```

[Senate Hearing 113-690]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 113-690
 
         EXAMINING MENTAL HEALTH: TREATMENT OPTIONS AND TRENDS

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                                   ON

        EXAMINING MENTAL HEALTH, FOCUSING ON TREATMENT OPTIONS 
                               AND TRENDS

                               __________

                           FEBRUARY 25, 2014

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

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

          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland         LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington              MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont          RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania    JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina          RAND PAUL, Kentucky
AL FRANKEN, Minnesota                 ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado           PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island      LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin              MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut    TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts

                            
                                       

                      Derek Miller, Staff Director

        Lauren McFerran, Deputy Staff Director and Chief Counsel

               David P. Cleary, Republican Staff Director

                                  (ii)
                                  

  

                            C O N T E N T S

                               __________

                               STATEMENTS

                       TUESDAY, FEBRUARY 25, 2014

                                                                   Page

                           Committee Members

Harkin, Hon. Tom, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Alexander, Hon. Lamar, a U.S. Senator from the State of 
  Tennessee, opening statement...................................     2
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    29

                               Witnesses

Cooper, William O., M.D., M.P.H., Professor of Pediatrics, 
  Vanderbilt University Medical School, Nashville, TN............     4
    Prepared statement...........................................     6
Fernandez, Benjamin S., M.S., Ed., School Psychologist, Loudon 
  County Public Schools, Ashburn, VA.............................    11
    Prepared statement...........................................    13
Arch, John K., FACHE, Executive Vice President of Health Care and 
  Director, Boys Town National Research Hospital and Clinics, 
  Omaha, NE......................................................    17
    Prepared statement...........................................    20
Martinez, Tiffany, Student, University of Southern Maine, 
  Portland, ME...................................................    22
    Prepared statement...........................................    24

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response to question of Senator Harkin by Tiffany Martinez...    39
    Response to questions of Senator Murray by Benjamin 
      Fernandez, M.S., Ed........................................    40

                                 (iii)

  

         EXAMINING MENTAL HEALTH: TREATMENT OPTIONS AND TRENDS

                              ----------                              

                       TUESDAY, FEBRUARY 25, 2014

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:04 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Tom Harkin, 
chairman of the committee, presiding.
    Present: Senators Harkin, Alexander, and Baldwin.

                  Opening Statement of Senator Harkin

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will come to order. Today our committee 
will examine treatment options and trends for mental health 
conditions. We held a successful hearing on mental health 
issues last year, and I'm pleased to have the opportunity to 
continue the dialog on this important topic with my colleagues 
and our panel of expert witnesses.
    Mental health is an issue that I care deeply about, and I 
believe we must do everything possible to ensure that 
individuals with mental illness get the services they need and 
deserve. I am proud to have championed the Mental Health Parity 
Act along with Pete Domenici and Paul Wellstone to end the 
absurd practice of treating mental and physical illness as two 
different things under health insurance.
    We also made a significant step forward in coverage by 
requiring treatment of mental health and substance abuse 
disorders as 1 of the 10 essential health benefits under the 
Affordable Care Act.
    Mental health problems often begin at a young age and can 
last throughout one's life. In fact, half of all mental 
illnesses manifest by age 14, and three-quarters appear by age 
24. This creates a special urgency to make sure that children 
and adolescents get appropriate treatment for mental health 
conditions, a challenge that our expert witnesses will address 
today.
    For many children, adolescents, and adults, finding the 
right mental health treatments can make a profound difference. 
We know that for some individuals, treatment may entail 
psychotropic medication, behavioral interventions, community 
supports, or some combination of all of these. There is, as I 
am aware, no one-size-fits-all treatment, which is why I have 
long been an advocate for patient-driven care that is 
individualized and takes many factors into consideration.
    As I noted, there are many individuals who need medication 
to help manage their symptoms. Yet I am concerned about data 
pointing to disturbing new trends which we will learn more 
about today. For example, we are seeing significant increases 
in the prescribing of psychotropic medications, while the use 
of behavioral and psychological treatments among children and 
youth has increased only slightly and has actually decreased 
among adults.
    The use of psychotropic drugs by adult Americans increased 
22 percent from 2001 to 2010, with one in five adults now 
taking at least one psychotropic medication. Another study 
demonstrates that the use of antipsychotic medications has 
increased eightfold among children, fivefold among adolescents, 
and doubled among adults between 1993 and 2009.
    This rapid growth of psychotropic drug use has alarmed some 
mental health professionals. I'd like to better understand why 
this is happening and what we can do to make sure people are 
getting the right treatments. I didn't say the right drugs. I 
said the right treatments.
    Today we'll hear from a panel of expert witnesses who will 
discuss mental health treatment options and best practices from 
a variety of perspectives. I know there are no easy answers or 
quick fixes to addressing mental health treatment challenges. 
So I'm looking forward to learning more from our witnesses 
today.
    I thank you all for being here, and I look forward to your 
testimony.
    With that, I'll turn to Senator Alexander.

                 Opening Statement of Senator Alexander

    Senator Alexander. Thanks, Mr. Chairman. Thanks for the 
hearing and thanks for working with us to come up with such a 
distinguished group of witnesses. We're looking forward to 
learning from them. I agree with what Senator Harkin said. I'm 
especially interested in learning all I can about whether 
children in our country are getting accurate diagnoses and 
appropriate prescriptions, especially for conditions like ADHD.
    I'm sure that older Americans like me read the statistics 
about the growing number of children who are diagnosed with 
ADHD with some alarm. We wonder if this is true, that one out 
of five boys have this diagnosis. Is this true about the 
doubling of the condition? What are the causes? Are there 
external factors?
    There's much speculation about whether conditions in a 
school might lead to these diagnoses and prescriptions, whether 
it's the fact that more money might follow a child if a child 
is in special education, or whether increased testing forces 
teachers to put pressure on children who then have more 
difficulty focusing their attention.
    I don't know the answers to those. But in our society, the 
larger number of children who are diagnosed with attention 
deficit hyperactivity disorders and who are deemed to have an 
unusual amount of difficulty focusing their attention--that's 
something that needs some explanation.
    As part of the larger question that Senator Harkin has 
raised with this hearing about mental health and over-
diagnosis, over-medication, and over-involvement, sometimes we 
hear the alarm on one side, and then the other side comes from 
the professionals that say, ``Don't get too alarmed. You're 
overreacting.'' So maybe you can help us put a proper balance 
into what we should be doing.
    One of the things that the Federal Government does most 
effectively to enable individuals in this big complex society 
of ours to look toward the future is research. We're not such 
good managers. Sometimes we're not even good regulators. But 
the research that we've funded and encouraged has enabled 
enormous breakthroughs in the country. So we'd like your advice 
about research.
    And if you have suggestions about the new rule, for 
example, from the Center for Medicare and Medicaid Services 
that would limit access to antidepressants, antipsychotics, and 
immuno-
suppressants for individuals in the Medicare Part D program, 
I'd like to know your thoughts about that. The rule, as far as 
I can tell, has been criticized by nearly everyone who has read 
it.
    But, basically, we're looking forward to some illumination 
and some discussion about trends in research. I think my goal 
would be to hope that as a result of this, as a country, we can 
come closer to the right diagnosis, the right treatment, the 
right person, and the right setting.
    Thank you very much for being here. I look forward to your 
testimony.
    The Chairman. Thank you very much, Senator Alexander.
