !lnguistical!y appropriate trauma services for these children and their families, including evidence-based, 

trauma-focused treatment. 

SOURCE 

Adapted from Children with Traumatic Separation: Information for Professionals, a fact sheet from the National Child 

Traumatic Stress Network Childhood Traumatic Grief Committee. Available at: https:j jvvww.nctsn.orgjresourcesj 

chlldren-traumatlc-separaUon-information-profess!ona!s. Other information available at: https:j ;www.nctsn.orgj 

what-fs-child-traumajtrauma-typesjrefugee-trauma. 

National Child Traumatic Stress Network 

Established by Congress in 2000, the National Child Traumatic Stress Network (NCTSN) brings a singular and 

comprehensive focus to childhood trauma. NCTSN's collaboration of frontline providers, researchers, and families 

is committed to raising the standard of care while increasing access to services. Combining knowledge of child 

development, expertise in the full range of child traumatic experiences, and dedication to evidence-based practices, 

the NCTSN changes the course of children's lives by changing the course of their care. 

This project was funded by the Substance Abuse and Menta! Healtl1 Services Administration {SAMHSA), US 

Department of Health and Human Services {HHS). The views, policies, and opinions expressed are those of 

the authors and do not necessarily reflect those of SAMHSA or HHS. 
51 


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7/19/2018 Nazts separated me from my parents as a child. The trauma lasts a lifetime 1 Yoka Verdoner l Opinion ! The Guardian 

GTh(}.. uaruian 

Nazis separated me from my parents as a child. The 

trauma lasts a lifetime 

Yoka Verdoner 

I know from experience that the Trump-sanctioned brutality at the US border with Mexico will scar its child victims for life 

Mon 18 Jun 2018 02.00 EDT 

My family was Jewish, living in 1942 in the Netherlands when the country was occupied by the 

Nazis. We children were sent into hiding, with foster families who risked arrest and death by 
52 


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7/1912018 Nazis separated me from my parents as a child. The trauma lasts a llfetlme 1 Yoka Verdoner 1 Opinion 1 The Guardian 

taking us in. They protected us, they loved us, and we were extremely lucky to have survived the 

war and been well cared for. 

Yet the lasting damage inflicted by that separation reverberates to this day, decades hence. 

Have you heard the screams and seen the panic of a three-year-old when it has lost sight of its 

mother in a supermarket? That scream subsides when mother reappears around the end of the aisle. 

This is my brother writing in recent years. He tries to deal with his lasting pain through memoir. 

It's been 76 years, yet he revisits the separation obsessively. He still writes about it in the present 

tense: 

In the first home I scream for six weeks. Then I am moved to another family, and I stop screaming. I 

give up. Nothing around me is known to me. All those around me are strangers. I have no past. I have no future. I have no identity. I am nowhere. I am frozen in fear. It is the only emotion I possess now. As a three-year-old child, I believe that I must have made some terrible mistake to have caused my 

known world to disappear. I spend the rest of my life trying desperately not to make another mistake. 

My brother's second foster family cared deeply about him and has kept in touch with him all 

these years. Even so, he is almost So years old now and is still trying to understand what made 

him the anxious and dysfunctional person he turned into as a child and has remained for the rest 

of his life: a man with charm and intelligence, yet who could never keep a job because of his 

inability to complete tasks. After all, if he persisted he might make a mistake again, and that 

would bring his world to another end. 

My younger sister was separated from our parents at five. She had no understanding of what was 

going on and why she suddenly had to live with a strange set of adults. She suffered thereafter 

from lifelong, profound depression. 

I was older: seven. I was more able than my siblings to understand what was happening and why. 

I spent most of the war with Dick and Ella Rijnders. Dick was mayor of a small, rural village, and 

he and Ella lived in a beautiful house next to a wide waterway. Ella had a warm smile and Dick 

referred to me as his "oldest daughter". I was able to go to school normally, make friends, and 

became part of village life. I was extraordinarily lucky, but I was not with my own parents, sister, 

and brother. And, eventually, I also had to leave the Rijnders, my loving second "family". I was 

returning to my own family, but this meant another separation. 

