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THE FINANCIAL AND SOCIETAL COSTS OF 

MEDICATING AMERICA’S FOSTER CHILDREN 

HEARING 

BEFORE THE

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT 

INFORMATION, FEDERAL SERVICES, AND 

INTERNATIONAL SECURITY SUBCOMMITTEE 

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

DECEMBER 1, 2011 

Available via the World Wide Web: http://www.fdsys.gov 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 

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(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

JOSEPH I. LIEBERMAN, Connecticut, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

MARK BEGICH, Alaska 

SUSAN M. COLLINS, Maine 

TOM COBURN, Oklahoma 

SCOTT P. BROWN, Massachusetts 

JOHN MCCAIN, Arizona 

RON JOHNSON, Wisconsin 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JERRY MORAN, Kansas 

MICHAEL L. ALEXANDER, Staff Director 

NICHOLAS A. ROSSI, Minority Staff Director 

TRINA DRIESSNACK TYRER, Chief Clerk 

JOYCE WARD, Publications Clerk and GPO Detailee 

SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT 

INFORMATION, FEDERAL SERVICES, AND INTERNATIONAL SECURITY 

THOMAS R. CARPER, Delaware, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

MARK L. PRYOR, Arkansas 

CLAIRE MCCASKILL, Missouri 

MARK BEGICH, Alaska 

SCOTT P. BROWN, Massachusetts 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

RON JOHNSON, Wisconsin 

ROB PORTMAN, Ohio 

JOHN KILVINGTON, Staff Director 

WILLIAM WRIGHT, Minority Staff Director 

DEIRDRE G. ARMSTRONG, Chief Clerk 

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(III) 

C O N T E N T S 

Opening statements: Page 

Senator Carper ................................................................................................. 1 

Senator Brown .................................................................................................. 4 

Senator Collins ................................................................................................. 6 

Senator Coburn ................................................................................................. 8 

Prepared statements: 

Senator Carper ................................................................................................. 39 

Senator Brown .................................................................................................. 42 

Senator Grassley .............................................................................................. 44 

Senator Landrieu .............................................................................................. 46 

WITNESSES 

THURSDAY, DECEMBER 1, 2011 

Ke’onte Cook, McKinney, Texas; accompanied by his mother Carol Cook ......... 8 

Gregory D. Kutz, Director, Forensic Audits and Investigative Service, U.S. 

Government Accountability Office ...................................................................... 17 

Bryan Samuels, Commissioner, Administration on Children, Youth and Families, U.S. Department of Health and Human Services ..................................... 19 

Matt Salo, Executive Director, National Association of State Medicaid Directors ........................................................................................................................ 21

Dr. Jon McClellan, Seattle Children’s Hospital .................................................... 23 

ALPHABETICAL LIST OF WITNESSES

Cook, Ke’onte: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 48 

Kutz, Gregory D.: 

Testimony .......................................................................................................... 17 

Prepared statement .......................................................................................... 52 

McClellan, Jon, Ph.D.: 

Testimony .......................................................................................................... 23 

Prepared statement .......................................................................................... 119 

Salo, Matt: 

Testimony .......................................................................................................... 21 

Prepared statement .......................................................................................... 113 

Samuels, Bryan: 

Testimony .......................................................................................................... 19 

Prepared statement .......................................................................................... 94 

APPENDIX 

Questions and responses for the Record from: 

Mr. Kutz ............................................................................................................ 124 

Mr. Samuels ...................................................................................................... 131 

Mr. Salo ............................................................................................................. 146 

Mr. McClellan ................................................................................................... 151 

Additional statements for the Record from: 

National Alliance on Mental Illness ............................................................... 158 

James H. Scully, Jr., M.D. Medical Director and CEO on behalf of The 

American Psychiatric Association ................................................................ 163 

Shadi Houshyar, Vice President for Child Welfare Policy, First Focus ....... 166 

Kristin Kroeger Ptakowski .............................................................................. 176 

Bazelon Center for Mental Health Law .......................................................... 180 

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(1) 

THE FINANCIAL AND SOCIETAL COSTS OF 

MEDICATING AMERICA’S FOSTER CHILDREN 

THURSDAY, DECEMBER 1, 2011 

U.S. SENATE, SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, FEDERAL SERVICES, AND INTERNATIONAL SECURITY, OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:37 a.m., in 

Room SD–342, Dirksen Senate Office Building, Hon. Thomas R. 

Carper, Chairman of the Subcommittee, presiding. 

Present: Senators Carper, Brown, Collins and Coburn. 

OPENING STATEMENT OF SENATOR CARPER 

Senator CARPER. Good morning, everyone. Welcome to this hearing today. And I am delighted especially to welcome our lead-off 

witness, Ke’onte Cook and his mom and dad. 

Ke’onte, in a few minutes, each of us are going to make some 

statements, and then we will turn it over to you to say whatever 

you would like to say to us. 

Over the past few years, this Subcommittee has been focused almost exclusively on how our Federal Government can achieve better results for less money. Among other things, we have examined 

cost overruns in major weapons systems and overpayments for additional spare parts that we do not need. We have focused on how 

to manage our Federal property, on bloated information technology 

projects that waste millions of dollars and, most notably for today’s 

hearing, on how we can spend taxpayer dollars on prescription 

medications in our Nation’s public health care system. In fact, 

today marks the third in a series of hearings over the past several 

years examining this particular subject. 

Nearly 2 years ago, our Subcommittee asked the Government Accountability Office (GAO), to look into the potentially improper prescribing of mind-altering medications, also known as psychotropic 

drugs, for children in foster care whose health care is paid for 

through Medicaid and managed by the States. 

We learned through various media reports and medical articles 

that many foster children, may have been receiving these medications at alarming and potentially dangerous rates. If these reports 

were true, not only were taxpayer dollars being misspent on these 

medications, but more importantly, the health and well-being of 

these children was very likely in danger. 

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We wanted an independent government audit from the GAO. In 

asking them to look at this issue, we wanted to know if overprescribing, or improper prescribing, of these powerful mind-altering 

medications was occurring and if it was, how prevalent was that 

and what were the costs. The report we are releasing today confirms some of our worst fears. 

GAO’s findings reveal that foster children in the five States that 

were examined are receiving mind-altering medications at between 

2 and 41⁄2 times the rate of other children under Medicaid. In 2008, 

the five States combined spent over $59 million on mind-altering 

medications for foster children. Beyond these rates, the GAO found 

three alarming patterns in their data. 

First, thousands of children were prescribed mind-altering medications in excess of the maximum doses for the child’s age as recommended by the Food and Drug Administration (FDA) and by 

medical literature. Furthermore, for the medications for which 

there is no FDA recommended dosage for their age, the GAO found 

a number of children receiving dosages beyond those even recommended for adults. 

Second, more than 600 foster children in these five States were 

found to be receiving five or more mind-altering medications at the 

same time. According to medical experts, one of whom is with us 

today as a witness, there is no evidence supporting the use of five 

or more mind-altering medications in adults, much less for children. In fact, I am told that there is only limited evidence that supports the use of even two mind-altering medications being prescribed to a child at the same time. 

Finally, and perhaps most disturbingly, dozens of foster care children under the age of one year in these five States and over 3,500 

non-foster children in those States, were prescribed a mind-altering 

medication. According to medical experts, there are no established 

medical health uses for mind-altering medications in infants and 

providing them these drugs can result in serious health effects for 

them over both the near term and the long term. 

We look forward to hearing more about the GAO’s findings today. 

Greg Kutz from GAO has joined us to discuss them. He has appeared before this Subcommittee many times before, and we welcome him back today. 

Along with him is Dr. Jack McClellan from Seattle Children’s 

Hospital. He is one of the medical experts hired by GAO to review 

their report. Mr. Bryan Samuels is here from the Department of 

Health and Human Services (HHS) to give us the Federal Government’s perspectives, and while Matt Salo is here on behalf of the 

State Medicaid Directors. We welcome all of you. 

I am probably most interested, however, to hear from our first 

witness today, Mr. Ke’onte Cook, who joins us all the way from 

McKinney, Texas. Ke’onte, I would like to say you are the one who 

came the furthest for this hearing. Mr. Cook is here with his mom 

and dad. I was fortunate to spend some time with all of them here 

earlier this morning, and we look forward to hearing a little more 

about him and his experience in just a few minutes. I also hope 

that today’s hearing and what comes from it will end up helping 

kids like him from all across the country. So something very good 

may happen because of your appearance here today. 

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In anticipation of today’s hearing, the Department of Health and 

Human Services sent a letter last week to all 50 States regarding 

the proper use and monitoring of mind-altering medications for 

children in the foster care system. The letter promises that the Department will convene a meeting of all 50 States in the next few 

months to discuss this issue further. 

It is my hope the Department’s letter also serves as a signal to 

States that more detailed guidance is coming, guidance that reflects the best practices from States across the country with regard 

to the use of mind-altering medications to treat children. 

It is also my hope that this letter will lead to solutions, solutions 

that will help to improve the health and welfare of some of our Nation’s most vulnerable children, foster kids, while also saving taxpayers’ dollars at the same time. 

I believe there is plenty of blame to go around in this report. Unfortunately, it appears that the Federal Government, State and 

local governments, doctors, nurses and perhaps others have not 

kept up with the increased frequency with which mind-altering 

medications have been prescribed over the past decade for children. 

There also appears to be a lack of cooperation between the 

Health and Human Services Department and the State Medicaid 

programs throughout the country concerning this issue. States 

have worked out piecemeal solutions based on their own experiences, and frankly, in at least some cases, those solutions were not 

arrived at until after young lives were damaged or lost. 

As I mentioned and as we will hear in testimony today, the children discussed in GAO’s report are some of the most vulnerable 

members of our society. It is our responsibility to take up their 

cause. As a former governor, I know that the foster care system is 

complex. But that complexity is no excuse for not dealing with this 

issue head-on. We all have a responsibility to ensure that the Medicaid program works for all children that it serves, whether they 

are in foster care or not. 

I oftentimes describe the 50 States as laboratories of democracy. 

And what this report reveals is that some States are managing 

their program better than others. That should not come as a surprise. There are best practices in use in some States that really do 

work in helping foster children. Every State should be adopting 

those practices or tailoring them for adoption. In addition, the 

American Academy of Child and Adolescent Psychiatry (AACAP) 

has promulgated some very good guidelines which both the GAO 

and others site. And if they are not already doing so, most States 

should follow those guidelines. What we cannot do is wait for another tragedy to happen before we make the right decisions. We 

cannot stand idly by while children’s lives or health are potentially 

put into danger. 

Now to be clear, it is important to realize that these drugs we 

will be talking about this morning are often used in dire, or even 

tragic, situations. In most cases, they are prescribed as intended 

and used in an appropriate manner, to help children who have experienced significant trauma in their young lives. In these cases, 

there is no doubt about their value. 

What is in doubt are the patterns and practices identified in 

GAO’s testimony today. What is in doubt is the effectiveness and 

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necessity of having children take five or more mind-altering medications at the same time. What is in doubt is an infant being given 

anti-psychotic medication. In these cases, I do not see any gray 

areas. What I do see is more black and white—what is appropriate 

and humane, and what is not. 

We need to begin the process now of developing a consensus 

about what is appropriate and humane when it comes to prescribing mind-altering medications to children and end the bad 

practices that are putting children in danger. We need to act quickly before one more child’s life or health is placed in jeopardy or before one more taxpayer dollar is spent inappropriately. Senator 

Brown. 

OPENING STATEMENT OF SENATOR BROWN 

Senator BROWN. Mr. Chairman, that was a very good opening 

statement, and I want to commend you and your staff for identifying this issue. One thing I have enjoyed about being on this Subcommittee is the wide range of topics that we investigate and try 

to understand and try to do it better. So thank you for bringing 

this up. 