    Senator Alexander. I'd be happy to introduce Dr. William 
Cooper. I'm always glad to introduce somebody from Vanderbilt 
University, such a distinguished university, and the School of 
Medicine. He is the Cornelius Vanderbilt professor of 
pediatrics and health policy and associate dean for faculty 
affairs at the Vanderbilt University School of Medicine. He is 
a practicing pediatrician, researcher, educator, and 
administrator. He has focused his research on medication safety 
for children, as well as prescribing habits.
    Dr. Cooper, we're delighted you're here today.
    The Chairman. Our next panelist is Mr. Benjamin Fernandez, 
a school psychologist with the Loudoun County Public School 
System in Virginia. Mr. Fernandez has been practicing in the 
field of school psychology for almost 18 years. He is a 
recognized leader, was named School Psychologist of the Year in 
2010 by the Virginia Academy of School Psychologists, and in 
2012 by the National Association of School Psychologists.
    Thank you for being here, Mr. Fernandez.
    Next is Mr. John Arch, the executive vice president of 
Health Care and director of Boys Town National Research 
Hospital and Clinics in Omaha, NE. Boys Town provides a range 
of treatment for the behavioral, emotional, and physical needs 
of vulnerable youth. He is here to tell us more about Boys 
Town's unique model of psychosocial care and careful management 
of psychotropic drugs among his patients.
    We thank you for being here.
    Our final witness is Ms. Tiffany Martinez, who is a 
graduate student at the University of Southern Maine studying 
to become a family psychiatric nurse practitioner. Ms. Martinez 
was involved with the Portland Identification and Early 
Referral program, which provides assessment and treatment for 
young people who are showing the early signs of mental illness. 
She is here to share her firsthand experiences with treatment.
    Thank you, Ms. Martinez, for being willing to speak to us 
today about something that is so personal.
    We thank you all for being here. I read all of your 
testimonies last night. They're very compelling. They'll be 
made a part of the record in their entirety. We'd like to ask, 
starting with Dr. Cooper, if you could perhaps give us a 
summary of 5 minutes or so. Then we'll go down the line and 
afterwards we'll open it for questions.
    Dr. Cooper, welcome and please proceed.

  STATEMENT OF WILLIAM O. COOPER, M.D., M.P.H., PROFESSOR OF 
PEDIATRICS, VANDERBILT UNIVERSITY MEDICAL SCHOOL, NASHVILLE, TN

    Dr. Cooper. Thank you. Chairman Harkin and Ranking Member 
Alexander, it's a privilege to be here to speak with you today 
about mental health disorders in children and ways in which we 
might ensure that all children are treated in the most 
appropriate manner.
    I'd like to start with a story about a patient that I took 
care of in the Vanderbilt Pediatric Primary Care Clinic. In 
late 2002, a 9-year-old boy was referred to our pediatric 
clinic from a rural community several miles from Nashville for 
evaluation of rapid weight gain. I noted that he had been 
placed on a powerful antipsychotic medication, one that is 
known to cause weight gain.
    The child had no history, however, of serious mental 
illness, but had a long history of disruptive behavior and was 
at risk for being expelled from school. The family was unable 
to find transportation to the nearest mental health facility 
and were told that this medication was his last chance.
    Treating mental health disorders can be challenging and 
requires a careful approach to diagnosis and management. Each 
child is unique and will respond to medications in their own 
way. Given the fact that 50 percent to 75 percent of the care 
for children with mental health disorders occurs in primary 
care settings, it's critical that consultation and 
communication between primary care professionals and mental 
health professionals be optimized.
    Guided by our clinical observations in this child and other 
children like him and a review of existing surveillance data, 
our research group has performed several studies assessing 
trends in antipsychotic medication use in children and the 
potential risk for adverse outcomes from medication used to 
treat attention deficit hyperactivity disorder, ADHD.
    Antipsychotics are a class of medications that have been 
shown to reduce symptoms of serious mental disorders such as 
schizophrenia, autism, and severe bipolar disorder. Their 
efficacy in treating other conditions, however, is just not 
known. In addition, we don't know whether or not they actually 
may be harmful to children. So it's important to understand 
more about this.
    In one study in Tennessee Medicaid and another study using 
a national data set, we identified a fivefold increase in the 
use of antipsychotics in children. Furthermore, more than half 
of these children were being placed on these medications for 
ADHD and other behavioral disorders for which we don't know 
whether these medications work.
    In October 2013, our group published a study using 43,000 
children in Tennessee Medicaid. We compared children who are on 
antipsychotic medication with children who are on comparable 
medications in terms of their risk for Type 2 diabetes. We 
found that children who were using antipsychotics were three 
times more likely to develop Type 2 diabetes than the similar 
children placed on other medications. We also found that 
children that were on higher doses of the antipsychotics and 
had been on the medications for longer periods of time were at 
even greater risk for this important complication.
    Our research group has also performed several studies 
assessing the potential risk of medications used to treat ADHD. 
Stimulant medications have been used to treat ADHD for over 40 
years and have had a relatively benign safety profile. However, 
in 2004, reports of adverse events from Canada and the United 
States that included cases of sudden cardiac death, heart 
attacks, and strokes in children taking these medications 
raised serious concerns about their safety.
    We studied the cardiovascular safety of ADHD medications in 
1.2 million children and young adults from all regions of the 
country and found no evidence of a significant increase in risk 
for serious cardiovascular outcomes in children. A separate 
study that we conducted in adults also found no increase in 
risk.
    The data on ADHD drug safety highlights the need to educate 
patients, families, and health care professionals, as well as 
educators, about the appropriate diagnosis and management of 
ADHD. While our results about the adverse effects of these 
stimulant medications were reassuring, ongoing surveillance is 
needed for these and all other drugs.
    What are the challenges we face? As we discussed in 
introductory comments, are we over-diagnosing these children 
with mental health disorders? We have excellent tools to make 
these diagnoses, and we must use these to diagnose individual 
children. It's critical that health care professionals receive 
training in the appropriate diagnosis and management, and 
partnerships between primary care providers and mental health 
professionals must be utilized to optimize the best diagnosis.
    Are we giving children the right medication? Are we giving 
children too many medications? We need to ensure that children 
who really need antipsychotics and other medications get them. 
That's a really critical part of this. But there's little 
reason to believe that the incidence of these disorders 
justifies a fivefold or eightfold increase in prescriptions for 
these drugs that has occurred in recent years.
    We need to ensure that children that have a need for mental 
health services have them available. This is particularly 
important for vulnerable children and children in States with 
rural populations where access can present a huge barrier to 
families. We must work to improve research into the diagnosis 
and surveillance about drug safety in these children so we can 
ensure that children are not suffering adverse effects from the 
treatments intended to help them.
    So in reflecting back on that 9-year-old boy and the 
antipsychotics I've encountered in my 23 years as a 
pediatrician, several thoughts come to mind. First, medications 
used to treat these disorders are not magic pills. Children and 
adolescents with serious mental health disorders may benefit 
greatly from medications, but it's important to weigh their 
risks and benefits in the context of a comprehensive treatment 
plan. Taking time to consider the right diagnosis and treatment 
is time consuming, but it's essential to ensure that this 
happens.
    In the future, it's possible that there may be other ways 
to identify individuals who may respond differently to 
different treatments. But in the meantime, we must address 
these children one child and one family at a time. We also need 
to expand our understanding of the best ways to diagnose and 
treat these children so that the 9-year-old boy who was in my 
clinic and children just like him can function and reduce the 
distress and suffering of mental health conditions.
    Thank you for the opportunity to speak with you today, and 
I look forward to the testimony of my fellow panelists and 
answering your questions.
    [The prepared statement of Dr. Cooper follows:]
           Prepared Statement of William Cooper, M.D., M.P.H.