In later life, I was never able to really settle down. I lived in different countries and was successful 

in work, but never able to form lasting relationships with Partners. I never married. I almost 

forgot to mention my own anxiety and depression, and my many years in psychotherapy. 

My grief and anger about today's southern border come not just from my personal life. As a 

retired psychotherapist who has worked extensively with victims of childhood trauma, I know all 

too well what awaits many of the thousands of children, taken by our government at the border, 

who are now in "processing centers" and foster homes - no matter how decent and caring those 

places might be. We can expect thousands of lives to be damaged, for many years or for ever, by 

"zero tolerance". We can expect old men and women, decades from now, still suffering, still 

remembering, still writing in the present tense. 

What is happening in our own backyard today is as evil and criminal as what happened to me and 

my siblings as children in Nazi Europe. It needs to be stopped immediately. 
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7/19/2018 Nazis separated me from my parents as a child. The trauma lasts a lifetime 1 Yoka Verdoner 1 Opinion j The Guardian 

Yoka Verdoner is a child survivor of the Holocaust. A retired teacher and psychotherapist now 

living in California, she edited Signs of Life: The Letters of Hilde Verdoner-Sluizer from Nazi Transit 

Camp Westerbork, 1942-1944 

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54 


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711912018 nHidden Children of the Holocaust~ Open Up About Border Situation, Sey Policy Separating Migrant Children Fr-om Parents Is Unconscio ... 

ADL 

ome ! News ,J, I Press Center I Press Releases/Statements I "Hidden ChUdrenofthe Holoea 

4f IMMIGRANT & REFUGEE RIGHTS 

"Hidden Children of the Holocaust .. Open Up 

About Border Situation, Say Policy Separating 

Migrant Children From Parents Is 

Unconscionable 

New York, NY, June 19, 2018 ..• The Anti-Defamation League (ADL) today issued a 

statement on behalf of a group of hidden children of the Holocaust who felt strongly 

compelled to oppose the Trump Administration's expanded "zero tolerance" policy 

for migrants seeking to cross the border, which has ledto thousands of children 

being separated from their parents. 
55 


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7/1912018 rtHidden Children ofthe Holocaust~ Open Up About Border Situation, Say Policy Separating Migrant Children From Parents ls Unconsdo ... 

The hidden children, many separated from their parents at the beginning of World 

War II, are recalling the severe and lasting trauma they experienced as a 

consequence of their forced separation. Now aged in their 70s and 8os, the 

Holocaust survivors are reacting to what is happening along America's southern 

borders with a mix of anger and disbelief, calling the practice of separating families 

with young children inhumane and unconscionable. 

According to news reports, nearly 2,500 children have been separated from their 

parents under the new policy. Such practices have the effect of causing unnecessa.ry 

trauma to the children- many of whom have already suffered significant traumatic 

experiences - negatively impacting their physical and mental health and increasing 

their risk of early death. 

In a video testimonial released today, Rachelle Goldstein, co-director of the Hidden 

Child Foundation, a New York-based organization which represents Jewish 

Holocaust survivors who were hidden during the war, spoke to the lifelong pain she 

-- and -- others have endured as a consequence of being separated from their parents 

at a very young age. Rachelle was just under 3-years-old when she was separated 

from her parents in Belgium. The video also includes her husband, Jack Goldstein, 

who was separated from his parents when he was 9-years-old. The video closes by 

urging viewers to sign an ADL petition calling on the Attorney General to stop this 

practice now. 

The Hidden Child Foundation issued the following statement: 

As former Hidden Children of the Holocaust, we know that the 

trauma of separation from parents lasts a lifetime. Now in our late 

70s and 8os, we still ache from the losses we suffered as a result of 

this separation. It is very difficult for us to see such inhumanity 

taking place today at our southern border. Let's be clear: We are not 

comparing what is happening today to the Holocaust. But forcibly 
56 


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7/1912018 "Hidden Children of the Holocausr Open Up About Border Situation, Say Policy Separating Migrant Children From Parents Is Unconscio ... 

separating children from their parents is an act of cruelty under all 

circumstances. 