And a lot of what you said is, quite frankly, unacceptable—to 

think that infants are getting drugs one year or younger and that 

somebody is getting five or more mind-altering drugs at once. 

And foster children, often being removed from neglectful and 

abusive homes, are one of the country’s most vulnerable populations. When tragic and traumatic circumstances obviously define 

their early lives, it is no wonder the studies show the tendency for 

more mental health conditions than in other children. 

I was especially concerned in reading the results from Massachusetts, and it is something that I can assure you, Mr. Chairman, we 

will not be taking lightly. We are going to immediately try to figure 

out why Massachusetts in particular was much higher than other 

States that were reviewed. 

And as our witnesses will discuss today, there are few options 

facing folks. For example, the challenges surrounding foster care, 

State authorities, caseworkers, and parents, they do not have a lot 

of options on treatments. I understand that, but we know basically 

from the study that including prescribing heavy-duty psychotropic 

drugs such as antidepressants, and in some cases even 

antipsychotics, are sometimes given first rather than as the last option. 

And with the use of these medications, although they have been 

shown to effectively treat mental disorders, the side effects and 

risks that they pose oftentimes outweigh the benefits, specifically 

to children. I, quite frankly, note that I do not believe they are well 

understood. 

That is why we have asked GAO to look at this issue more closely, and their investigation has produced some alarming results. Not 

only are foster children being prescribed these drugs at a higher 

rate than the nonfoster kids in general, but also in ways that hold 

significantly higher risks, such as multiple medications at once, as 

you have noted, exceeding the Federal FDA recommendations. 

And in Massachusetts, nearly 40 percent of the foster children 

population analyzed in the report were prescribed at least one psyH605-41331-79W7 with DISTILLER

5 

chotropic drug at a rate almost four times that of nonfoster children in my home State. In over 900 cases in Massachusetts, foster 

children were being prescribed three or more drugs at once. And 

while the scope of the report does not address the appropriateness 

of these prescriptions in a case-by-case basis, it does reignite the 

debate over whether the rates of prescribing match the scientific 

evidence behind the medical conditions. 

So regrettably, the concerns raised in this report are not just limited to foster children. Though high risk prescribing practices for 

foster children were found at higher rates than nonfoster children 

in most cases, the significantly larger population of nonfoster children covered by Medicaid makes these statistics just as alarming. 

For instance, thousands of prescriptions, a total of 5,265 according 

to the report, were filled for infants under one year old. 

When I read that, Mr. Chairman, I said to myself, what? How 

can you do that? 

This is just the data from five States. So we just imagine what 

it is like nationwide. 

And considering that experts have found no mental health indications for the use of psychotropic drugs in infants, this is particularly shocking and disturbing. As our witnesses will testify today, 

providing these powerful drugs to infants could result in serious 

adverse effects that will potentially affect them for the rest of their 

lives. And the risks seem to me, and I believe every member of this 

Committee, simply too great. 

Medicaid, which is run by the States and administered by the 

Department of Health and Human Services, reimburses the costs 

of these drugs to foster children. And as of today, HHS has limited 

authority to adequately oversee State monitoring programs. Well, 

Mr. Chairman, maybe we need to change that, to be that check and 

balance that they need. As a result, States’ comprehensive oversight policies are a mishmash of programs of various effectiveness, 

as you also noted. 

Although HHS provides informational resources such as best 

practices to help inform State monitoring programs for children in 

State custody, each Sate is responsible for designing and implementing its own program. GAO has examined five States. And 

many of these programs, quite frankly, fall short, and comprehensive oversight is desperately needed. 

It is obvious that consistent and comprehensive guidelines in this 

area are needed to ensure and effectively treat and reduce harmful 

risks to children in the Medicaid program, and particularly with 

foster children. In addition, better oversight in this area can have 

a broad impact in reducing the fraud, waste and abuse that we 

have noted for the last year and identified in the Medicaid program 

in general. And every dollar we save there can be used in a more 

effective and cost conscious way. 

The Child and Family Services Improvement and Innovation Act 

that recently passed Congress was a good step, but it, quite frankly, does not go far enough. I encourage HHS to rapidly endorse 

guidelines and best practices and use its current authority to push 

State Medicaid and child welfare agencies to improve as quickly as 

possible. 

So once again, Mr. Chairman, thank you for holding this hearing. 

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6 

I look forward to hearing your testimony, young man. I know we 

spoke briefly. Thanks. 

Senator CARPER. Thank you, Senator Brown. 

Ke’onte, the way this works, I have the privilege of chairing this 

Subcommittee. I am a Senator from Delaware. Senator Brown the 

senior Republican Member of this Subcommittee, and he is from 

the State of Massachusetts. And sitting next to him is Senator 

Susan Collins from Maine, and she is the senior Republican Senator on the entire Homeland Security and Governmental Affairs 

Committee, and she is going to make a statement next. Susan. 

OPENING STATEMENT OF SENATOR COLLINS 

Senator COLLINS. Thank you very much, Mr. Chairman. Let me 

thank you for holding this hearing to examine the potential overuse 

of psychotropic drugs by children in foster care, who are covered by 

the Medicaid program. 

On any given day, more than a half a million children are in foster care in our country. Typically, these children have been placed 

in care because they have been abused or neglected by their parents. Children in foster care also tend to have more serious mental, 

emotional or behavioral disorders than other children. As a consequence, they are exceedingly vulnerable. 

I am very troubled by recent reports that the use of powerful 

psychotropic drugs to treat depression, anxiety and other mental 

health disorders is particularly high for children in foster care, especially in certain States like Texas. The statistics that the GAO 

found in analyzing Texas are truly astounding. In that State, foster 

children were 53 times more likely to be prescribed five or more 

psychiatric medications at the same time than nonfoster children. 

While some children with behavioral and mental disorders may 

benefit from taking these drugs, children in foster care appear to 

be at particular risk of being given too many of these drugs and 

often concurrently. They often experience frequent changes in their 

foster placements and, as a result, are much less likely to receive 

the careful medical and psychological oversight that would normally be exercised by a parent. 

State agencies also appear to do far too little to monitor the use 

of these medications. That is why I was pleased to join my colleagues on this Committee in requesting that the Government Accountability Office compare the rates of psychotropic prescriptions 

for foster and nonfoster children on Medicaid. We also asked the 

GAO to review State efforts to monitor the prescription of these 

powerful medications for children in foster care. 

According to the GAO, foster children in the five States examined 

were prescribed these powerful drugs at more than two to more 

than four times the rate that these drugs were prescribed to nonfoster children who were also participating in Medicaid. 

I am alarmed that the GAO found that in hundreds of cases five 

or more psychotropic drugs were prescribed at the same time. 

Moreover, in thousands of cases, the prescribed doses exceeded the 

maximum guidelines. 

Of greatest concern was the finding that my two colleagues have 

already alluded to, and that is that these powerful drugs were prescribed to thousands of infants who were less than one year old. 

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7 

Given the possibility for serious adverse side effects, I find it 

hard to imagine any scenario that would justify the prescription of 

five or more of these powerful drugs to a child, and I find it impossible to imagine that it would ever be appropriate to prescribe them 

for an infant. The scientific literature supports this skepticism. 

We have a moral responsibility to provide for the health and welfare of these children. We provide funding for their medical care, 

for the foster systems that support their welfare and for the schools 

that they attend. Our responsibility, however, does not end with 

just writing the check. That is what this hearing is all about. The 

GAO report suggests that we have a long way to go before we have 

fulfilled our responsibilities to these children and young people. 

Earlier this year, Congress did pass legislation to require States 

to establish protocols for the prescription of psychotropic drugs to 

children in foster care as a condition of eligibility for Federal child 

welfare funds. This new law, however, does not specify what these 

protocols should be. As a consequence, we found that there is tremendous variation from State to State, and none of the States examined by the GAO met the standards established by the American Association for Child and Adolescent Psychiatry. 

While my first concern is obviously for the welfare of these children and for short and long-term impact on their health, I am also 

concerned about the costs involved. Many of these drugs are very 

expensive. If they are being overprescribed and needlessly prescribed, it not only has an adverse impact on the health of these 

vulnerable children, but it also costs our Medicaid programs a lot 

of money. 

Clearly, more needs to be done to strengthen the oversight of the 

care provided to children in foster care. The GAO has recommended that the Department of Health and Human Services endorse best practices guidelines. 

And I think it is not a coincidence, Mr. Chairman, that the Department appears to now be acting in light of your calling this 

hearing. 

I look forward to hearing the additional recommendations and 

particularly the testimony of our first witness, and I thank you for 

allowing me to give an opening statement today. 

Senator CARPER. We are delighted that you are here. Thank you 

for your comments. 

Ke’onte, those of us who serve in the Senate today have our own 

families in many cases. We have careers that we have spent years 

of our lives on. Senator Brown and I spent some years in the military. He was in the Army. I was in the Navy. 

Senator Collins, in addition to serving as a U.S. Senator, she did 

a great job of telling other Senators what to do for a number of 

years, and how to do it well, and she is from Maine, as I said earlier. 

One of us, Senator Coburn, who is about to speak next, is from 

Oklahoma, and he is also a physician. Until just a few years ago, 

he still—even as a member of the House and as a member of the 

Senate—still delivered babies. He is what is called an obstetrician 

and gynecologist (OB–GYN) and he has done a lot of good work in 

his life, and he still does. Senator Coburn. 

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1The prepared statement of Mr. Cook appears in the appendix on page 48. 

OPENING STATEMENT OF SENATOR COBURN 

Senator COBURN. I am anxious to hear Ke’onte’s testimony. I will 

just make one point. Access to a government health care program 

is not access to real care, and we are seeing that in this hearing 

today. 

Senator CARPER. Let me now introduce our lead-off witness, and 

his name, as you have gathered by now, is Ke’onte Cook. Ke’onte 

is 12 years old and is a former foster care child. He has recently 

been adopted by Mr. and Mrs. Scott Cook. 

And Scott and Carol, we welcome you two today. 

Mrs. Cook is actually joining Ke’onte at the witness table, and 

I believe Mr. Cook is seated right over Ke’onte’s right shoulder. 

Ke’onte and his family live in McKinney, Texas, where he is now 

attending middle school. His many interests include volunteering, 

competing in cross country meets, playing the clarinet and spending time with his family. 

On behalf of all my colleagues and myself, Ke’onte, we want to 

thank you for being with us here today, and we want to thank your 

mom and your dad for joining us as well. Thank you for bringing 

them with you. All right. 

And with that, you are recognized to say whatever is on your 

mind. Please proceed. 

TESTIMONY OF KE’ONTE COOK,1 MCKINNEY, TEXAS, 

ACCOMPANIED BY CAROL COOK, MOTHER 

Mr. COOK. Thank you, Mr. Chairman. Chairman Carper, Ranking Member Brown and Members of the Subcommittee, thank you 

for allowing me to share part of my life with you today, and my 

experiences with medications during foster care. 

My name is Ke’onte Cook. I am 12 years old and in the 7th 

grade. This year, I participated in cross country with my middle 

school in which I ranked in the top 15 of my class, allowing me to 

go to regionals. I am currently first chair for clarinets in my band, 

and I have three small roles in my school play, Cinderella, that 

was showed this month on December 15th—also, the date for my 

second year anniversary in my adopted home. One of my favorite 

things to do is dance for fun, especially hip-hop and the robot. 

I was adopted 2 years ago in 2009, and I was in foster care from 

ages 6 to 101⁄2. Besides the medicines, foster care was all right to 

me except for my third foster home. The first two foster homes 

seemed more like they cared about me, but the third home always 

felt awkward, and I felt pressured by them when I chose my adoptive home. 

I was pretty ignorant about the medicines I was on at the time. 

I also did not know what type of drugs I was on during foster care 

or how many drugs I was on since I was put into foster care at age 

six. All I knew was that if I did not take them like I was told to 

I could not watch TV, play video games or play with my toys. 