                                summary
    In late 2002, a 9-year-old boy was referred to our clinic from a 
rural town several miles from Nashville for evaluation of rapid weight 
gain. I noted that he had been placed on a powerful antipsychotic 
medication, one that is known to cause weight gain. The child had no 
history of serious mental illness, but had a long history of disruptive 
behavior and was at risk for being expelled from school. The family was 
unable to find transportation to the nearest mental health facility and 
were told that this medication was his last chance.
    Treating mental health disorders can be challenging and requires a 
careful approach to diagnosis and management as each child is unique 
and will respond to treatments in his or her own way. Given the fact 
that 50-75 percent of the care for children with mental health 
disorders occurs in primary care settings, it is critical that 
consultation and communication between primary care professionals and 
experts in mental health be enhanced.
    Guided by our clinical observations and review of existing 
surveillance data, our research group has performed several studies 
assessing trends in antipsychotic medication use in children and the 
potential risk for adverse outcomes from medications used to treat 
attention deficit hyperactivity disorder, ADHD. In one study in 
Tennessee Medicaid and another studying children from a national data 
set, we identified a 5-fold increase in the use of antipsychotics in 
children. Furthermore, more than half of these children were placed on 
the antipsychotic for ADHD and behavioral disorders for which these 
drugs have not been studied. In October 2013, our group published a 
study drawn from 43,000 children in Tennessee Medicaid in which we 
compared the risk for type 2 diabetes in children who were recently 
placed on antipsychotics to comparable children treated with other 
psychotropic medications. We found that children who were using 
antipsychotics were three times more likely to develop type 2 diabetes 
than children on other medications.
    Our research group has also performed studies assessing potential 
risks of medications used to treat ADHD. Stimulant medications have 
been used to treat ADHD for over 40 years and until recently have had a 
reputation for relative safety. In 2004, reports of adverse events from 
Canada and the United States that included cases of sudden cardiac 
death, heart attacks and strokes in children taking medications for 
ADHD raised serious concerns about their safety. We studied the 
cardiovascular safety of ADHD drugs in 1.2 million children and young 
adults from all regions of the country and found no evidence of a 
significant increase in risk for serious cardiovascular outcomes in 
children. A separate study that we conducted in adults also found no 
increase in risk. The data on ADHD drug safety highlight the need to 
educate patients, families, health care professionals, and teachers 
about the appropriate diagnosis and management of ADHD. While our 
results about the adverse effects of stimulant medication are 
reassuring, ongoing surveillance is needed for these and all other 
drugs.
                        what are our challenges?
     Are we over-diagnosing children with mental health 
disorders? We must use the excellent tools currently available to 
diagnose the individual child. It is critical that health care 
professionals receive training in the diagnosis and management of 
mental health disorders. Partnerships between primary care clinicians 
and mental health professionals must be utilized to optimize the best 
diagnosis.
     Are we giving children the right medication? We need to 
ensure that children who really need antipsychotics get them, but there 
is little reason to believe that the incidence of these disorders 
justifies the fivefold increase in prescriptions for these drugs that 
has occurred in recent years.
     We need to ensure that children with a need for mental 
health services have them available. This is particularly important in 
States with rural populations, where access can present a huge barrier.
     We must work to improve the diagnosis and management of 
these children with thoughtful research and surveillance to ensure that 
children who are treated go on to live healthy lives without adverse 
consequences.
                                 ______
                                 
    Chairman Harkin, Ranking Member Alexander, and members of the 
committee, my name is William Cooper. I provide general pediatric care 
for underserved children in the primary care clinic at the Monroe 
Carell Jr. Children's Hospital at Vanderbilt and direct a research 
program in epidemiology, conducting population-based studies of 
medication use in children and assessing adverse effects of certain 
medications, including many of the medications used to treat mental 
health disorders. I consider it a tremendous privilege to speak with 
you today about mental health disorders in children and ways in which 
we might ensure that all children are treated in the most appropriate 
manner.
                   a 9-year-old boy on antipsychotics
    In late 2002, a 9-year-old boy was referred to our clinic from a 
rural town several miles from Nashville for evaluation of rapid weight 
gain. I noted that he had been placed on a powerful antipsychotic 
medication, one that is known to cause weight gain. The child had no 
history of serious mental illness, so I spoke with the family to gain a 
greater understanding of why he was taking this medication and found 
that he had been placed on the medication by the primary care provider 
in his rural community. The child had had a long history of disruptive 
behavior and was at risk for being expelled from school. The family was 
unable to find transportation to the nearest mental health facility and 
were told that this medication was his last chance. This story and 
several like it led our team to pursue a series of studies to further 
understand how commonly these medications were being prescribed to 
children and whether or not there were risks to their widespread use in 
children.
          epidemiology of mental health disorders in children
    To place our conversation in context, I'd like to share some 
information with the committee about mental health disorders in 
children. Nearly 1 in 10 children are affected by a mental health 
disorder, including attention deficit hyperactivity disorder (ADHD), 
depression, anxiety, and other mental health disorders.\1\ Symptoms of 
mental health disorders usually begin in childhood, but some do not 
begin to develop until the teenage years. In my pediatric practice, I 
have seen firsthand the devastating effects of mental illness on 
children and their families, particularly for our most vulnerable 
children, including those who live in poverty and those in the child 
welfare system.
    In recent years, we have seen a tremendous increase in the numbers 
of children diagnosed with mental health disorders.\1\ \2\ Whether this 
is a result of increased awareness, improved diagnosis, or other 
factors is not clearly understood. While we must acknowledge that a 
part of the increase could be due to over-diagnosis, there is no 
disputing the fact that a large number of children and their families 
suffer significantly because of mental illness. Furthermore, given the 
fact that suicide is the second leading cause of death in 12-17-year-
old children,\1\ tragic consequences of childhood mental health 
disorders highlight our sense of urgency in addressing this important 
problem.
            treatment of mental health disorders in children
    In recent years, there has been a lot of progress in identifying 
treatment options for children with mental health disorders. Early 
diagnosis and treatment of children is critical to reduce suffering and 
the likelihood that the disorder will persist into adulthood.\1\ 
Important advances in the diagnosis and treatment of these children 
include evidence-based guidelines for appropriate diagnosis and greater 
understanding of treatments for certain disorders.
    Treating mental health disorders can be challenging and requires a 
careful approach to diagnosis and management. Each child is unique and 
will respond to treatments in his or her own way. We have come to 
recognize that 50-75 percent of the care for children with mental 
health disorders occurs in primary care settings,\2\ making it critical 
that consultation and communication between primary care professionals 
and experts in mental health be enhanced. In our practice, we routinely 
engage our mental health colleagues in diagnosis and management of 
patients in a collaborative model.
    Despite guidelines, much of the health care in children occurs in a 
manner inconsistent with optimal practice, including use of medications 
for diagnoses for which there is little evidence of benefit, use of 
multiple medications at the same time (a problem illustrated in 
particularly vulnerable children such as children in foster care, where 
a recent study demonstrated multiple psychiatric medications in up to 
75 percent of children being treated),\3\ and use of medications alone 
without proven psychotherapies.