When speaking about the fate of such children, White House Chief of 

Staff John Kelly said recently: "The children will be taken care ofput into foster care or whatever." That "whatever" mostly means 

institutional warehousing. For a child, this is a wrenching experience 

even under the best conditions. We, who were placed in orphanages 

and convents during World War II, know that it takes more than a 

clean bed and three meals a day to endure being severed from one's 

parents. 

Children can bear all sorts of adversities and cruelties as long as they 

are with a parent. A mother or father's presence assures the child 

that he or she will be cared for even under the direst circumstances. 

All Hidden Children suffered lifelong anxieties that resulted from 

that early separation. The youngest, particularly, worried about their 

parents' "disappearance." All wondered if they would ever be 

reunited. 

These migrant children are surely longing for their parents- as we 

did. We feel compelled to raise our voices for them. 

The Hidden Child Foundation represents the youngest survivors of the Holocaust. 

With a worldwide membership of more than 6,ooo, the organization has a mission 

to educate all people about the consequences of bigotry and hatred so that never 

again will anyone suffer the atrocity. the injustice and the agony of genocide. 
57 


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7/19/2018 "Hidden Children of the Holocaust" Open Up About Border Situation, Say Policy Separating Migrant Children From Parents Is Unconscio 

IMMIGRANT & REFUGEE RIGHTS 

The Anti-Defamation League was founded in 1913 to stop the defamation oft he Jewish people and to secure 

justice and fair treatment to all. Today it is the world's leading organization combating anti-Semitism, 

exposing hate groups, training law enforcement on hate crimes, developing anti-bias education programs for 

students, countering cyber-hate and relentlessly pursuing equal rights for all. 

RELATED TO THIS PRESS RELEASE 

The Hidden Child Foundation 

II PRESS RELEASE 

ADL Statement on Recent DOJ/DHS "Zero Tolerance" Immigration Policy Announcement 

4f IMMIGRANT & REFUGEE RIGHTS 

E LETTER 

Letter to Attorney General Sessions and Secretary Nielsen Regarding "Zero Tolerance" 

Family Separation Policy for Migrants 

IMMIGRANT & REFUGEE RIGHTS 

MORE FROM THIS SECTION 

!liiJ BLOG 

Hidden Children ofthe Holocaust- "Let's get back to our values 

because this is not what America stands for." 

Hidden Children of the Holocaust open up about border situation- say policy 

separating migrant children from parents is unconscionable. 

IMMIGRANT & REFUGEE RIGHTS 
58 


35691.025

GREG WALDEN, OREGON 

CHAIRMAN 

ONE HUNDRED FIFTEENTH CONGRESS 

FRANK PALLONE, Jf1"' NEW JERSEY 

RANKING MEMBER 

C!ongress of tbe mniteb ~tates 

,i!~ouse of ~cprescntatil.les 

COMMITTEE ON ENERGY AND COMMERCE 

2125 RAYBURN HousE OFFICE BuiLDING 

WASHINGTON, DC 20515-6115 

The Honorable Elinore McCance-Katz 

Assistant Secretary 

Majonty !202) 225··2927 

!\111nority {202)225-3641 

August 6, 2018 

Substance Abuse and Mental Health Services Administration 

5600 Fishers Lane 

Rockville, MD 20857 

Dear Dr. McCance-Katz: 

Thank you for appearing before the Subcommittee on Health on July 19,2018, to testify 

at the hearing entitled "21st Century Cures Implementation: Examining Mental Health 

Initiatives." 

?·Jrsuant to the Rules of the Committee on Energy and Commerce, the hearillf; record 

remRins open for ten business days to permit Members to submit additional questions for the 

w;~··", which are attached. To facilitate the printing of the hearing record, please respond to 

the:', :.c:estions with a transmittal letter by the close of business on August 20,2018. Your 

responses should be mailed to Dan Butler, Legislative Clerk, Committee on Energy and 

Commerce, 2125 Rayburn House Office Building, Washington, DC 20515 and e-mailed in Word 

format to dan.butler@mail.house.gov. 

Thank you again for your time and effort preparing and delivering testimony before the 

Subcommittee. 

cc: The Honorable Gene Green, Ranking Member, Subcommittee on Health 

Attachment 
59 


35691.026

Attachment- Additional Questions for the Record 

The Honorable Michael C. Burgess, M.D. 