About a year after I was adopted, I found out I was on 20 different drugs total and sometimes I took up to five drugs at one 

time. At one point, I was on Vyvanse 70 milligrams for attention 

deficit hyperactivity disorder (ADHD); Seroquel 200 milligrams as 

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a mood stabilizer; Guanfacine 2 milligrams for impulse control and 

ADHD; Buspar for depression; and Clonidine, 0.2 milligrams for insomnia. I have also been told that the amounts of some of the 

drugs I was given were more than most adults take. 

Some of the things I was diagnosed with were post-traumatic 

stress disorder, insomnia, ADHD, depression, but I was never told 

I was diagnosed with anything other than the ADHD. They seemed 

way too much for a regular kid, which I am, and I was very confused when my adoptive parents told me what I was on and why. 

I have been in the mental hospital three times during foster care, 

and every time I had to get on more meds or new meds to add to 

the ones I was already taking. Some of the meds were for bipolar 

and seizures, and I am not bipolar and never had a seizure. Sometimes the meds they gave me made me easy to get irritated, which 

I feel is not good for a kid to experience. The meds made my appetite go away, too, for a long time. I would barely eat anything. I 

remember having a bowl of spaghetti, and I ate about three bites, 

and then I was done. I had side effects no one told me about, no 

one told me I would have or talked with me about before taking 

a new med. I was so out of it when I had the side effects sometimes 

it seemed like it did not bother me at all. 

One time I went to visit my youngest sister in her adoptive 

home. Her mom told me that she did not want to give me my meds 

because it made me glazed and tired. My adoptive parents said 

that when I stayed for my trial weekend with them in October 

2009, my meds put me in a lights-out mode 15 minutes after I had 

taken them. Some of the meds I took made me have stomachaches. 

I would get so tired all of a sudden. It felt like I would collapse 

wherever I was in the house. My foster parents would tell me 

something, and I would not be able to process it like a normal person would. Sometimes I would even try turning my head away and 

then closing my mouth to refuse taking the meds, but I had to take 

them eventually. 

I think putting me on all these stupid meds was the most idiotic 

thing I have ever experienced in foster care and was the worst 

thing someone could do to foster kids. I was upset about my situation, not bipolar or ADHD, and I think therapy is a better choice 

over meds if meds are not a necessity in that moment. And I 

should know because I went to therapy with my adoptive parents 

for 11⁄2 years with Dr. Jason Mischalanie, an attachment therapist 

who helped me understand why I acted the way I did and to figure 

out how to react in a better way to the things that upset me rather 

than the way I was doing them. Now I am not only more focused 

in school, succeeding above other classmates in reading, band, athletics, not going to the office anymore for bad behaviors, and I am 

happy. 

Chairman Carper, Ranking Member Brown and Members of the 

Subcommittee, thank you for inviting me to Washington, D.C. to 

tell my story. 

Senator CARPER. Ke’onte [Applause.] 

We have a lot of witnesses that come before this Subcommittee. 

I do not ever remember having one as young as you. And it is rare 

that we have one as eloquent as you have been this morning. 

Thank you for just an amazing statement. 

H605-41331-79W7 with DISTILLER

10 

Mr. COOK. Thank you too, Mr. Chairman. 

Senator CARPER. How long have you been in Washington, D.C.— 

you and your mom and dad? 

Mr. COOK. A day and a half. 

Senator CARPER. Have you done anything that was fun? 

Mr. COOK. At the Lincoln Memorial, there is something that 

looked like a slide, and I slid down it and ran into the sign that 

says do not touch. [Laughter.] 

Senator CARPER. It turns out I got up early this morning. I usually go home to Delaware at night, but I got up early this morning. 

Senator Brown and I like to run and work out, and I ran down to 

the Lincoln Memorial today. It is my favorite run. It is 5 miles 

down there and back. 

And so you are right. I saw a sign that looked like somebody 

knocked it over. [Laughter.] 

I wonder who might have done that, Scott. 

Well, we are glad you are here— 

Mr. COOK. Thank you. 

Senator CARPER [continuing]. And hope you have had a little bit 

of fun as well. And thank you for preparing and for joining us here 

today. 

You mentioned in your testimony that you had lived in three foster homes before finding the Cooks, or before they found you, and 

you became their adopted son and they became your adoptive parents. And I think I understood you to say that your experience in 

the first two foster homes was generally pretty good and not so 

good in the third one. 

Do you recall whether it was in the first home, the second home 

or the third home when you first began taking these drugs? Do you 

have any recollection of that? 

Mr. COOK. It was the first home. 

Senator CARPER. And were you taking a lot of them or some of 

them? 

Mr. COOK. I was taking about three a day. 

Senator CARPER. Do you recall why the doctors or someone 

thought you should be taking those? 

What was it about your behavior that people thought, well, he 

should be taking some kind of mind-altering drug? What was it? 

Mr. COOK. I would throw tantrums because I was upset and I 

could not let it out in the way that I needed to. So then they 

thought, well, let’s just put him on meds so he will basically be 

quiet. 

Senator CARPER. Ok. And it sounds like you kind of like zoned 

out. Is that what you said? You sort of zoned out? 

It is hard to do well in school when you are zoned out. It is hard 

to do well in the Senate when you are zoned out. [Laughter.] 

But somewhere along the line somebody figured out, and maybe 

it is when you came to live with your mom and dad, that this was 

not working and there was a better way to help you deal with 

whatever behavior problems you were having. Who helped figure 

that out? 

And what turned out to be more helpful than taking those medicines? 

Mr. COOK. Therapy with an attachment therapist. 

H605-41331-79W7 with DISTILLER

11 

Senator CARPER. Can you talk just a little bit about that for us, 

please? 

Mr. COOK. I would go every Saturday, and we would talk about 

how I was doing in school, and we would talk about deep conversations about my mom, and that would help me get over my anger 

about my mom. 

Senator CARPER. Right. But it worked? 

Mr. COOK. It did. 

Senator CARPER. Yes, it worked. 

I have a fellow that—Senator Coburn and I serve on the Finance 

Committee together, and we had a witness. A bunch of witnesses 

came to see us a couple months ago, and they were talking to us 

about how to reduce this big budget deficit we have. We are spending more as a government than we actually take in, in taxes. 

And one witness was talking to us about how do we get better 

health care results, and he said here is what we should do. He said 

we should find out what works and do more of that. That is all he 

said. Find out what works and do more of that. 

And in this case, we need to find out what works and do more 

of that. 

We have 50 States across this country. In some of those States, 

they are figuring out what works. We need to find out what works 

and, throughout the country, do more of that. 

I said when we had a chance to meet earlier today and talk; I 

said to Ke’onte, you have been—for a guy 12 years old, you had a 

pretty rough ride. It sounds like you have ended up in a really good 

place for yourself and for your mom and dad, but you had a rough 

ride. And a lot of foster kids do in life. 

But I think because of your presence here today a whole bunch 

of kids, thousands of kids across this country, kids that are foster 

kids and kids that are not, are going to have a chance for a better 

life, a more productive life, to be better students and to go on and 

be a real success. 

I just want to ask if I do not know if there might be one thing 

that you would like to pass or share with us, like advice. This is 

like a child advises the elders. So maybe one piece of advice you 

have for all of us here today, one thing that you think maybe we 

could take away from your testimony to help more children across 

the country—what would that one thing be? 

Mr. COOK. That meds are not going to help a child with their 

problems. It is just going to sedate them and make them tired, 

make them forget it for a while, and then it comes back and it happens again. 

What I learned in therapy is that when you are taking therapy 

you talk about the deepest thing, it hurts, then it comes back, but 

you can handle it better. 

Senator CARPER. Well, that is a mouthful. Thank you for those 

words of wisdom. 

And with that, let me turn to Senator Brown. Thank you. 

Senator BROWN. Thank you, Mr. Chairman. 

Mr. Chairman, I have seen you run, OK, and I know how fast 

he does a mile, and I think he can beat us both. All right? [Laughter.] 

Senator CARPER. He can run us into the ground. 

H605-41331-79W7 with DISTILLER

12 

Senator BROWN. And that loop is only 31⁄2 miles, not 5. [Laughter.] 

Senator CARPER. It is 5. Trust me. 

Senator BROWN. OK, I feel better then. 

Well, thank you. Everyone is in a good mood because this is obviously a nice young witness. 

And I am curious actually, Mrs. Cook and Mr. Cook. How did you 

identify, obviously, the overprescription? Was it the fact that he, in 

his own words, was zoning out? 

I mean, what led you to take that proactive step to get your child 

back? 

Ms. COOK. We have had about 31⁄2 years of experience in foster 

care and lots of training, including a little bit of training from 

Nancy Thomas. She actually came and helped teach kind of a 

course at our foster care community, for attachment therapy. 

And stemmed from that, we learned. We just got really educated 

fast about how foster kids, they do; they come with a lot of baggage. They are sad. Why would they not be sad? Their situation is 

not a happy one. 

And it is so easy to just find something to help them feel better 

for the moment, and that is not the right thing. And there are so 

many ways to help them through consistency and just not letting 

them down and being there for them. 

So really, it was right from the time when we had foster care. 

When we got him, we knew something was off. We knew that. The 

medications—that is terrible. He was just lights-out. That was it. 

You can just tell that there was more to the situation. 

But we only had him a weekend. So of course, we had to give 

him his meds correctly that weekend. But when we got him, we 

asked the physician at his new pediatrician. We said, what can we 

do to start getting him off these things? We need to start seeing 

how he really reacts. 

And he was very interesting for the first few months. He gave 

us some fun times, but that is it. It took a few months, and he was 

already a different child. 

Senator BROWN. Well, I could only imagine. Of course, it is going 

to be interesting. He was on some very serious medications, affecting a young man. So I want to commend you and your husband for 

taking that step. 

Is this your first adoption from foster care? 

Ms. COOK. Yes, this is our first actual adoption. 

Senator BROWN. So what made Ke’onte so special? 

Ms. COOK. Well, we were looking. 

Senator BROWN. Get out the earmuffs. [Laughter.] 

Ms. COOK. I have told him this so many times because I really 

want him to know that I really feel like God brought him to us because we were originally looking for a little girl, but we were not 

necessarily picky. We really prayed that God would bring us who 

he wanted us to have. And after not having our foster kids, it was 

really hard. So when we moved to Texas. 

Our caseworker, she was amazing. From a refuge house, an 

adoption agency in Dallas, she sent this video, this little book. She 

goes, I know you said you were looking for a little girl, but you 

H605-41331-79W7 with DISTILLER

13 

know, just something about this hit me, and I think you should 

look at it. 

And we did. And it was a Wednesday’s Child feature on him, and 

it was actually the second time that he was Wednesday’s Child. He 

had been on it 2 years prior. 

And there was a possible adoption from the first time he had 

been seen on it, but it fell through. It did not happen. 

And so, they let him come back 2 years later and do it again, and 

we saw that and his story. He just wanted a home. He wanted 

somewhere to belong. And you could tell from the first time to the 

second time he had a little less hope in his tone. 

And we had looked at some of the other Wednesday’s Child just 

because we were on that Web site at that time, and no one else 

hit us like Ke’onte did. 

And we just knew. After the situation of not having the girls that 

we had in Florida, we knew he needed someone and we needed 

someone to need us back. It was just perfect in the way that he 

was brought in so quickly, right before Christmas. It was amazing. 

Senator BROWN. Great. 

And Ke’onte, I see you are giving the thumbs-up there. That is 

great. 

When you were going through your transition and you were 

being medicated, what are your thoughts or memories about 

transitioning from being highly medicated to where you are now? 

Obviously, I am presuming it was filled with some real struggles 

and battles. So what gave you the strength to actually become the 

young man that you are now and be where you are here today, testifying before the U.S. Congress? 

Mr. COOK. It was basically that I had hope that it would soon 

be over and I would not have to go through the same struggles that 

we did during those few months ago. So that drove me to get 

through it, and that is why. 