    These deficiencies likely result from several factors on the 
system, provider, and family levels. Many clinicians may be unaware of 
current guidelines and may practice in a way inconsistent with best 
practice.\4\ In some settings, there may be inadequate mental health 
resources to provide best treatments and few, if any professionals with 
training in providing mental health care to children. For some 
families, access to mental health care may be hampered by cost or 
physical barriers such as long travel distances. Furthermore, stigma 
associated with mental illness may reduce families' willingness to 
acknowledge a mental health disorder and seek treatment in the first 
place.\1\
                research into medication use and safety
    Guided by our clinical observations and review of existing 
surveillance data, our research group has performed several studies 
assessing trends in antipsychotic medication use in children and the 
potential risk for adverse outcomes from medications used to treat 
ADHD.
                 antipsychotic medications in children
    Antipsychotics are a class of medications that have been shown to 
reduce symptoms of serious mental disorders such as schizophrenia, 
severe bipolar disorder, and autism. Their efficacy in treating other 
conditions in children is not known. In addition, we know very little 
about whether or not they actually may be harmful to children.
    In one study in Tennessee Medicaid \5\ and another studying 
children from a national data set,\6\ we identified a fivefold increase 
in the use of antipsychotics in children. Furthermore, more than half 
of these children were placed on the antipsychotic for ADHD and 
behavioral disorders for which these drugs have not been studied.\6\ 
Several studies followed ours and found a similar increased trend in 
use in children as young as 3 years of age \7\ as well as many children 
receiving multiple antipsychotics at the same time.\8\ In high risk 
populations, such as children in foster care, use of antipsychotics and 
multiple medications at the same time has been reported to occur in up 
to 75 percent of children receiving treatments.\3\ We know that 
children are more sensitive to adverse effects of some medications than 
adults,\9\ so it is not possible to extend safety findings from adults 
to children. Thus, more research was needed to provide sufficient 
information to guide our considerations of the risks as well as the 
benefits of therapeutic options.
    In October 2013, our group published a study drawn from 43,000 
children in Tennessee Medicaid in which we compared the risk for type 2 
diabetes in children who were recently placed on antipsychotics to 
comparable children treated with other psychotropic medications.\10\ We 
found that children who were using antipsychotics were three times more 
likely to develop type 2 diabetes than similar children on other 
medications. We also found that children on higher cumulative doses 
were at even higher risk and that the elevated risk remained for up to 
a year after the medications were discontinued.
    It's important to note that for some children and teens with 
serious mental health disorders, antipsychotics may be a critical part 
of their treatment. For many, however, these medications are being used 
for conditions such as ADHD for which there are safer alternatives. 
These studies highlight the critical need to ensure that children 
receive an accurate diagnosis with careful attention to all possible 
conditions that might be present and that if an antipsychotic 
medication is needed, children should be monitored for potential safety 
concerns.
                     medications used to treat adhd
    Our research group has also performed studies assessing potential 
risks of medications used to treat attention deficit hyperactivity 
disorder, ADHD. ADHD is an important mental health problem and affects 
up to 8-10 percent of children.\11\ The diagnosis of ADHD has increased 
in recent years, perhaps resulting from greater awareness of the 
condition on the part of families, teachers, and health care 
professionals,\12\ \13\ yet many children with ADHD still have serious 
disruptions in home, school, and social functioning and for many, these 
symptoms last into adulthood.
    There are clear guidelines for the diagnosis and management of 
ADHD.\4\ It is critical to obtain input from multiple sources, 
including parents, teachers, and others who observe the child's 
behavior and use validated tools to provide the correct diagnosis. 
Because up to 40 percent of children with ADHD have other problems 
including learning disabilities and additional mental health 
diagnoses,\4\ it is also critical to assess children for other issues 
that may interfere with their ability to function.\13\ Guidelines for 
the care of ADHD include recommendations for behavioral therapies and 
stimulant medication in selected children, reflecting the 70 percent 
rate of improvement seen in several studies.\4\ I recall one of my 
patients with ADHD who told me he felt like his brain was like a 
``motor going too fast'' and that the medications allowed him to slow 
down enough so that the other interventions we were using could work.
    Stimulant medications have been used to treat ADHD for over 40 
years and until recently have had a reputation for relative safety. 
Like antipsychotics and any medication, it is critical, however, to 
observe a child for potential side effects of the medications. In 2004, 
reports of adverse events from Canada and the United States that 
included cases of sudden cardiac death, heart attacks and strokes in 
children taking medications for ADHD raised serious concerns about 
their safety.\14\ Several regulatory and policy decisions resulted from 
the review of adverse-event reports and led to concern and confusion 
among health care professionals, patients, and families about the risks 
of these drugs. In this context, we studied the cardiovascular safety 
of ADHD drugs in 1.2 million children and young adults from all regions 
of the country and found no evidence of a significant increase in risk 
for serious cardiovascular outcomes in children.\11\ A separate study 
that we conducted in adults also found no increase in risk.\15\
    The data on ADHD drug safety highlight the need to educate 
patients, families, health care professionals, and teachers about the 
appropriate diagnosis and management of ADHD. While our results about 
the adverse effects of stimulant medication are reassuring, ongoing 
surveillance is needed for these and all other drugs.
                        what are our challenges?
     Mental health disorders are a common and serious public 
health problem. Mental health disorders affect 1 in 10 children and in 
addition to causing tremendous disruptions in their lives, these 
disorders tragically can end in suicide.
     Are we over-diagnosing children with mental health 
disorders? We must use the excellent tools currently available to 
diagnose the individual child. It is critical that health care 
professionals receive training in the diagnosis and management of 
mental health disorders. Partnerships between primary care clinicians 
and mental health professionals must be utilized to optimize the best 
diagnosis.
     Are we giving children the right medication? We need to 
ensure that children who really need antipsychotics get them, but there 
is little reason to believe that the incidence of these disorders 
justifies the fivefold increase in prescriptions for these drugs that 
has occurred in recent years.
     We need to ensure that children with a need for mental 
health services have them available. This is particularly important in 
States with rural populations, where access can present a huge barrier 
to families.
     We must work to improve the diagnosis and management of 
these children with thoughtful research and surveillance to ensure that 
children who are treated go on to live healthy lives without adverse 
consequences.
           closing the loop: the 9-year-old on antipsychotics
    In reflecting back on the 9-year-old boy on antipsychotics and many 
like him I have encountered in my 23 years as a pediatrician, several 
thoughts come to mind. First, medications used to treat mental health 
disorders are not magic pills. Children with serious mental health 
disorders may benefit greatly from medications, but it is important to 
weigh their risks and benefits in the context of a comprehensive and 
individualized treatment plan, which typically includes other 
personalized interventions. Taking time to consider the right diagnosis 
and the right treatment for each child takes time, but is essential to 
ensure that children with mental health disorders have the best 
possible outcomes. In the future, it is possible that other ways to 
identify individual children who might respond to different treatments 
might allow us to individualize treatments even further. In the 
meantime, however, we must address these issues one child and family at 
a time. Finally, we need to continue to expand our understanding of the 
best ways to diagnose and treat these children so that that 9-year-old 
boy and other children just like him can function and reduce the 
distress and suffering of mental health conditions.
    Thank you for the opportunity to testify. I look forward to the 
testimony of my fellow panelists and I welcome any questions the 
committee may pose.
                               References
    1. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health 
surveillance among children--United States, 2005-11. MMWR Surveill Summ 
2013;62 Suppl 2:1-35.
    2. Olfson M, Blanco C, Wang S, Laje G, Correll CU. National trends 
in the mental health care of children, adolescents, and adults by 
office-based physicians. JAMA Psychiatry 2014;71:81-90.
    3. Breland-Noble AM, Elbogen EB, Farmer EM, Dubs MS, Wagner HR, 
Burns BJ. Use of psychotropic medications by youths in therapeutic 
foster care and group homes. Psychiatr Serv 2004;55(6):706-08.
    4. Rappley MD. Clinical practice. Attention deficit-hyperactivity 
disorder. N Engl J Med 2005;352(2):165-73.