1. Texas has a few innovative mental health programs, particularly addressing the K-12 schoolage population. One of these programs is the Tclemedicine Wellness, Intervention, Triage, 

and Referral Project at Texas Tech University Health Science Center. I think it is important 

for states and institutions to have ample flexibility to effectively address their citizens' 

particular mental health needs. What Cures implementation and other efforts are underway at 

SAMHSA that would provide a flexible framework and resources for states? 

2. As an OB/GYN I am particularly interested in maternal mental health, which was addressed 

in 21st Century Cures. What specific initiatives have been employed to increase the screening 

and diagnosis of postpartum depression, suicide risk and prevention, etc. within maternal 

mental health? If no initiatives have been employed, what are the plans and timelines for 

improving/increasing maternal mental health screening and/or suicide prevention in mothers? 

3. The Children's Mental Health Services section of the SAMHSA FY19 budget request states 

that "Recent research by the National Institute on Mental Health indicates that there is an 

opportunity to improve treatment for youth who are at high risk of forming serious mental 

illness through earlier intervention." What kind of programs does SAMHSA fund through 

Children's Mental Health Services and other grant programs to achieve this goal of early 

identification and intervention? 

4. Once children and adolescents are identified as potentially needing mental health screening 

or treatment, what resources are available to schools and other entities outside of the health 

care industry to help families obtain help for their children? 

5. 21st Century Cures Act authorized the Department Health and Human Services to provide 

federal grants to states for the purpose of screening, assessing and treating postpartum 

d~pression. 

a. What specific initiatives have been employed to increase the screening and diagnosis 

of postpartum depression, suicide risk and prevention, and other issues related to 

maternal mental health? If no initiatives have been employed, what are the plans and 

timelines for improving/increasing maternal mental health screening and/or suicide 

prevention? 

b. What are the various ways in which maternal mental health services could be better 

organized or coordinated across the government? Are there specific efficiency and 

effective measures that can be taken? 
60 


35691.027

The Honorable Greg Walden 

I. Thank you again for testifying before the subcommittee today. One aspect of this issue that's 

important to me is suicide prevention. Oregon has the 16th highest suicide rate in the US, 

which is high but what's more striking is the prevalence of rural areas at the top of the listMontana, Alaska, Wyoming, Idaho, etc. My very rural district in Oregon looks a lot more 

like Montana than New York or New Jersey- two states with the lowest suicide rates. As I 

mentioned in my opening statement, I worked closely with Senator Gordon Smith to enact 

the original Garrett Lee Smith Memorial Act. As those dollars have flowed out into states 

and local communities, what are you seeing that works as we try to reverse increasing suicide 

rates? 

a. Our committee recently marked up and reported out the National Suicide Hotline 

Improvement Act which will direct FCC and SAMHSA to study and report on the 

feasibility of anN 11 dialing code for the national suicide prevention hotline. Have 

you looked at that and would that help in your view? 

b. I also mentioned in my opening statement that there are providers in my district who 

have worked hard to integrate primary care and behavioral health. Some clinics that 

I've met with and toured have as much as 90% patient overlap between primary and 

behavioral health, and they emphasize coordination of care to address the root of the 

patient's health issues, not just the symptoms. Can you talk about ways that 

SAMHSA is evaluating these models, and if the success in my district is not unique, 

ways that you're encouraging this through grants, etc.? 

The Honorable John Shimkus 

1. Many of the patients we have heard from and about during our consideration of public policy 

proposals also suffer from other mental health challenges, such as depression. In fact, studies 

have shown patients with depression are nearly three times more likely to use and become 

dependent on opioids than patients who are not depressed. 

a. Can you please provide us with your understanding of the relationship between 

depression and opioid dependence or abuse? In addition, can you tell us whether 

effective treatment of depression is important to help prevent or combat opioid 

dependence and abuse? What is SAMSHA currently doing to investigate the 

relationship between depression and opioid dependence and abuse, and/or to promote 

screening and treatment strategies that take into account the link between depression 

and opioid dependence and abuse? 

b. Further, has SAMHSA examined the effect of access limitations on the effectiveness 

of depression treatment, and if so, what it found? What can SAMHSA do and what 

is it doing today-to reduce the risk that Americans suffering from depression will be 

unable to obtain the medication their doctor recommends as most appropriate for 

them? 