Senator BROWN. Great. Well, thank you for testifying. Good luck 

to you and your family. God bless. 

And I look forward to hearing the rest of the testimony. Thank 

you, Mr. Chairman. 

Senator CARPER. Thank you, Senator Brown. Senator Collins. 

Senator COLLINS. Thank you very much, Mr. Chairman. 

Ke’onte, that must have been a wonderful Christmas present, 

when you went to live with the Cooks and when they became your 

parents. I bet that was one of your best Christmases ever. 

Mr. COOK. Hm. [Laughter.] 

Ms. COOK. You can say it. 

Mr. COOK. It was awkward. 

Senator COLLINS. It was hard? 

Mr. COOK. I kind of love my DS more, but you know. [Laughter.] 

But then I grew attached. So I cannot say anything now. 

Senator COLLINS. Well, they probably will get better and better. 

That, I am sure of. I bet when you look back you will consider it 

as being a great Christmas present. 

I am curious, when you were put on these medications, whether 

any of the doctors explained to you what the medications were for 

and how you might feel when you were taking them. Did they talk 

to you about that? 

H605-41331-79W7 with DISTILLER

14 

Mr. COOK. They did not say anything. 

Senator COLLINS. They did not say anything? They just said, 

here is your medications; take it? 

Mr. COOK. Basically. 

Senator COLLINS. Did your previous foster parents explain to you 

what the medications were for or how you might feel? 

Mr. COOK. Only one. And then they did not tell me how I would 

feel. They just told me what it was for, and it was for ADHD. 

Senator COLLINS. That had to be really scary, not to know what 

you were taking or why you were taking it. And I just cannot imagine the doctors piling on drug, after drug, after drug without explaining to you what it was for, how long you should take it, what 

the impact might be, how you would feel and what you should do 

if you did not feel well taking it. 

Did any of them ask you—did any of the doctors tell you to be 

sure to come back to see them or call them if the drugs made you 

feel zoned out? 

Mr. COOK. They did, but the foster parents did not go back like 

they were supposed to. 

Senator COLLINS. I see. 

Ms. Cook, what kind of differences after the very difficult transition period did you notice in Ke’onte’s behavior once he was off 

most of those medications? 

Ms. COOK. His behaviors were it was just a light and day difference. He went from break-dancing on the principal’s conference 

room desk in her office to not even going to the principal’s office 

for a whole month, in just a short period of time. When he started 

school, it was January to May. He was almost a different child altogether. 

He was happy. He was always smiling. I mean even to this day 

he smiles all the time. He is happy. You can tell. Even if I give him 

a consequence—he has to do chores for forgetting his homework— 

he is happy. I mean not to do the chores, but he is there with us, 

doing the chores, almost like you are not supposed to enjoy that. 

No, he is happy, and you can tell. And he does not have the tantrums. He is not upset for no reason. If he is upset, he is upset, 

and it is a real reason and not just for no reason. 

His tantrums—he would be on the floor and just be wailing, or 

he would tear things up in his room. It was like he did not know 

how to be a real kid. He had been kind of doped up for 4 years. 

It was almost like we had to show him what a kid his age is supposed to be like. 

Senator COLLINS. Thank you. 

Ke’onte, I just want to thank you so much for coming here today. 

I think it is very brave of you to tell your story, and it is going to 

help a lot of other children, and it is going to help us make sure 

there are better policies in place. 

So I thank you very much for coming forward 

And Ms. Cook and Mr. Cook, I think you are a great family. 

Thank you. 

Mr. COOK. Thank you. 

Senator CARPER. Amen. Dr. Coburn. 

Senator COBURN. Ke’onte, you have a great smile. 

Mr. COOK. Thank you. 

H605-41331-79W7 with DISTILLER

15 

Senator COBURN. It is infectious. Are you on any medicines now? 

Mr. COOK. No, not at all, just a couple of vitamins. 

Senator COBURN. Think about that. As a physician, I can tell you 

three of the medicines you were on are contraindicated for a child 

your age, and were not approved, never been studied. 

The other thing, looking at these medicines, is each one interacts 

with the other one. In other words, two out of the five work against 

three out of the five. 

So probably the most important question I would have for you is 

about this therapy that you had on Saturdays; did you ever experience anything like that while you were in foster care? 

Mr. COOK. Not exactly. We would go to a therapist. It would 

more be like a psychiatrist, and basically what we would do, we 

would talk about how the week was going. If we were good, we 

would get donuts or chips, and then we would just quit and then 

play. 

Senator COBURN. But nobody spent the time talking to you about 

the disappointment with your birth mom? Nobody allowed you an 

opportunity to express your feelings about some of your anger? 

Mr. COOK. Not at all. 

Senator COBURN. Yes. Has there ever been a time—and maybe 

Ms. Cook, you can answer this. Were you ever on Social Security 

disability? 

Was Ke’onte ever on Social Security disability as a consequence 

of being on these medicines? 

Ms. COOK. Not that I am aware of, no. 

Senator COBURN. OK. All right. 

What would be the message, Ke’onte, that you would have for 

other kids who are not yet adopted that are in foster care that are 

on medicines? What would your experience tell them? 

It is a tough question, I know. 

Mr. COOK. My experience would tell them that there is someone 

coming. You just have to wait for them and sit tight. 

Senator COBURN. That is a great answer. All right. Thank you, 

Mr. Chairman. 

Senator CARPER. Well, as we approach Christmas, that thought 

of someone is coming, all you have to do is hold on and sit tight, 

is probably in the minds of a lot of kids your age and across the 

country. 

Fortunately, for a lot of kids your age and younger across the 

country, they have never had to go through what you have gone 

through. They are lucky they were born on third base, if you will, 

and pointed to a home where they had loving, caring parents who 

took wonderful care of them and made sure that they had what 

they needed and, frankly, were not subjected to what they did not 

need and was not good for them. 

I, too, want to thank you very much for joining us today and for 

speaking with the wisdom of someone well beyond your years. 

And I just want to say to your mom and dad it is just a joy to 

be here with you, and I think Ke’onte is here representing all the 

good that can come from kids when they have the kind of home 

that you have provided for him. He has received the kind of treatment and care that really has helped him. So we thank you for 

being role models on your own. 

H605-41331-79W7 with DISTILLER

16 

And finally, I would say as I said at the beginning, Ke’onte, some 

real good is about to come out of what was not so good in your life 

and the lives of a lot of other kids. Some real good is going to come, 

and not just in Texas, and not just in Delaware or Massachusetts 

or Maine or Oklahoma but in all 50 States. So you can feel, I think, 

good and proud of that. 

And as we think about gifts that we are going to send to our 

friends and family this Christmas, I can think of few gifts of greater value than that. 

And with that having been said, Mr. Cook, you are excused from 

the witness table and you are free to take your mom and dad with 

you. I understand you have not had any breakfast yet maybe, or 

at least not enough, and so we are going to excuse you and you can 

head out and get some chow. 

And then I guess do you head on back to Texas today? 

Mr. COOK. No, New York. We go talk to Diane Sawyer. 

Senator CARPER. Diane Sawyer. Oh, how about that? All right. 

Well, give her our best. 

Mr. COOK. I will. 

Senator CARPER. All right. Good luck. God bless. Thanks so 

much. 

Well, we welcome our second panel, all accomplished witnesses, 

some of whom have been good enough to join us before. 

I will just say to Senator Collins and Senator Coburn, ole Ke’onte 

is going to be a tough act to follow, but I think this panel might 

be up to it. So I am going to take just a moment and introduce each 

of them and then ask them to go forward with their testimony. 

Thank you all for coming today. 

The first witness on our second panel, Mr. Greg Kutz, Director 

of GAO’s Forensic Audits and Special Investigations Unit, Mr. Kutz 

has spent over 20 years at GAO, working to uncover abuse of any 

number of things—government credit cards, Hurricane Katrina/ 

Hurricane Rita fraud, problems with U.S. border security among 

any other issues. He has testified before us on any number of 

times. We thank him for agreeing to join us, to be here again 

today. 

If we had to pay you on a per witness basis, our Nation’s debt 

would probably be a little higher. So thanks for coming and doing 

this. 

Our second witness is Mr. Bryan Samuels. He is the Commissioner of the Administration on Children, Youth and Families at 

the Department of Health and Human Services. 

Prior to his current position, Mr. Samuels served as the Chief of 

Staff for Chicago Public Schools, the third largest school system in 

the Nation. 

Who was the head of Chicago Public Schools when you were 

there? 

Mr. SAMUELS. I think it is a guy by the name of Arne Duncan. 

Senator CARPER. Would you say that again? 

Mr. SAMUELS. A guy by the name of Arne Duncan. 

Senator CARPER. What ever happened to him? 

Mr. SAMUELS. I think he moved to Washington. 

Senator CARPER. Yes, he did. He is doing a good job. 

H605-41331-79W7 with DISTILLER

17 

1The prepared statement of Mr. Kutz appears in the appendix on page 52. 

Before that, Mr. Samuels served as the Director of the Illinois 

Department of Children and Family Services where he worked 

daily with the Illinois foster care system. 

Our next witness is Matt Salo, good to see you—Executive Director of the National Association of Medicaid Directors which represents Medicaid directors across our country. 

And prior to being named executive director, Mr. Salo worked on 

reform and issues at the National Governors Association, an organization I am very familiar with. Actually, it is an organization I 

loved being a part of for 8 years. 

And you served there as Health Policy Analyst for State Medicaid Directors. Thank you very much for that service too. 

Our final witness today is Dr. Jon McClellan. I understand that 

you go by Jack. A child psychiatrist at Seattle Children’s Hospital 

and a professor in the Department of Psychiatry at the University 

of Washington, his research focuses on the identification of genes 

vital to the study of psychiatric diseases and the diagnosis and 

treatment of severe mental health disorders in youth. 

Dr. McClellan is a member of the American Academy of Child 

and Adolescent Psychiatry and spent many years on the committee 

there that develops treatment guidelines for patients. 

And again we thank you. 

We thank all of our witnesses for being here. Your entire testimonies will be made part of the record. And if you can summarize 

your testimonies, or give your testimonies, within 5 minutes or so, 

that would be fine. If you go way beyond that, I will have to ask 

you to sum it up and we will turn it over to the next witness. 

Mr. Kutz, you are lead-off witness. Welcome. Please proceed. 

TESTIMONY OF GREGORY D. KUTZ,1 DIRECTOR, FORENSIC AUDITS AND INVESTIGATIVE SERVICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Mr. KUTZ. Mr. Chairman and Senator Coburn, thank you for the 

opportunity to discuss the use of psychotropic drugs for foster and 

other children paid for by Medicaid. 

My testimony has two parts. First, I will discuss our analysis of 

psychotropic prescriptions for these children, and second, I will discuss state programs to oversee the use of these drugs to treat foster 

children. 

First, as you have mentioned, foster children in the five States 

that we analyzed were prescribed psychotropic drugs at rates that 

were 2.7 to 4.5 times higher than nonfoster children in Medicaid 

in 2008. 

Federal and State officials, academic studies and the child psychiatry experts that we contracted with pointed to several factors 

to help explain these differences. For example, greater exposure of 

foster children to neglect and physical abuse often leads to mental 

health conditions that need treatment. Other factors include frequent foster placements and varying state oversight programs, 

which I am going to discuss in a moment. 

These higher rates do not necessarily indicate inappropriate activity. However, we did identify a number of high risk indicators 

H605-41331-79W7 with DISTILLER

18 

in both groups but more prevalent, as you have mentioned, for foster children. 

For example, over 1,700 children were prescribed 5 or more psychotropic drugs at the same time. Our experts said that no clinical 

evidence supports this practice, which can increase the risk of adverse reactions and long-term side effects such as diabetes. 