    5. Cooper WO, Hickson GB, Fuchs C, Arbogast PG, Ray WA. New users 
of antipsychotic medications among children enrolled in TennCare. Arch 
Pediatr Adolesc Med 2004;158(8):753-59.
    6. Cooper WO, Arbogast PG, Ding H, Hickson GB, Fuchs DC, Ray WA. 
Trends in prescribing of antipsychotic medications for U.S. children. 
Ambul. Pediatr 2006;6(2):79-83.
    7. Olfson M, Blanco C, Liu L, Moreno C, Laje G. National trends in 
the outpatient treatment of children and adolescents with antipsychotic 
drugs. Arch GenPsychiatry 2006;63(6):679-85.
    8. Toteja N, Gallego JA, Saito E, et al. Prevalence and correlates 
of antipsychotic polypharmacy in children and adolescents receiving 
antipsychotic treatment. Int. J. Neuropsychopharmacol 2013:1-11.
    9. Correll CU. Antipsychotic use in children and adolescents: 
minimizing adverse effects to maximize outcomes. J. Am. Acad. Child 
Adolesc. Psychiatry 2008;47(1):9-20.
    10. Bobo WV, Cooper WO, Stein CM, et al. Antipsychotics and the 
risk of type 2 diabetes mellitus in children and youth. JAMA Psychiatry 
2013;70(10):1067-75.
    11. Cooper WO, Habel LA, Sox CM, et al. ADHD Drugs and Serious 
Cardiovascular Events in Children and Young Adults. N. Engl. J. Med 
2011;365(20):1896-1904.
    12. Brown RT, Amler RW, Freeman WS, et al. Treatment of attention-
deficit/hyperactivity disorder: overview of the evidence. Pediatrics 
2005;115(6):e749-57.
    13. Increasing prevalence of parent-reported attention-deficit/
hyperactivity disorder among children--United States, 2003 and 2007. 
MMWR Morb.Mortal.Wkly.
Rep 2010;59(44):1439-43.
    14. Perrin JM, Friedman RA, Knilans TK. Cardiovascular monitoring 
and stimulant drugs for attention-deficit/hyperactivity disorder. 
Pediatrics 2008;122(2):451-53.
    15. Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk 
of serious cardiovascular events in young and middle-aged adults. JAMA 
2011;306(24):2673-83.

    The Chairman. Thank you very much, Dr. Cooper.
    Mr. Fernandez, please proceed.

     STATEMENT OF BENJAMIN S. FERNANDEZ, M.S. ED., SCHOOL 
    PSYCHOLOGIST, LOUDOUN COUNTY PUBLIC SCHOOLS, ASHBURN, VA

    Mr. Fernandez. Chairman Harkin, Ranking Member Alexander, 
and members of the committee, thank you for inviting me today 
to speak about the critical importance of meeting the mental 
and behavioral health needs of children and youth and the roles 
schools can play in addressing these issues. My name is 
Benjamin Fernandez and I work as a lead school psychologist for 
Loudoun County Public Schools.
    I've served Loudoun County Public Schools for the last 12 
years, and I've been practicing as a school psychologist for 
almost 18 years. Loudoun County Public Schools is a school 
system west of DC in northern Virginia that has experienced a 
significant amount of student growth in the last 10 years.
    In my service to Loudoun County Public Schools, like many 
school psychologists, I provide a broad range of services to 
support the successful learning and well-being of our students, 
create a positive school climate, and ensure ongoing 
collaboration among schools, families, and community to meet 
the mental health and behavioral health needs of children and 
youth. School psychologists provide comprehensive services at 
both the district and building levels.
    Comprehensive school psychological services are defined by 
the National Association of School Psychologists practice 
standards. These services include individual student 
psychological evaluations; consultation with teachers, 
administrators, and families; social, emotional, and behavioral 
supports; individual and group counseling; skills building 
groups; threat assessment; and crisis intervention services.
    School psychologists serve on a number of multidisciplinary 
teams with parents and educators to meet the diverse needs of 
children and families in our school community. In addition, 
school psychologists provide critical universal prevention and 
early intervention services for all students and deliver 
targeted intervention for those struggling with academic, 
behavioral, emotional, and mental health concerns.
    Mental health is developed early in life, and educators 
play a significant role in ensuring that students' experiences 
throughout their school careers contribute to their positive 
mental health. Mental health issues not only impact students at 
the individual level, but they also impact school culture and 
climate, making it imperative that schools adequately address 
the mental health and behavioral needs of students to ensure 
the best possible outcomes for the entire school population.
    It is estimated that 13 percent to 20 percent of children 
experience a mental disorder in a given year. However, it's 
important to note that schools are the largest access point for 
the majority of these students who require mental health 
services. Additionally, students are more likely to seek help 
if they know that school-based services are available to them. 
That is where school psychologists in collaboration with other 
school-based mental health professionals and educators come 
into play.
    As families strive to assist their children, the topic of 
medication is raised. Schools do not recommend or prescribe 
medication. Families are encouraged to work with their 
physicians to make the decision that is most appropriate for 
their child.
    Research indicates that certain medication can be a highly 
effective treatment modality for many students with ADHD, 
depression, and other mental health issues. I have personally 
seen this with certain students. However, behavioral 
interventions, counseling, and other supports have also been 
shown to be effective and is where my focus as a school-based 
mental health professional is.
    In my service to Cool Spring Elementary and Heritage High 
School in Loudoun County, I've been able to support students in 
need by providing group counseling, skills groups, individual 
support and mentoring, and working collaboratively with various 
teams. Additionally, I work with other educators to deliver 
supports and prevention initiatives from a multi-tier system of 
supports for all students.
    An example of a student I worked with was at the elementary 
level. It was a little girl who came to Cool Spring Elementary 
with a number of issues from behavioral, mental health and 
emotional, to significant anger issues, as well as academic 
issues. Through collaborative work with her teachers, her 
school counselor, her assistant principal, and principal, we 
were able to deliver a variety of interventions to help address 
all those needs that she brought to us.
    In addition, we built relationships with her grandmother, 
who was her guardian, her therapist, and other providers that 
she worked with outside of the school to further address her 
emotional and behavioral needs in the school as well as in the 
home. With these combined supports, this student was able to 
demonstrate academic and behavioral success as she went through 
elementary school.
    Students come to school with more than just a back pack and 
a lunch box. Some come to school with behavioral, social, 
emotional, or mental health issues that impede their ability to 
be successful. For these students, intervention and support is 
found within a multi-tiered system of supports, as well as 
through dedicated staff such as school psychologists and other 
school-based employed mental health professionals.
    Addressing the mental health needs of children rarely 
occurs in isolation. Children access mental health supports 
within their schools as well as outside a school. Coordinated 
psychological intervention and medical treatment occur when 
schools collaborate with medical professionals to address these 
mental health needs. Providing access to school-based mental 
health professionals and allowing them to function in the broad 
role in which they are trained can ensure that the behavioral 
and mental health needs of students are met.
    Thank you.
    [The prepared statement of Mr. Fernandez follows:]
         Prepared Statement of Benjamin S. Fernandez, M.S. Ed.
                                summary
    School psychologists provide comprehensive services at both the 
district and building levels. Comprehensive school psychological 
services are defined by the National Association of School 
Psychologists' practice standards, known as the NASP Practice Model 
(NASP, 2010). School psychologists provide critical universal 
prevention and early intervention services for all students, and 
deliver targeted interventions for those struggling with academic, 
behavioral, emotional, and mental health concerns. A former NASP leader 
may have said it best, ``School psychologists are the educators who 
know the most about psychology and the psychologists that know the most 
about education.''