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The Honorable Leonard Lance 

1. What has SAMHSA has done to implement Section 13006 of CURES, which authorized 

eating disorders early identification trainings for health professions to provide our medical 

professionals the tools they need to identify and intervene for their patients from eating 

disorders? 

2. What will SAMHSA do to ensure eating disorder early identification trainings are 

disseminated broadly throughout to the health professional community? 

3. The second tranche of monies ($485 million in STR grants) called for in the 21st Century 

Cures Act to address the opioid crisis has been released and made available for states. The 

final report of the Presidents Commission on Combating Drug Addiction and Opioid Crisis 

identified a strong corollary effect of Substance Use Disorder in patients with mental health 

issues, citing a reference to a CDC finding that 40% of patients with a SUD also have a 

mental health issue, and calling for an increase in the use of screening measures to identify 

patients at high risk for this co-morbity. Realizing there is large overlap between SUD and 

Mental Health Disorders, what steps is SAMHSA taking to encourage states to use this 

money to screen for patients with mental health issues who are also at a high risk for 

developing an SUD? 

4. We are interested in learning more about SAMSHA operations in delivering care in rural 

communities affected by the opioid crisis, 

a. How is SAMSHA addressing resource gaps in terms of physician and specialist care 

in rural communities affected by the opioid crisis? 

b. What programs does SAMSHA provide aimed at preventing as well as treating 

infectious diseases among people injecting drugs, particularly in rural areas? 

c. Are there active or planned community grant programs for diagnosing and treating 

infectious disease at the site of care? 

d. Is SAMSHA collaborating with any other agencies (CDC or HRSA) to address the 

public health risk of hepatitis and HIV posed by the opioid epidemic? 

e. How does SAMHSA work with FQHC's to ensure that they are equipped to provide 

other wrap around medical services for rural opioid users, including mental health, 

harm reduction, and testing and treating for infectious diseases? 

5. Has SAMHSA considered the value of public health education efforts for community 

grantees regarding the connection between infectious disease and opioid injection 

use/addiction? 

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The Honorable H. Morgan Griffith 

1. In your testimony you discussed concerns brought up about the enforcement of parity 

protections. I was in a meeting with Secretary Acosta where he brought up similar concerns 

from the Department of Labor (DOL) about the fact that they have enforcement authority but 

no ability to implement penalties on those not in compliance with parity laws. 

a. Do you have suggestions about steps we can take at the federal level to ensure 

compliance with parity laws? 

2. Is there statutory language that needs to be changed in order to facilitate loving parents being 

able to receive information about their adult child's mental health and/or medical issues, 

while making sure we maintain patient privacy protections? Do you have any suggestions on 

how to strike the appropriate balance? 

3. Because of privacy laws, if a school employee identifies a child that may need to be referred 

for mental health treatment, they can do so but then are not privy to any of the information. I 

understand why this is the case, but in situations where it is discovered that the child may 

have violent tendencies, though they have yet to commit a violent act or directly threatened 

anyone, should school officials be alerted? Do current laws allow this information to be 

communicated to school officials (again, before a violent act has occurred or is imminent, if 

there is no direct threat, etc.)? If not, are there ways you think we could balance privacy 

concerns and getting school officials the appropriate information? 

a. Is there guidance published for school personnel that makes them aware of signs they 

should be looking for that may indicate a student could pose a threat in the future? 

The Honorable Gus M. Bilirakis 

1. In your testimony, you mentioned the National Child Traumatic Stress Initiative conducted a 

Psychological First Aid Train the Trainer course for the State of Texas in response to 

Hurricane Harvey. Participants were selected from HHS-contracted behavioral health 

providers, and priority given to regions most impacted by the storm. 

a. Given Florida's history with major storms, has SAMHSA rolled out a similar 

program in Florida? 

b. Is this program model able to be replicated in other states continually in the crosshairs 

for natural disasters like Florida? 