Over 20,000 children had doses above those set by the FDA, 

which also can increase the risk of side effects without providing 

additional benefit. 

And over 3,500 infants were prescribed antihistamine drugs, and 

a small number were prescribed other psychotropic drugs. Whether 

used for mental or nonmental health conditions, our experts expressed significant concern over adverse reactions for these babies. 

We will investigate a number of high risk cases and report the 

results back to you next year. 

Moving on to my second point, we found that State programs to 

oversee the use of these drugs for foster children can be improved. 

We reviewed programs in these six States that you mentioned 

against guidelines from the American Academy of Child and Adolescent Psychiatry. 

States have no requirements to follow any specific guidelines although the recent legislation mentioned requires protocols in this 

area. All six States have programs that cover some or many of 

these guidelines, but none address them all. 

For example, AACAP says that States should identify caregivers 

who can give consent for drug treatment, which all States do. However, three States do not require caregivers to seek input from the 

child who is actually taking the drugs, which we heard from the 

first witness. 

Five States have fully or partially established guidelines for the 

use of psychotropic drugs. However, none have fully implemented 

guidance and programs to monitor the rates of adverse reactions. 

And AACAP recommends consultation programs that involve 

child psychiatrists meeting with consentgivers, physicians and children. 

One State covers all of these guidelines, at least partially, while 

another States covers none. The remaining States fall in the middle. 

In conclusion, psychotropic drugs can be an important tool to 

treat mental health conditions. However, evidence supporting the 

effectiveness and safety of these drugs for children is limited. We 

recommend that HHS endorse guidance to the States for monitoring the use of these drugs for foster children. More consistent 

and comprehensive guidance should better protect these vulnerable 

children. 

Mr. Chairman, that ends my statement, and I look forward to 

your questions. 

Senator CARPER. Thanks very much. Excellent statement. 

Mr. Samuels, please proceed. Welcome. 

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19 

1The prepared statement of Mr. Samuels appears in the appendix on page 94. 

TESTIMONY OF BRYAN SAMUELS,1 COMMISSIONER, ADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Mr. SAMUELS. Welcome. Chairman Carper and Senator Coburn. 

I want to express appreciation for the invitation to be here and to 

talk to you today. 

This is obviously a serious issue. HHS clearly shares the concerns that this Committee has, and we really do look forward to 

working with Congress to address the issues and reform a system 

that cares for the most vulnerable children in our society. 

I have to say to you, however, that the issue of psychotropic 

drugs in foster care is not a new issue. It is not a new problem. 

I was the Child Welfare Director in the State of Illinois between 

2003 and 2007. During my tenure, on a regular basis, foster parents, adoptive parents, biological family members approached me to 

express their concerns about the impact of psychotropic medications on the well-being of their children. I can also describe for you 

examples of visiting residential treatment programs where well 

over 50 percent of these young people were being prescribed 

psychotropics, and I can provide you one example in which 100 percent of children in a residential treatment program were on a psychotropic drug. So again, unfortunately, this is not a new problem. 

I can tell you that when I was the director what I did was to put 

in place a comprehensive oversight process. We had strict processes 

related to informed consent. We trained all of our caseworkers and 

social workers on all of the necessary procedures. We established 

an independent review of all prescriptions made for children who 

were in foster care, and we established an electronic database that 

captured every child in the State that was on a psychotropic. That 

electronic database allowed us to also review patterns of prescription and to look at particular prescribers to identify whether they 

were engaged in practices that we believed to be inappropriate. 

Now I would like to try to tell you, or convince you, that I took 

these steps because of my great child welfare expertise. I cannot 

tell you that. The first day on the job as Director of Child Welfare 

was the first day I had ever worked in child welfare. However, I 

can tell you that I spent the last 26 years of my life on high dosages of psychotropic medications. So I both appreciate the benefits 

that come from being on a psychotropic as well as the side effects. 

I also have the same challenge that has been mentioned earlier, 

which is I, too, worry about the long-term effects of psychotropics 

on my own health and well-being. So I do appreciate the challenge 

that we are talking about here, and I really do believe that there 

are things that States can do to correct their practices and to operate more effective programs. 

And I have to tell you part of our response to psychotropics also 

involved expanding the array of services that children had. We 

found that there were many children in the State of Illinois that 

were being misdiagnosed with a mental illness and being prescribed psychotropics that were intended for adults. In reality, 

much of the behavior that these prescriptions were being made for 

were behaviors that were better explained by the trauma that 

H605-41331-79W7 with DISTILLER

20 

comes from abuse and neglect and the trauma that comes from a 

child being removed from their homes. And so, instead of continuing to focus on an acute approach to intervening in the lives 

of these young people we put in place more therapeutic interventions that had the basis of evidence to demonstrate that they were 

both appropriate and safe for children in foster care. 

So again, unfortunately, this is not a new problem. 

If you go to the Internet, any Web site—try Google—and type in 

child welfare and psychotropics, you will see hundreds of articles 

that pop up. They go back to the mid-90s, and they articulate even 

in the mid-90s that there were more than 13 percent of children 

in foster care that were prescribed psychotropics. So it is an important point to be made. 

I provided you three slides. I will not go into them in great detail, but what I will tell you is that this data comes from the National Survey of Child and Adolescent Well-Being. It is a study that 

has been funded by Congress for the last 8 years. From this study, 

there have been articles published beginning in 2004 that document that more than 12 percent of all children in foster care were 

prescribed psychotropics. 

More recent data from this study demonstrate that about 16 percent of children between the ages of 11 and 17 known to child welfare are being prescribed psychotropics. More than—almost 20 percent of children who are between the ages of 6 and 11 known to 

child welfare are being prescribed psychotropics. And most importantly, almost 50 percent these of children who are being prescribed psychotropics are being prescribed more than two 

psychotropics. 

The other slide also intends to show you that this issue of prescriptions cuts across all placement types so that the children that 

are remaining in their home but being provided child welfare services (CWS) versus children that are being removed from their 

homes and placed with foster care parents, in both instances, the 

rate of psychotropic prescription is almost identical. So this issue 

cuts across all placements in child welfare. 

So I am going to summarize by just making five quick points 

about the steps that HHS is prepared to take to address this issue. 

First, we do support the recommendation of the GAO, and we 

will take steps in the next 90 days to provide specific guidance to 

States about putting into place the appropriate protocols and procedures to oversee psychotropics. 

We also are committed to doing consumer education. We want to 

make sure that foster parents, adoptive parents and biological parents understand the drugs that their children are being prescribed, 

and we want the young people to understand the prescriptions that 

they are being prescribed. 

We also will put in place, and will work with States to put in 

place, the kind of oversight activities that actually make them better, that put them in the possession of real data so that they can 

make good decisions. 

We also are prepared to provide support so that States are much 

more effective at screening, diagnosing and treating issues related 

to trauma and exposure to violence. 

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21 

1The prepared statement of Mr. Salo appears in the appendix on page 113. 

And we already know—we know this from the Centers for Disease Control (CDC), we know it from the Substance Abuse and 

Mental Health Services Administration (SAMHSA) and we know it 

from the National Institute of Mental Health (NIMH) that there 

are evidence-based practices, therapeutic practices, psychosocial 

interventions that work for almost all of the issues that children 

in foster care have. 

We are prepared to take these steps. We welcome the opportunity to have further conversations with Congress about additional steps that we can take to meet the needs of children who are 

absolutely the most vulnerable young people in our society. 

So thank you, Chairman. 

Senator CARPER. Thank you for sharing that testimony and for 

giving us a glimpse into your own life and the relevance. I think 

it is especially appropriate that you are a witness here today. 

Thank you. 

Mr. Salo, please proceed. 

TESTIMONY OF MATT SALO,1 EXECUTIVE DIRECTOR, 

NATIONAL ASSOCIATION OF MEDICAID DIRECTORS 

Mr. SALO. Great. Thank you, Chairman Carper and Senator 

Coburn. We appreciate being invited to testify here today. I wish 

it were on a happier issue, but I do think that the silver lining is 

we are laying the groundwork for trying to do better, which clearly 

is what we need to do. 

Medicaid is the Nation’s health care safety net. It is jointly financed by the States and the Federal Government and will spend 

more than $400 billion this year providing health care to more 

than 60 million people. And it is administered by the States under 

broad Federal guidelines, which leads to enormous variation across 

the States. We have talked about that a little bit. But it is also a 

very complex program within any given State. 

But the one piece that obviously we are talking about here is the 

fact that Medicaid is essentially the sole funding source for health 

care for kids in the foster care system. 

Now pharmaceutical coverage and expenditures have been a 

large and growing concern of the Medicaid directors for a number 

of years. Psychotropics, in particular, pose a unique concern because the trends in the costs and utilization are far outstripping 

every other baseline. And analysis of the data shows us that this 

is due to a variety of reasons, some of which are legitimate, some 

of which, less so. 

And clearly, we have talked a little bit about overutilization and 

misutilization, and the challenge is we are seeing this everywhere. 

We are seeing this in adults. We are seeing this in seniors. We are 

seeing this in kids. And as clearly noted in the GAO report, it is 

particular true for, quite frankly, some of the most vulnerable kids 

in our country—kids who are in foster care. 

Psychotropics show an enormous amount of promise in treating 

very serious concerns. But obviously, there are clear concerns with 

how current prescribing patterns can negatively impact this very 

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22 

vulnerable population. And the report pointed out several potential 

problems, and they must be taken very seriously. 

And I want to be very clear that there is no question that subjecting the most vulnerable people in our society to bad medicine 

is unacceptable and that we can and should and will do better by 

them. 

But I also want to sort of lay out that this is not just a Medicaid 

challenge, that this is, quite frankly, a result of a number of serious flaws in the broader U.S. health care system: 

The prescribing patterns in this country today, from physicians 

and others; 

The serious shortfalls in clinical research to tell us how are we 

supposed to treat kids as opposed to adults let alone children in the 

foster care system. 

Quite frankly, as talked about, a lack of effective oversight from 

a variety of levels of government, and on behalf of the State agencies, we accept that and we take that on and we will try to do better; 

But also includes the lack of widespread health information technology which can try to really put a hold on questionable prescribing patterns. 

And then at the end of the day, the fragmented nature of the relationship between acute care and behavioral health care in this 

country. 

And so, the solutions that we need to embrace are going to have 

to involve all of these pieces—a variety of levels of government, 

mental health professionals, primary care practitioners, researchers and others. 

I want to highlight a couple of sort of unique challenges and then 

talk about a couple of quick solutions. 

One of the things that States face in trying to do proper oversight of this is resistance in the community. It is no surprise that 

trying to do things like prior authorization, a common-sense tool 

for very serious medications like this, is sometimes completely prohibited at the State level. This is due to influence of the manufacturers. This is due to the influence of advocates. This is due to the 

influence of the general public who do not like to see government 

get in between a patient-physician relationship. These are all legitimate issues, but they do lead to challenges in trying to lay out 

some oversight here. 

And as has been mentioned, the unique situations that these 

kids face in the foster care system and the reasons why they are 

in the foster care system to begin with really is a result of a variety 

of traumas which are under-diagnosed and really do require specialized treatment approaches. 

So in light of time, I would just sort of lay out a couple of different solutions. 

The GAO recommended additional Federal guidance. We absolutely welcome that and are going to work with all of the different 

parts of HHS, whether it is the Medicaid side, the Administration 

for Children and Families (ACF) side, SAMHSA, to try to work 

with that. We embrace that. 

But we clearly need more clinical research on how these drugs 

affect kids. We need to do more to break down the barriers to tryH605-41331-79W7 with DISTILLER

23 

1The prepared statement of Mr. McClellan appears in the appendix on page 119. 

ing to do coordinated care for the most fragile and vulnerable people in this country, whether it is the dual eligibles, whether it is 

adults with chronic conditions or whether it is kids in the foster 

care system. And whatever Medicaid can do and should do, we also 

need to make sure that the medical community and their representative associations are also at the table. And then finally, I 

pledge that through our association we will work to try to not only 

develop—identify, develop, disseminate best practices in this area 

across the country. 