    Mental health is developed early in life and educators play a 
significant role in ensuring that students' experiences throughout 
their school careers contribute to their positive mental health. Access 
to school-based mental health services and supports directly improves 
students' physical and psychological safety, social-emotional learning, 
and academic performance. We can best meet the needs of children if we 
provide prevention, early identification, and targeted intervention for 
academic, mental health, and behavioral concerns within a multi-tiered 
system of supports (MTSS) which encompasses universal prevention for 
all students, and more targeted interventions for those students in 
need of additional support. A common vehicle in schools for 
facilitating the MTSS process and meeting student needs is through the 
Child Study Team, which is a multi-disciplinary team of professionals 
who work together to identify causes of academic and behavioral 
difficulties, develop interventions to address those problems, and 
monitor their effectiveness.
    It is important to note that in the school setting, we do not 
routinely diagnose disorders, nor are we restricted to a specific 
diagnosis in order to provide services. Certainly if a student has a 
diagnosis, we take it into account, just as we assess how the classroom 
and school environment, social interactions, and family factors might 
also contribute to behaviors or cause academic learning barriers. Our 
focus is always on what intervention and supports will help the student 
best regardless of the cause. If a student is having trouble with 
outbursts and impulsivity, what matters more in the child study process 
is which interventions help him or her learn to understand and control 
their behavior. In terms of medication, schools do not recommend or 
prescribe medication. In fact many States have laws prohibiting school 
personnel from even raising it in conversation with families. The 
decision to use medication rests entirely with the parents and child, 
in consultation with medical professionals. Research indicates that 
certain medications can be a part of a highly effective treatment 
modality for many students with ADHD, depression, and other mental 
health issues. However, behavioral interventions, counseling, and other 
supports have also been shown to be effective and this is the focus of 
school-employed mental health professionals. Ultimately, it is the 
parents' decision to share information related to their child's medical 
status; regardless, school psychologists collaborate with other members 
of the child study team to ensure that the student is receiving the 
necessary evidence-based supports he/she needs to be successful at 
school. Students come to school with more than a backpack and a 
lunchbox. Some come to school with behavioral, social, emotional, or 
mental health issues that impede their ability to be successful. 
Providing access to school-employed mental health professionals, and 
allowing them to function in the broad role in which they are trained, 
can ensure that the behavioral and mental health needs of all students 
are met.
                                 ______
                                 
    My name is Benjamin S. Fernandez, and I am a lead school 
psychologist for Loudoun County Public Schools (LCPS) in Virginia. I am 
pleased to have the opportunity to be here today to discuss the 
critical importance of meeting the mental and behavioral health needs 
of children and youth and the role schools can play in doing so.
                        professional background
    I have served LCPS as a school psychologist for 12 years and have 
been practicing in the field for almost 18 years. In my service to 
LCPS, like many school psychologists, I provide a broad range of 
services to support the successful learning and well-being of our 
students, create a positive school climate, and ensure ongoing 
collaboration among school, families, and the community to meet the 
mental and behavioral health needs of children and youth.
What is a School Psychologist?
    School psychologists provide comprehensive services at both the 
district and building levels. Comprehensive school psychological 
services are defined by the National Association of School 
Psychologists' practice standards, known as the NASP Practice Model 
(NASP, 2010). In broad terms, these services include assessment and 
evaluation, data-based decisionmaking at the student, classroom and 
building levels, academic, behavioral and mental health supports, case-
management and collaboration with community providers, and consultation 
with teachers, administrators and families. Specific examples include 
individual student psychological evaluations, classroom behavior 
management, supports for positive behavior and discipline, individual 
and group counseling, mental health screening, social skills 
development, threat assessment, and crisis intervention. School 
psychologists serve on a number of multidisciplinary teams with parents 
and educators to meet the diverse needs of the children and families in 
our school community. In addition, school psychologists provide 
critical universal prevention and early intervention services for all 
students, and deliver targeted interventions for those struggling with 
academic, behavioral, emotional, and mental health concerns. A former 
NASP leader may have said it best, ``School psychologists are the 
educators who know the most about psychology and the psychologists that 
knows the most about education.''

  Comprehensive School Psychological Services Promote Student Success
                   mental health supports in schools
    Mental health is developed early in life and educators play a 
significant role in ensuring that students' experiences throughout 
their school careers contribute to their positive mental health. Access 
to school-based mental health services and supports directly improves 
students' physical and psychological safety, social-emotional learning, 
and academic performance. Mental health issues not only impact students 
on the individual level, but they also impact school culture and 
climate, making it imperative that schools adequately address the 
mental and behavioral needs of students to ensure the best possible 
outcomes for the entire school population. It is estimated that 13-20 
percent of children experience a mental disorder in a given year. 
However, only 16 percent of children who need mental health services 
receive them, and the majority of students who do, access mental health 
services in the school setting. Additionally, students are more likely 
to seek help if they know school based-services are available. 
Therefore, it is vital that schools provide the appropriate supports 
for students and have the resources needed to connect students with 
significant needs with more intensive community supports. We can best 
meet the needs of children if we provide prevention, early 
identification, and targeted intervention for academic, mental health, 
and behavioral concerns within a multi-tiered system of supports 
(MTSS). Many school districts are moving to an MTSS model which also 
aligns with and reinforces successful school-wide initiatives such as 
Positive Behavior Interventions and Supports (PBIS) and Response to 
Intervention (RtI).
    MTSS begins with a universal tier of supports and services provided 
to all students and that research tells us will meet the academic and 
behavioral needs of the majority of students. This first tier focuses 
on prevention, wellness promotion, teaching shared behavioral 
expectations, and skills building. The second tier focuses on those 
students who still struggle despite the universal supports and need 
more targeted interventions. The specific needs of these students are 
identified through universal screenings; appropriate interventions are 
delivered and monitored in small groups. An example of such a subset of 
students might be those who exhibit appropriate behavior most of the 
time but repeatedly struggle under specific circumstances such as 
acting out when frustrated, being disruptive during transitions, or 
having difficulty in social situations. The third tier targets a 
generally very small population of students who require the most 
intensive academic, behavioral, or emotional supports. At this level, 
interventions are often delivered through special education services or 
other individualized school-based supports. Frequently at this tier, a 
student is also receiving services from medical and other community 
providers and ideally school mental health personnel are collaborating 
closely with them to ensure continuity and efficacy of the 
interventions. At all levels of service delivery, the school 
psychologist collaborates with teachers and families to ensure that the 
proper services are being delivered and that information about the 
child is being shared with the appropriate people.
                          child study process
    A common vehicle in schools for facilitating the MTSS process and 
meet student needs is the Child Study Process. This process is 
initiated when a teacher, administrator or parent has a concern about a 
child and it is implemented by the Child Study Team. This is a multi-
disciplinary team of professionals who work together to identify causes 
of academic and behavioral difficulties, develop interventions to 
address those problems, and monitor their effectiveness. School 
psychologists play an integral role on this team, and are often the 
person that provides the targeted interventions, in group and 
individual settings, for students struggling with behavioral or mental 
health concerns. To illustrate how this process works and to re-iterate 
the importance of prevention and early intervention, I would like to 
share some examples from my experience. (All names have been changed.)
         prevention and intervention in elementary school (amy)
    Amy was a young girl being raised along with her brothers by her 
grandmother. She and her brothers struggled with a variety of 
behavioral issues, but this girl in particular struggled with defiance, 
refusal to comply with adult directives, cursing, disrespect, stealing, 
and aggression. Because of her behavior, she missed a great deal of 
instruction, peers avoided playing with her, and she was generally 
unhappy and frustrated with school. There were concerns that Amy was 
struggling with ADHD and perhaps depression, but she had not been 
formally diagnosed with either of these.