The Honorable Markwayne Mullin 

1. Your office recently announced that you are accepting applications to help tribes address the 

opioid crisis. How does your agency plan on allocating and fairly awarding these grants to 

ensure tribes have equal access to SAMHSA's resources? 

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a. How is your agency coordinating with IHS to award these grants? 

b. Do you believe that most tribes have the resources to apply for these grants? 

c. Do you believe most tribes have the data to show that they are in need of the grants? 

Even the smaller tribes? 

d. Do you believe that Congress should continue to appropriate opioid funds specifically 

to tribes? 

e. Do you believe that additional public grants available to tribes should be more 

streamlined and coordinated? 

The Honorable Frank Pallone, Jr. 

1. How should communities without a DATA-waived provider, Opioid Treatment Program, or 

other MAT provider respond to individuals in need of treatment for an opioid use disorder 

(OUD)? What efforts are underway at SAMHSA to expand access to MAT for the treatment 

of OUD in such communities? 

2. Could you provide an update on what actions SAMHSA has taken to promote the awareness 

and adoption of evidenced-based behavioral health programs and practices since SAMHSA 

terminated the National Registry of Evidence-based Programs and Practice 

(NREPP)contract? Specifically, could you provide an update on: 

a. the Evidence-Based Practice Resource Center established by SAMHSA; 

b. any proposed or published Toolkits or other resources to support the adoption of 

evidence-based programs and practices; 

c. process for identifying topics covered by such Toolkits or other resources, including 

whether there will be opportunities for stakeholders to submit topics for 

consideration; 

d. process for developing Toolkits or other resources; 

e. how uptake and success of Toolkits and other resources in supporting the adoption of 

evidence-based programs and practices will be measured and evaluated? 

f. will the NREPP website remain as a legacy website or does SAMHSA plan to remove 

it completely? 

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The Honorable Eliot L. Engel 

1. I have heard concerns about the ability of scientists to access national data resources they 

need to carry out opioid-related research- specifically, data from the National Survey on 

Drug Use and Health. Certain data from the survey, which researchers had access to in the 

past, have been unavailable for close to three years. The inability to access this data makes it 

more difficult for researchers to conduct epidemiological studies on opioid use. In the midst 

of this ongoing opioid crisis, I think we need to do everything possible to ensure that 

scientific experts have all the tools they need to fight this battle. Can you provide any clarity 

as to when these vital data from the National Survey on Drug Use and Health will once again 

be available to researchers? Will the data will be readily accessible to researchers at minimal 

or no cost? Will the data be made available via remote access? 

2. I have heard concerns from local governments regarding the need to get Cures funding out to 

communities faster. Can you speak to how SAMHSA is working to ensure funding reaches 

communities as quickly as possible? 

The Honorable Doris 0. Matsui 

1. Co-Occurring Mental health and substance use disorder 

This Committee passed a package of bills intended to address the opioid epidemic. 

Throughout the process, I have pushed my colleagues to take a broad view of the epidemic. 

We need treatment for those addicted to opioids now, but we also need to truly bolster our 

behavioral health system to ensure that we address the root causes of mental illness and 

addiction. Today, we have an opioid crisis, but tomorrow the drug of choice will change (and 

in fact, in some communities today, opioids are not the most prevalent challenge). If we don't 

treat underlying mental illness and work to prevent addiction, we will be doing our 

communities a disservice. 

a. Dr. MCCANCE-KATZ, what is the relationship between underlying mental illnesses, 

such as depression, and substance use disorder, including opioid use disorder? 

b. Is effective treatment of underlying mental illness, such as depression, important to 

help prevent or combat substance use disorder, including opioid use disorder? 

c. What work is SAMHSA doing on the relationship between underlying mental illness 

and substance use disorder? Is SAMHSA working to promote screening and 

treatment strategies that take the link between the two into account? Has SAMHSA 

examined or worked to address the effect of limited access to mental health treatment 

on substance use disorder? 

d. Does SAMHSA plan to encourage states to use STR funding to expand access to 

programs, treatments, education, or awareness efforts to address patients with 

untreated mental health disorders? 

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e. It's always important for us to recognize that there is more work to be done. Do you 

have suggestions for the Committee about how we can better support efforts to 

increase access to both mental health and substance use disorder treatment and 

prevention? 

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