So I look forward to answering your questions, and thank you for 

having me. 

Senator CARPER. Thank you, Mr. Salo. 

Dr. McClellan, I am going to slip out just for a minute to say 

goodbye to Ke’onte and his family. You go right ahead. I will be 

back within less than minute. OK. Thank you. 

TESTIMONY OF DR. JON MCCLELLAN,1 CHILD PSYCHIATRIST, 

SEATTLE CHILDREN’S HOSPITAL 

Dr. MCCLELLAN. Thank you, Mr. Chairman and Senator Coburn. 

Thank you for inviting me today to participate in this important 

discussion regarding the use of psychotropic medications in foster 

children. 

As noted, I am a child psychiatrist at Seattle Children’s Hospital, 

a professor at the University of Washington. I am also the Medical 

Director of Child Study and Treatment Center which is the State 

psychiatric hospital for youth in Washington State. 

The high risk practices identified by the GAO study raise significant concerns regarding the treatment of severely mentally ill and 

vulnerable youth. Although the focus of the study is on foster care, 

the concerns raised are relevant to all children and adolescents 

prescribed psychotropic drugs. 

Children in foster care often have emotional and behavioral difficulties. The high rate of medication used in this population is not 

a new discovery nor does the use of these drugs always imply bad 

practice. Several psychiatric medications have been studied and approved for use in children and adolescents. When used correctly, 

these treatments can help reduce suffering and enhance the functioning of young people. 

However, it is also well documented that many children in the 

child welfare system do not receive high quality psychiatric services. Treatment too often occurs during times of crisis without adequate support or access to skilled clinicians and programs capable 

of providing effective social and behavioral interventions. In these 

situations, the medications become stop-gaps used to prevent the 

child from hurting themselves or others, or to help control disruptive behavior that threatens the child’s foster placement. The lack 

of effective long-term treatment exacerbates the risk for excessive 

an inappropriate medication use. 

This problem is evident in the problems of high risk prescriptions 

identified by the GAO study. As a group, children in foster care 

were more likely than other children to be treated with multiple 

psychiatric drugs and were also more likely to be treated with dosH605-41331-79W7 with DISTILLER

24 

ages that exceed recommended standards of care. These practices 

impacted thousands of children. Some young people were prescribed as many as 10 different psychotropic drugs at the same 

time per the data. Some children younger than 5 years of age were 

prescribed as many as five different medications concurrently. 

Unfortunately, these practices are not uncommon. In my State 

hospital, kids are often admitted taking four or more medications. 

A few years ago, one young boy admitted to Seattle Children’s Hospital was taking 13 different psychotropic drugs. There is no research that justifies these practices. 

The most troubling finding of the GAO study is the use of psychotropic drugs in infants. Most of the prescriptions in babies were 

for antihistamines, some of which may have been used to treat 

other types of medical problems. Regardless, there is little research 

supporting the use of these medicines in very young children and 

the prescriptions remain concerning. 

Furthermore, dozens of babies were prescribed antipsychotics, 

antidepressants, Clonidine or Lithium. Some infants were prescribed more than one drug. The use of psychotropic medications 

in babies defies both standard of care and common sense. 

The findings of the GAO study strongly suggest the need for better oversight. The best principles outlined by the American Academy of Child and Adolescent Psychiatry provide a useful set of 

monitoring guidelines. 

Washington State had implemented a model system to oversee 

psychotropic drugs. Criteria were developed to identify prescriptions that exceed safety thresholds based on dose, number of medications and age of the child. For prescriptions flagged by this process, a second opinion by a child psychiatrist is required before the 

medication is dispensed. This oversight system has reduced high 

risk prescriptions and over a two-year period saved the State $1.2 

million. 

The results of the GAO study also strongly call for more research. A hodge-podge of prescribing practices occurs in part because none of our current treatments work well enough. Genetics 

and neurobiological sciences have advanced substantially over the 

last decade, in large part due to the leadership of the National Institute of Mental Health. Nonetheless, given the marked complexity of brain functioning, the underlying causes of most psychiatric illnesses remain unknown. Without known causes, research on intervention inevitably struggles. We need continued investment, both fiscal and intellectual, in order to develop safer and 

more effective treatments and to eventually find cures. 

Thank you for listening and look forward to questions. 

Senator CARPER. Dr. McClellan, thank you. Senator Coburn. 

Senator COBURN. Thank you. 

I am going to have to leave, and I am going to submit some questions to the record for each of you. 

Dr. McClellan, thank you for being here. Your expertise is important in what we are talking about here, for a lot of our foster kids 

do not have true organic disease outside of the trauma they have 

experienced. Not many of them are schizophrenic. Not many of 

them have true bipolar disease. But what they have is situational 

disease based on what has happened. 

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25 

In your opinion, is it a shortfall in what we have set up through 

Medicaid that we do not have the type of psychotherapy versus 

drug therapy to work on some of these problems, and what would 

be your recommendation if we had the resources available? 

What would you do to change this to where we actually put the 

resources not just in the research but in the actual treatment? Because what we heard from Ke’onte is he is not on a drug now and 

yet he had all these diagnoses which probably psychotherapy has 

helped cure. Plus, the situation has helped. 

Can you help me with understanding this? 

Dr. MCCLELLAN. No, it is an excellent point. The system of care 

is not adequate built around—it is not just kids in foster care or 

the welfare system. The entire system of psychiatric services for 

kids is not well organized, they are not organized enough. 

There are a number of evidence-based care, evidence-based psychosocial treatments that have been shown to work in kids. It is 

hard to access them. It is hard to find providers that can do them. 

There is a long waiting list, and many communities have no one 

in the area that can provide it. 

Senator COBURN. So we have a shortage, first of all, of child psychiatrists? 

Dr. MCCLELLAN. Child psychiatrists. 

Senator COBURN. And child therapists? 

Dr. MCCLELLAN. Well, child therapists capable of providing these 

kinds of psychosocial interventions. 

Senator COBURN. Right. 

Dr. MCCLELLAN. And so, accessing them, finding skilled providers and then finding consistent providers over time with a wraparound team that stays with the kid over time is really what is 

needed. It takes an investment in the front end, but you will not 

only have better outcomes, but you will keep kids off the medicines 

that they do not need. 

Senator COBURN. Yes, and you will have continuity of care which 

is probably one of the most important things. 

Dr. MCCLELLAN. Yes. 

Senator COBURN. The Cook family actually got continuity of care 

to Ke’onte in terms of his therapy. It was consistent. I guarantee 

you they had him there. They had the same therapist working with 

him all the time. They built a relationship and trust which allowed 

the therapy to actually work. 

There is no evidence that psychotropic drugs, not antihistamines 

but true psychotropic, are effective or indicated in infants, correct? 

Dr. MCCLELLAN. There are absolutely, that I know of, no studies 

at all that have ever—it would not make any sense to study it. 

Senator COBURN. So that is one thing that can be fixed tomorrow. That can be a ruling coming out of HHS—this will not happen, and we will not pay for it. So that is something that could be 

fixed tomorrow. 

I will have a couple of other questions for you. 

Again, you all do not know how valuable Dr. McClellan is and 

how few of him there are. 

Dr. MCCLELLAN. You should tell my children that. 

Senator COBURN. I will. 

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In my practice, finding a child psychiatrist when it is really needed is so difficult to get. And it is not just in a foster home. It is 

in an insurance-paying patient, to find that. So one of the things 

we have to do is create the funds so there are more Dr. Jack 

McClellans. We have to do that because we have a need. 

The second point I will make before I run—most of the time, are 

symptoms of a greater problem, which is the family destruction in 

our country. And we are treating symptoms rather than some of 

the underlying problems. So we have to bear that in mind. Although we address treating the symptoms, we also need to go back 

and see what we can do in terms of firming that up. That is our 

biggest cultural problem, which we are paying a tremendous 

amount to do. 

Dr. MCCLELLAN. It is true that the best intervention Ke’onte got 

is from his new parents. 

Senator COBURN. Yes. Mr. Samuels, thank you for your testimony. HHS—the law states HHS says the States have to have a 

plan. 

Mr. SAMUELS. It does. 

Senator COBURN. But there is no regulation at HHS that says 

you all have to oversight that plan and look at it and do the oversight. Is that correct? 

Mr. SAMUELS. What we are required to do, again by statute, is 

to make sure that a State has a plan. 

Senator COBURN. Yes. 

Mr. SAMUELS. We do not have authority to intervene or to determine whether a plan is consistent or inconsistent with best practice. 

Senator COBURN. OK. But that does not mean you cannot create 

a regulation that says you are going to submit your plans, we are 

going to look at the plans and then do the oversight to compare 

what their performance is against their plan. 

Mr. SAMUELS. That is correct. And in our response to the GAO 

report we indicated that we would put out an HHS-endorsed protocol and we would do that in the first 90 days. But the larger consideration is whether you start a regulatory process today that 

would lead to a single standard for which all States would have to 

meet. 

And the reality is—and again, it is the right thing to be talking 

about, but the reality is the Federal regulatory process would require about a year and a half’s period of time in order to have that 

single confirmed standard that we could apply to all. And so, we 

are going to start with the guidance but move in as specific a direction as we can as it relates to holding States accountable. 

Senator COBURN. OK. 

And Mr. Kutz, thanks for the study. You guys do great work. 

Mr. KUTZ. Thank you. 

Senator COBURN. I am for you. I think you all know that. 

Mr. KUTZ. We are aware of that. 

Senator COBURN. I have lost my thought. I am having a Rick 

Perry moment. [Laughter.] 

I think what I would like to know is in terms of where we have 

all these medicines used and the costs associated with the medicines and how that impacts, not just in terms of child psychiatry, 

H605-41331-79W7 with DISTILLER

27 

is there—I guess the point is did you look at who were writing the 

prescriptions because my guess is the people with the qualifications 

to write a prescription were not necessarily the people with the 

qualifications to actually give the prescription and make the judgments. Somebody untrained in child psychiatry, like me, might 

have been writing the prescription because that is who was available. So the expertise in terms of making that judgment did not follow. 

Did you look at who was writing the prescriptions? 

Mr. KUTZ. No, but as I mentioned in my opening statement we 

are planning to delve into some of the high risk cases and we will 

look at that as part of that, along with the diagnoses and whether 

the State controls worked, et cetera. So any input you have into 

that—— 

Senator COBURN. I think what you are going to find is people like 

Dr. Jack McClellan were not the ones writing the vast majority of 

these prescriptions. It was people not trained in child psychiatry, 

not clinically, did not have the clinical expertise to be doing what 

they were doing. And what they were doing was treating a symptom rather than a disease. What can I do to solve this problem for 

this foster parent. 

We have such a shortage of qualified people to actually address 

these, and so, I would love to make sure that you do that so we 

end up getting to see—— 

Mr. KUTZ. Yes, any input you have—— 

Senator COBURN [continuing]. What the source was. 

Mr. KUTZ. OK. Any input you have into that with your expertise, 

we would be happy to meet with you to go over that, but that 

would be something we can build into our plan at this point, yes. 

Senator COBURN. OK. 

Mr. SAMUELS. Senator Coburn, it is worth noting that through 

the National Survey of Child and Adolescent Well-Being (NSCAW), 

the study that I described earlier that Congress funds, we actually 

do track who is making the prescription, and so it could be an important database for GAO to consider in terms of trying to get their 

arms around that data specifically. 

Senator COBURN. Yes. I would just tell you my practice wasn’t 

limited to delivery of babies. I did a wide family practice. And I 

never once felt comfortable giving an adolescent any psychotropic 

drug. So I did not because I did not feel competent to do it, and 

so I always tried to get a referral to somebody that was more competent than me. 