    When the Child Study Team first convened to discuss Amy's 
difficulties, our collective goal was to help her be more successful at 
school and to provide advice and supports to her grandmother to help 
her deal with the challenging behavior at home. Our team included Amy's 
grandmother, her teacher, the school social worker, the school 
counselor, and the principal. We created behavior plans, worked with 
the classroom teachers on how to consistently implement the behavior 
plan, and how to work with the student. We also determined which type 
of mental health supports she needed and devised a plan to ensure she 
received these supports at school while also making sure that she was 
in the classroom during critical instructional time as much as 
possible. As she moved through the grade levels, she was placed with 
teachers who best fit her as a student and would be able to meet her 
emotional and behavioral needs. Because we were able to identify her 
needs, and provide Amy with the proper supports, she made continuous 
academic progress and had a successful transition to middle school. Amy 
continues to need support but with the supports she was given, she was 
able to reach her full potential, which included keeping the required 
GPA to participate on the soccer team.
    Schools can provide a number of supports for students to help them 
cope with behavioral and mental health concerns. Amy received the 
following supports:

     Small group counseling to address anger management skills 
with a group of students with similar issues.
     Behavior management plan to help her increase her on-task 
time in the classroom.
     Individual counseling.
     Connection with supports in the community via the social 
worker.

    In addition to these individualized targeted interventions, there 
were universal supports that are available to ALL students but also 
benefited Amy. These include:

     Character education for all students.
     Mentoring program.
     Effective discipline.
     Social emotional learning curriculum in the classroom.
              prevention at the high school level (thomas)
    An example of one of the universal prevention initiatives is LCPS's 
Depression Awareness/Suicide Prevention presentations. Many other 
school districts also offer this type of prevention programming in 
their high schools and middle schools. Suicide is one of the leading 
causes of death in children ages 10-19. This initiative's goal is to 
teach students the signs and symptoms of depression and the warning 
signs and risk factors related to suicide. Students are also taught how 
to seek assistance by telling a trusted adult and that telling a 
trusted adult is not betraying a friend. These presentations have 
helped to destigmatize depression and mental health issues allowing for 
an environment where students feel comfortable approaching staff when 
they have concerns about a friend or someone else considering harming 
themselves. This atmosphere has also assisted with students who have 
concerns for bullying and student threats. In LCPS, these presentations 
are conducted in all ninth grade health and PE classes. Within the last 
few years, Heritage High School--along with a number of Loudoun County 
High Schools--has begun implementing Depression Awareness Booster 
sessions.
                           the case of thomas
    Another example of how this process works at the high school level, 
involves a student named Thomas. I first met him when he was a 9th 
grade student returning to school after his long-term suspension for 
vandalizing a school bus. Thomas was a student receiving group 
counseling focusing on social skills, anger management, and coping. 
Additionally, his mother had health difficulties and there had been a 
number of deaths within his immediate family that directly impacted 
him. Overall, he struggled academically, behaviorally, and emotionally. 
He was frequently late for class, struggled with controlling his temper 
with peers and adults, and was failing. For Thomas, support and 
intervention started with staff relationships. This began with his 
participation in a counseling group that I co-led with a school social 
worker and with weekly check-ins. Through this process, we were able to 
identify skill areas he lacked and were able to work with him to manage 
his anger and appropriately engage with adults in the classroom. In 
addition to this work, Thomas worked closely with a special education 
teacher to focus on his academics, which helped foster another positive 
relationship with an adult in the building. Finally, the multi-
disciplinary team, which included myself, the school social worker, 
teachers assigned to the clinical program, a school counselor, and the 
assistant principal met twice a month to discuss the progress of not 
only Thomas, but other students who needed behavioral and mental health 
support. These problem-solving meetings focused on student successes 
and challenges with the goal of supporting these students. These 
supports followed Thomas through his high school career when he 
ultimately graduated.
    As in the example of Amy above, schools cannot only provide a 
number of supports for students to help them cope with behavioral and 
mental health concerns, but deliver them at all grade levels. Thomas 
received the following supports:

     Small group counseling to address social and anger 
management skills with a group of students with similar issues.
     Behavior management plan to help him increase his on-task 
time and display of appropriate behaviors in the classroom.
     Individual counseling.
     Direct collaborative and attentive relationships with his 
teachers and other adults within the school.

    In addition to these individualized targeted interventions, there 
were also universal supports at the high school level that are 
available to ALL students as well as Thomas. These include:

     Character education for all students.
     Mentoring program.
     Effective discipline.
     Social emotional learning curriculum in the classroom.
          role of diagnoses and medication in school services
    It is important to note that in the school setting, we do not 
routinely diagnose disorders, nor are we restricted to a specific 
diagnosis in order to provide services. Certainly if a student has a 
diagnosis, we take it into account, just as we assess how the classroom 
and school environment, social interactions, and family factors might 
also contribute to behaviors or cause academic learning barriers. Our 
focus is always on what intervention and supports will help the student 
best regardless of the cause. If a student is having trouble with 
outbursts and impulsivity, what matters more in the child study process 
is which interventions help him or her learn to understand and control 
their behavior.
    In this vein, we also do not ``treat'' students in schools; rather 
we provide interventions and supports to them. This is both a 
terminology difference and a perspective. Treatment implies a medical 
model that is usually diagnosis specific and focused on that diagnosis 
only. Cognitive behavioral therapy provided in school isn't different 
than cognitive behavioral therapy provided in a clinic but we call it 
an intervention, not a treatment, and it is almost always just one of a 
number of strategies being used. Additionally, as noted earlier in the 
child study process, school-based interventions almost always engage 
multiple people in the student's life, such as teachers, parents, and 
other key adults, in order to fully support the student's progress in 
all relevant settings.
    In terms of medication, schools do not recommend or prescribe 
medication. In fact many States have laws prohibiting school personnel 
from even raising it in conversation with families. The decision to use 
medication rests entirely with the parents and child, in consultation 
with medical professionals. When the student needs to take medication 
during the school day, the school nurse would be in charge of 
administering it, with explicit permission from the parents or 
guardians. Research indicates that certain medications can be a part of 
a highly effective treatment modality for many students with ADHD, 
depression, and other mental health issues. I personally have seen this 
with certain students. However, behavioral interventions, counseling, 
and other supports have also been shown to be effective and this is 
where my focus is as a school-based mental health professional.
    Sometimes parents raise the issue of medication with us, in which 
case we can share information, but we do not give advice. We encourage 
parents and families to work with their doctor to make the decision 
that is most appropriate for the child. Ultimately, it is the parents' 
decision to share information related to their child's medical status. 
In some cases, the school will not know because the parent has decided. 
In other instances, a parent chooses to share that their child is 
prescribed medication. In these instances, if the parent gives 
permission, the school nurse and school psychologist may maintain 
contact with the doctor to make sure that teachers and other staff are 
aware of any potential side effects of medication that may impact the 
student at school. Regardless, school psychologists collaborate with 
other members of the child study team to ensure that the student is 
receiving the necessary supports he/she needs to be successful at 
school.
                               conclusion
    Students come to school with more than a backpack and a lunch box. 
Some come to school with behavioral, social, emotional, or mental 
health issues that impede their ability to be successful. Providing 
access to school employed mental health professionals, and allowing 
them to function in the broad role in which they are trained, can 
ensure that the behavioral and mental health needs of all students are 
met.
                               References
National Association of School Psychologists. (2010). Model for 
    Comprehensive and Integrated School Psychological Services. 
    Bethesda, MD: Author. http://www.nasponline.org/standards/
    2010standards/2_PracticeModel.pdf.