And in our work day today, that is not happening. So we are not 

deferring to somebody of better training and more qualification as 

we treat. What we are doing is throwing a medicine at a symptom 

rather than treating the underlying problem. 

And I apologize for having to leave. Thank you, Mr. Chairman. 

Senator CARPER. Those were great questions and points. 

As Mr. Kutz knows, what we do here in this Subcommittee, week 

after week, month after month, is to try to drill down on how to 

get better results for less money. And today, we are especially focused on better health care results for less money. 

Dr. Coburn raised in his comments and questions the notion of 

whether or not any infant, any child under the age of one, should 

H605-41331-79W7 with DISTILLER

28 

be taking these psychotropic or mind-altering drugs and suggested 

that is something that is inappropriate, that it should not be allowed, that we can stop that fairly easily. 

Let me ask—and I will just start with Mr. Samuels if I could— 

is it that easy? 

Mr. SAMUELS. It is not that easy. In many respects, what we 

could do today is to provide States the guidance that they would 

need to make their own decisions. We do not currently have the authority to either prescribe a specific set of steps that they take nor 

do we have the authority to intervene on any particular patterns 

of psychotropic prescriptions that we might find in the data. And 

so, it would require an act of Congress if you wanted us to be able 

to immediately intervene and stop the practice of making prescriptions to infants. 

Senator CARPER. Let me just ask anyone on the panel. Mr. Salo, 

do you want to comment on that, please? 

Mr. SALO. Sure. I think Bryan is right. I mean one of the challenges is in the law itself. One of Medicaid’s challenges is we are 

required by law to cover essentially every drug that is approved by 

the FDA, with very few exceptions. 

We can do prior authorization, and I think that is a key best 

practice that we have talked about in certain circumstances. 

Senator CARPER. Talk about that. How would it work? 

Mr. SALO. So in an instance where you have a prescriber who is 

looking at prescribing a psychotropic for a child under one, which 

in most cases sounds horrible although I do know that there are 

some instances in which that turns out to be Benadryl, that might 

be— 

Senator CARPER. I am sorry. In some instances, that turns out 

to be what? 

Mr. SALO. Benadryl. 

Senator CARPER. Benadryl, OK. 

Mr. SALO. That might be more legitimate. So just sort of doing 

a blanket ‘‘you cannot do any of this’’ may not work. 

But under the current system, if a prescriber chooses to do something more, a stronger medicine for a young child, some States are 

putting in place things called—they have a variety of names, but 

prior authorization or red flags, in which the system sort of says: 

Wait a minute. You just dinged. You prescribed this perhaps inappropriate drug for this patient. 

And then, that sets off sort of a warning at which point a couple 

of different things can happen. Either the physician then has to 

say: No, I really know what I am doing. This is the right thing. 

And they push it through. 

Or, you have sort of a more kind of comprehensive peer review 

team where the State agency or other peers will sort of give feedback back to that prescriber to say: You just did X. Are you aware 

that maybe Y or Z might be more appropriate? 

So those kinds of things can work. I think those are key best 

practices. Probably easier to do those than just outright prohibitions under the current law, although, as I had mentioned earlier, 

you do run into challenges at the State level sometimes, trying to 

do those types of controls. Some State laws just outright prohibit 

you from doing that for a variety of reasons that I mentioned. 

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Senator CARPER. You say that some State laws actually prohibit— 

Mr. SALO. So some State laws actually prohibit prior authorization— 

Senator CARPER. Oh, really? 

Mr. SALO [continuing]. For example, for atypical antipsychotics 

because it is the view of the State legislature that this is for a variety of reasons, whether driven by the manufacturers of the drugs 

who do not want people saying you should put any barriers up or 

whether it is just sort of a community sense that you know what, 

we should not have government involved in this patient-physician 

relationship. 

So State legislative laws are not set in stone. They can be 

changed, but they require a different kind of tactic than some of 

the best practices we have been talking about here. 

Senator CARPER. All right. 

Dr. McClellan, any comments on this point? 

Dr. MCCLELLAN. I do not know anything about the State laws 

other than the State of Washington. We did set up a system where 

if you want to prescribe an antipsychotic to a child underneath the 

age of six it requires a second opinion. And there is a process in 

place where there is a group of child psychiatrists mostly through 

the university. And there is a form. There is a phone call. 

And sometimes they are approved, and sometimes they are not. 

But that process has definitely helped with high risk prescriptions, 

and it has reduced the use of antipsychotics in younger children. 

Senator CARPER. OK. Thanks. 

Does the introduction of electronic health records (EHRs) have 

the potential for being a valuable tool in ensuring that children at 

very early ages are not administered these drugs and particularly 

in ensuring that children at younger ages, whether they are foster 

kids or not, do not receive a toxic mixture of these drugs? 

My mom, who is now deceased, passed away about 3 or 4 years 

ago, and she had Alzheimer’s disease. She had heart disease, arthritis, all kinds of problems in a lot of years of her life. 

With my sister in Kentucky and me in Delaware and my mom 

in Florida, what we did over time is we increased the around-theclock care for her within her home. 

We kept her medicines in what looked like one of my dad’s old 

fishing tackle boxes. Some of you have probably seen these before. 

And it was divided into medicines before breakfast, at breakfast, 

between breakfast and lunch, at lunch and so forth throughout the 

day. We kept it under lock and key because she would forget what 

she had taken and what she had not. 

And she had about five different, maybe six, doctors down there. 

About every other month, my sister and I would take turns going 

down to be with her, go visit her doctors and all. It turned out none 

of the doctors ever talked to each other, and all the doctors were 

prescribing these different medicines and did not know what the 

other doctors were prescribing. 

My guess is if it happened with my mom it is probably still happening with a lot of these kids. And my sense is that we did not 

have electronic health records for my mom, but we ought to have 

them for a lot of patients today, including a lot of children. 

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30 

Would you all, whoever wants to, just talk about how this can 

help us in this particular concern, how to address this particular 

concern? 

Mr. SAMUELS. What I can say is that at HHS we did bring together a broad group of entities within the umbrella of HHS to look 

at this issue, and the Centers for Medicare and Medicaid Services 

(CMS) did identify electronic records as a potential solution to part 

of this issue so that you could in real time monitor the decisions 

that were being made by clinicians. It would provide a great resource. 

As I indicated, in Illinois, we created a system where we had an 

electronic database that had all of the children in foster care who 

were on psychotropics. It also had what psychotropics they were on, 

and who was prescribing them. So it allowed us to see where there 

are going to be interactive effects, where there are going to be 

issues of that child being on multiple psychotropics from different 

doctors, and it also allowed us to flag doctors who were clearly exceeding what would be best practice and intervene specifically with 

them. 

So it was a great tool for us. Electronic records represent a real 

resource and asset in trying to address this issue in real time. 

Senator CARPER. Right. 

Mr. SALO. Yes, no question. That is absolutely right. It is a key 

ingredient. It is not the panacea. It is not a silver bullet. It has to 

be a part of trying to look more holistically at how we are delivering care because you cannot just have a health record and then 

continue to treat behavioral health issues as completely separate 

from physical acute care. It is a part of that mix. 

And I think one of the things that it could help resolve, one of 

the States that I talked to in preparing for this, one of their frustrations was in trying to build the capacity of the child welfare 

caseworkers and staff in this particular issue. 

These are really hardworking folks, but for the most part they 

are college educated. They have a Bachelor of Arts (BA), a Bachelor 

of Science (BS) and in many cases, a Master in Social Work (MSW). 

But if they are put in situations where they are having to countermand decisions made by practicing physicians, PhDs, et cetera, 

there are identified, clear liability issues for the State staff, and so 

they had to back away. 

If you build that kind of thing into an electronic system, you do 

not really have that kind of problem. So, yes. 

Senator CARPER. Senator Brown. 

Senator BROWN. Thank you, Mr. Chairman. 

I think there are issues. Reading the report, I really was shocked 

at the results, especially as it affects Massachusetts as I referenced 

earlier. 

I look at it as there are a couple of different tiers here. One is 

what is the best interest of the child. In listening to the witness, 

the young man who spoke before us, and recognizing—I think he 

indicated he was on 20 different drugs at one point. It is abuse. It 

is child abuse. It is medical malpractice. And it is also; if you take 

the reason that we are here, it is the cost to the government too, 

the taxpayer dollars that are paying for this abuse and this malpractice. 

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31 

In listening to you, Mr. Samuels, you indicated that there is no 

authority to kind of fix it. Well, I mean, do you want the authority 

to fix it? Do you want that authority? 

Is it something you want us to start working on, or what? 

Mr. SAMUELS. Sure. So let me be clear. I am not suggesting that 

we cannot go a long way in fixing the problem, and I think we have 

articulated some of the steps that we could take. 

But clearly, yes, this is a problem that we are all concerned 

about, and it is something that we need to fix. And if Congress was 

given the opportunity or we were given the opportunity by Congress to fix this problem, we would move aggressively to do so. 

Senator BROWN. That being said, Mr. Chairman, I would ask 

that you—Mr. Samuels—that you actually provide us with the tools 

that you need to do your job. If that is something that we can get 

to the Committee Chair, we will look at it and see if we cannot get 

support because, I mean, I felt heartbroken listening to the previous testimony. 

And I am saying to myself: OK, now. So how does something like 

that happen? Where is the breakdown? 

If you do not have the authority to fix it, who has the authority? 

Are you saying the States have the authority? 

In the State of Massachusetts, I have already sent out the letter 

today, based on this hearing, saying how does this happen and who 

is responsible and how do we fix it? That is one of the things that 

we have always tried to do here. 

So could I ask that you and whoever else would have an interest 

in this get this information to us? 

Mr. SAMUELS. We would both put together a set of recommendations as well as work with your staff to craft a solution that this 

body could support and move forward. 

But can I make one other point which I think is really important 

here? 

Senator BROWN. Sure. 

Mr. SAMUELS. I think it is really important to recognize in the 

larger child welfare context that over the last 14 years most of the 

energy, both in terms of Congress as well as the States, has focused on the issue of reducing the size of the foster care system. 

So we have focused more on trying to resolve issues of permanency 

and get kids home than we have focused on what is their social and 

emotional well-being and what contribution does the child welfare 

system have to make to it when it removes them from their home 

or validates that they have been abused or neglected. 

So another strong message that this Subcommittee could send, 

both to the other Members as well as the broader country, is that 

we have an obligation to do more than just do safety and permanency. We have an obligation to affect the mental and physical 

well-being of children and that means addressing the exact issues 

that you see before because in many instances the assumption is 

well, if we can just get them medicated long enough and stabilize 

them long enough we can find a solution, move these children to 

that solution and then somebody else will make sure that they are 

OK. 

And I think we have a Federal obligation to say that this is unacceptable and that all of us should be working toward their wellH605-41331-79W7 with DISTILLER

32 

being. Whether they leave the system through adoption, guardianship or they age out, we all have an obligation to work to their 

well-being. 

Senator BROWN. In listening to the testimony and reading the reports and referencing other reports that have been done, how do 

you consider it in the best interest or the well-being of the child 

when you are basically overmedicated to the point as was referenced in our earlier testimony as being a zombie and being 

glassed over and having no knowledge of what is going on really 

and having no ability to function as a young child? 

Do you even have any ability to get out of that cycle of abuse and 

neglect. Are you talking stabilizing, or are you talking about just 

overly drugging to the point where they are just vegetables and 

they are going to do whatever they are told? 

It is basically, hey, here is another pill. Just go in the corner and 

shut up. Play with your Nintendo or whatever. 

But at that point, they cannot even do that they are so drugged 

up. 

So I do not disagree with you, I think it is important to get that 

information. 

And Dr. McClellan, you are the expert here, I mean, and we obviously have Dr. Coburn who is an expert on everything apparently. 

Dr. MCCLELLAN. It is a good job. [Laughter.] 

Senator BROWN. That is going to cost me. That will be on the 

front page of something, I am sure. But all kidding aside, he is a 

great man and has a working knowledge of everything. 

That being said, I enjoyed listening. I am bouncing back and 

forth because we are dealing with the defense authorization. 

But in hearing his testimony, in hearing him up here speaking 

to Senator Collins, it is clear that the drugs were counterproductive. They were reacting to each other. No wonder Ke’onte 

was taking insomnia pills, sleeping medication, because the drugs 

that he was taking were firing him up so much. 

Is there any instance at all that some child under one year old 

would be given the medication that is referenced in this report? Is 

there any instance at all that you are aware of? 

Dr. MCCLELLAN. I have not looked at the actual medical records 

for the kids in this report. 

Senator BROWN. In your experience then. 

Dr. MCCLELLAN. I think before you say about any case you would 

have to look at it, but I cannot think of a situation where it would 

be indicated. I just cannot think of one. 

Senator BROWN. So how do they do it? How do they get away 

with it? 

Where is the check and balance? 

Where is somebody raising a red flag and saying hey, why are 

you giving this 6-month-old this drug when it is absolutely not appropriate to be prescribed for it? Where are the so-called red flags? 

I mean, is it a State-by-State issue? Is that the problem, that 

there is a complete lack of the ability for us to go in and monitor 

that stuff? 

I am still trying to zero in on where there is the breakdown, and 

I will take an answer from anybody. 

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33 

Dr. MCCLELLAN. I cannot speak from a policy standpoint. I mean 

oftentimes pharmacies—physicians sometimes just write— 

Senator BROWN. Where is the doctor’s responsibility? Where is 

the doctor’s responsibility to say hey, this is not right? 

Dr. MCCLELLAN. Oh, I agree with that, but at some level the 

oversight has to then pick up on for clinicians, and it is either doctors or nurse practitioners who are writing the prescriptions. 

I mean, again, the number of prescriptions that were for babies 

for psychotropics other than antihistamines were very small. So 

you are talking a very small number of prescribers compared to all 

the other work that was done. 

Senator BROWN. Right. 

Dr. MCCLELLAN. There are outliers in every field, and there does 

need to be some checks and balances to pick up when someone is 

just not doing their job very well. 

Senator BROWN. Mr. Salo, I think you wanted to jump in. 

Mr. SALO. Yes. I would just add that I think there are a lot of 

breakdowns, and some of it is in medical practice. There are certain things you just should not be doing. 

And some of it is in failure on our part as States or as HHS to 

red-flag it and to catch it and to stop it. There are reasons why 

there are different practices out there. But we need to do better, 

clearly. 

And I would just make one final point, that clearly we need to 

do better for these kids, but this is a problem throughout the system too. 

Senator BROWN. Oh, yes. 

Mr. SALO. And let’s keep that in mind. 

Senator BROWN. Yes, I know. Well, we are focused on the kids 

right now, but I do not disagree with you. 

What I would hope, Mr. Chairman, is that certainly, my staff 

would be ready whenever you are ready, but I would hope that we 

could get the guidance from our witnesses to let us know what we 

can do. OK, we have identified it. Now where do we go from here? 

As you have said, we need to learn—I am paraphrasing—we 

need to learn how to do it better, and I do not disagree on this 

issue. 

So Mr. Chairman, I mentioned I am back and forth. I have to get 

down on the floor and work on some issues 

Senator CARPER. Sure. 

Senator BROWN [continuing]. Affecting our soldiers. 

Senator CARPER. Good luck. 

Senator BROWN. So thank you all for your testimony. 

Senator CARPER. Yes, thanks very much for being here today. 

One of the things that witnesses before us hear almost every 

time we have a hearing is I mention one of my core values—if it 

is not perfect, make it better. And I think that certainly applies 

here too today. Obviously, this is not a perfect situation. I do not 

know that we ever can make it perfect, but we sure can make it 

better. 

What do we need to do as members of the Senate and members 

of the Congress, members of the Legislative Branch? What do we 

need to do to make this better, Mr. Kutz. 

H605-41331-79W7 with DISTILLER

34 

Mr. KUTZ. We have talked about reimbursement, and what Senator Brown was saying is this is all paid for by the Federal Government and State governments. Medicaid is matching, mostly Federal 

in some cases, otherwise, 50–50. 

But the issue of whether in some cases the government should 

reimburse legally under current law is one we are looking. We are 

still looking to get answers from HHS about drugs that are not 

FDA-approved and in these drug compendia, et cetera. What is the 

legal authority right now that the government is reimbursing those 

drugs? 

And then we have heard here some of these other high risk practices. Should there be some restrictions of whether the Federal 

Government reimburses for infants getting these drugs, or 5 or 

more, 10 or more or whatever the case may be? 

So I think reimbursements. As you have mentioned at the beginning of the hearing, we are talking about taxpayer dollars here. Is 

there something better that can be done to help taxpayer dollars 

and protect the children at the same time? 

Senator CARPER. Thank you. Mr. Samuels. 

Mr. SAMUELS. I would rattle off two or three issues that I think 

are really important. 

The first one that I would really push hard for is the recognition 

that we need to build capacity to provide therapeutic interventions, 

that there simply are not enough clinicians and not enough clinicians trained in effective interventions to really meet the needs of 

these children, and so we have to build capacity in this area. 

We certainly would support that. We have put some ideas forward. We would be glad to continue to talk to you about that issue. 

The second one that I would really recommend is even if we cannot have an electronic record system that allows us to look at this 

more closely in the immediate future I think that there are probably opportunities for us to look more closely at the Medicaid data 

from a national perspective. Most of the reports that you see, including the GAO report, are based on Medicaid data. However, the 

data does not allow us to differentiate foster children from other 

children in a way that allows us to see patterns that are troubling 

and concerning. 

And so, instead, what we do is rely on academic researchers or 

the good work of folks at the GAO to go look at this data and then 

come back and tell us something. We ought to have a national 

overarching ability to know who is doing what in prescribing 

psychotropics for kids in foster care. 

And then, the last point that I would make is that—in my earlier 

comments and echoed by Senator Coburn—much of the challenges 

that young people in foster care have are related to behavioral 

issues that they need help on. And instead of recognizing issues of 

trauma we are overdiagnosing children with mental illness, and we 

ought to build the capacity in child welfare to be able to differentiate children who are expressing traumatic symptoms because of 

stuff that has happened to them versus children that are showing 

symptoms of a mental illness. If we can make those separations, 

then we can reduce the use of psychotropics and target effective 

interventions for the children who would benefit most. 

Senator CARPER. OK. That was a very good summation. Mr. Salo. 

H605-41331-79W7 with DISTILLER

35 

Mr. SALO. Yes, I would agree with that last point wholeheartedly, and I think just a couple of other things. 

The easy thing to do is just to continue to use the bully pulpit 

and to shine through the use of the GAO and others. 

Senator CARPER. Through hearings? 

Mr. SALO. Through hearings and just shine light on little-known 

problems like this. 

I think there is also clearly a role for helping build capacity, not 

just for electronic health records and HIT, building capacity for the 

research, the clinical research that is out there, so we know so little about how these drugs interact with each other and how they 

work with kids in general, and we know very little about how the 

unique challenges faced by kids in foster care interact with all 

those. 

And then, I think the last piece is just continue to demand accountability. I think that is certainly something that we are talking 

a lot about with Medicaid. Medicaid is a very process-driven system, and in many ways Medicaid is less of an entitlement to the 

beneficiary than it is an entitlement to streams of revenue for a 

bunch of different providers. 

And I think there is a way to kind of think more holistically 

about how we use Medicaid, not just to reimburse for things but 

to drive better health outcomes, and I think that is an ongoing conversation we would love to have with you. 

Senator CARPER. OK. Good. 

Dr. McClellan, how do we make it perfect? How do we make it 

better, if not perfect? 

Dr. MCCLELLAN. Yes, I will have to send you that in writing, I 

think. I mean it is a very complicated system. I agree with what 

has been said. 

I go back to your point about figure out what works and do more 

of it. We actually know a lot of psychosocial interventions that are 

effective for treating trauma problems and treating behavior problems. And yet, most kids cannot access them, and many of the people who are out there providing do not use them. And the system 

has to be more reinforcing for those that do and urging those that 

do not to change their ways. 

Senator CARPER. All right. Good. Thank you all for your responses. I appreciate that. 

I have one more question. I am going to read it. I am not going 

to ask you to answer, but I will ask you to answer it for the record, 

and we will follow up in writing on this. 

In the testimony today from GAO, they reported that the State 

of Maryland did not have reliable data for its foster children, I believe, in 2008. I am told that this is why we only had five States 

examined and not six. 

I am also told that the data that the GAO received from Maryland was—I think this is a quote—‘‘materially different’’ than the 

data that Maryland provided to Health and Human Services. I find 

that troubling, and the fact that they do not have a good accounting for the children under their care. 

I am going to ask Mr. Samuels and Mr. Salo to respond for the 

record. And basically, we will be asking you were you aware that 

Maryland could not account for all of its foster children apparently 

H605-41331-79W7 with DISTILLER

36 

in its records in 2008, and we will ask if you are aware of any other 

States that have similar difficulty in accurately maintaining data 

for foster children under their care. 

And finally, we will ask, does this lack of accountability by a 

State have adverse effect on its foster care and Medicaid Federal 

grant funds? 

So those will be for the record. There will be some other questions, I expect, for the record from me and my guess, from others 

as well. 

Let me ask John Collins who has done a lot of work on this hearing. John, how long do our colleagues on the Subcommittee have 

to submit questions? 

Mr. COLLINS. Two weeks. 

Senator CARPER. Two weeks. So we will get our questions in to 

you within two weeks. We just ask that you respond promptly. 

I will close just by saying this; I mentioned this to Ke’onte when 

I slipped outside to say goodbye to him, and his mom, and dad, 

after he had a bite to eat. We talked a little bit about Christmas 

coming up. 

And I said to him at Christmas time a lot of us, especially young 

kids—I remember when we were all kids, especially when I was a 

kid—we really look forward to what we are going to get. And it was 

a source of great joy to go down on Christmas morning and find 

out what was under the tree for us, my sister and me. 

But I have learned over time that the real source of joy is not 

what we get but what we give, and that is a valuable lesson that 

hopefully all of us learn somewhere along the line, hopefully, sooner rather than later. 

I also learned along the way that in adversity lies opportunity. 

These kids, these foster kids especially, have gone through a lot of 

adversity in their lives, and there is also some opportunity here. 

The opportunity we have is to use really the gift of Ke’onte’s testimony, and yours, and the good will of, I think, a lot of us to be able 

to help a whole bunch of kids to end up having a better—not just 

a better childhood but a better life and a more productive life. And 

that is a gift for us to give back to others. 

I am one of those people who have these core values. One of 

them is to figure out is there a better way to do everything. How 

do we get a better result? 

But I do not give up on stuff. When I can see that there is a 

wrong that needs to be righted, I just do not give up. I am pretty 

persistent. With that in mind, we are going to stay on this one, and 

we invite all of you to stay on it with us. 

We did not invite anyone today to come from the pharmaceutical 

industry. I think a conversation with the representatives from the 

pharmaceutical industry and from the pharmacies, pharmacists 

themselves, probably would be helpful. If we really want to help a 

bunch of kids, we will be reaching out to them and asking them 

to meet with us, probably not in a hearing—maybe—but probably 

at least to have a good conversation and feel how they can be part 

of the solution here as well. 

Again, my thanks to each of you for sharing your time, especially 

to our friends from GAO and those who work with you on your 

H605-41331-79W7 with DISTILLER

37 

study. We are deeply grateful for the work that you have done here 

as well as in so many other areas. 

With that having been said, this hearing is adjourned. Thank 

you all. God bless. 

[Whereupon, at approximately 12:34 p.m., the hearing was adjourned.] 

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