National Association of School Psychologists. (2006). School Based 
    Mental Health Services and School Psychologists. http://
    www.nasponline.org/resources/handouts/sbmhservices.pdf.

    The Chairman. Thank you, Mr. Fernandez.
    Mr. Arch.

 STATEMENT OF JOHN K. ARCH, FACHE, EXECUTIVE VICE PRESIDENT OF 
HEALTH CARE AND DIRECTOR, BOYS TOWN NATIONAL RESEARCH HOSPITAL 
                     AND CLINICS, OMAHA, NE

    Mr. Arch. Thank you. Good morning, Chairman Harkin, Senator 
Alexander, and Senator Baldwin. Thank you very much for 
inviting me to speak. I am John Arch. I'm the executive vice 
president of Health Care at Boys Town and director of Boys Town 
National Research Hospital in Omaha, NE.
    First, I'd like to personally thank Senator Harkin for your 
friendship to Boys Town Hospital over the years, especially 
your work with our communication disorders kids, deaf and hard 
of hearing. Thank you very much for your friendship.
    The Chairman. Young kids diagnosed early.
    Mr. Arch. Yes, early diagnosis for the communication 
disorders. Thank you very much for that friendship.
    The Chairman. You've been very good at that.
    Mr. Arch. I'm honored to represent Boys Town. Founded in 
1917, we serve now over 72,000 kids each year across the United 
States in nine different States with sites. We have a mission 
that is very bold. We want to change the way America cares for 
kids, families, and communities. So that's what brings me here 
today to talk about the use of psychotropic meds, in 
particular, one service that I'll mention here in just a 
second.
    Boys Town is divided into two divisions. There's a youth 
care division and a health care division. The youth care 
division is probably the better known division, in that that's 
the Mickey Rooney-Spencer Tracy--the movie, Boys Town--that 
residential care. While residential care was where Boys Town 
started, most of their care now is in-home services, trying to 
keep families intact, trying to keep kids in the home, and 
those are, again, across nine States.
    The Health Care Division that I'm responsible for has the 
medical services, medically directed services, as well as 
medical research--I mentioned communication disorders in 
children--as well as the behavioral health research. Our 
division, the Health Care Division, serves 45,000 children 
annually, including the most troubled kids that Boys Town cares 
for in our Residential Treatment Center. Since opening this 
center in 1996, we have accepted kids from 38 different States 
for treatment there. This treatment center is located in Omaha, 
NE.
    Our treatment center provides a secure environment that's 
designed to offer medically directed care for the most 
seriously troubled youth. If you can imagine this continuum of 
care, inpatient care would be most acute care, and that's 
usually a 3- to 5-day length of stay.
    The Residential Treatment Center is a step down from that 
care. There, we treat children from ages 5 to 18 with an 
approximate length of stay of about 120 days. These children do 
not require that acute inpatient care. Their crisis has 
stabilized, where perhaps they were a danger to themselves or 
others at that time, and then they maybe step down to our care 
in the residential treatment. But they include school failures, 
multiple placements, perhaps a history of self-injury--the 
truly serious.
    Most kids have had some contact with the law by the time 
they reach the Residential Treatment Center. They've not been 
successful at lower levels of care. They've experienced 
multiple placements within the mental health system. So they 
are admitted to the Residential Treatment Center.
    The child psychiatrist is the medical director and the head 
of the treatment team. The treatment then begins with the 
assessment of the child and very, very specific--we call it a 
bio-psychosocial treatment model that includes the medical, the 
psychological, as well as the social aspects of that child, the 
behavioral treatment.
    The model of care at Boys Town is very behavior-focused. So 
when the child is admitted to the Residential Treatment Center, 
certain behaviors are identified that that child needs to work 
on. During the day, that behavior is taught. All the while, 
there is a medical management that is going on regarding the 
use of meds.
    When we see kids enter our program, we see kids on multiple 
psychotropic meds, generally, and we've had kids on up to eight 
different psychotropic meds admitted to the program. This is a 
result of them seeing different physicians throughout their 
life, perhaps a family practice, pediatrician, maybe a child 
psychiatrist, all attempting to help the family get some self-
control and some control with the child's behavior. So when 
they come to us, it's because that has not been successful.
    Approximately 79 percent of the children that are admitted 
to our treatment center are being prescribed at that time 
multiple psychotropic meds. And, like everyone has testified, 
we're also very concerned about this lack of scientific 
evidence as to exactly what these antipsychotics can do, both 
developmentally as well as educationally. When these kids come 
to our program, they're generally 2 years behind in the 
educational process and need to catch up.
    I have an example. I'll call the child David. He came to us 
in his early teens. He weighed about 300 pounds, and he was 
really struggling. He had some extreme temper issues. He was 
referred to us by a judge to seek some care.
    We began to reduce the number of psychotropic meds as well 
as doses. And successfully, over a period of time, he was 
tapered off several of those meds as well as reducing the 
doses. He was able to move down to one of Boys Town's 
residential homes.
    He actually graduated from the high school and went on to 
an engineering career at the university. So that combination of 
reducing those psychotropic meds and putting in self-control, 
those behavior interventions, has worked within our treatment 
model.
    We had a recent study that was conducted at our treatment 
center, and utilizing this medication management program within 
that structure of the strong behavioral, we demonstrated a 33-
percent reduction in the number of youth on any psychotropic 
med, a 38-percent reduction in the average number of meds being 
prescribed at the time of discharge. So we moved from about 75 
percent of our kids on meds in the Residential Treatment Center 
to 50 percent upon discharge.
    Then we reduced from about 3.3 average medications per 
child to about 2.1. In both dose as well as removing completely 
from psychotropic meds by putting the behavioral model and 
other interventions into place and teaching to that behavior, 
we saw that. And, actually, we saw a 63 percent reduction in 
aggressive behavior at the same time we were moving these kids 
off of these psychotropic meds. So it obviously was successful 
in doing that.
    But our mission is to change the way America cares for 
kids. So we are pushing hard into behavioral health research, 
as we've done in our communication disorders research.
    In 2012, we hosted an NIMH-sponsored conference specific to 
psychotropic meds in kids and gathered experts around the 
United States to come to Omaha to discuss that and created some 
task forces. Those task forces, going forward, are going to be 
taking a look at the forces that drive the current high 
medication rates, establishing processes for taking children 
off the medications, and defining effective management of 
medication use within the context of other treatment. So that 
work is ongoing after that NIMH-sponsored conference.
    But we needed to do more. So we launched a Neurobehavioral 
Research Center in Omaha. We want to take a look at not only 
the psychotropic meds, but also alternatives. What we see is 
not enough evidence of the biological markers. So using FMRI, 
we want to use that as a primary research modality and take a 
look at kids.
    One of the studies we have is, as they come in on multiple 
psychotropic meds, having that FMRI done at that time, and as 
we move the kids off psychotropic meds, continue to examine--
are we seeing a normalization of brain activity as we remove 
these kids and we put other interventions in place, behavioral 
interventions. We want to take a look at exercise and see what 
that does.
    We want to take a look at some of the alternatives, such as 
computer games specifically designed to treat depression, and 
see if some of that can be used--whatever we can do in an 
attempt to reduce and only use medications when appropriate and 
when necessary and implement other alternatives.
    Thank you very much for allowing me to speak today. I would 
encourage this committee and the Senators to consider very 
seriously the ongoing funding for research that's needed, and 
as those alternatives are developed and intervention 
strategies, that those alternatives are available in 
communities, because that's what's driving a lot of this.
    Some of the physicians don't have alternatives in those 
communities to refer to, especially as you get into the rural 
areas. So they are left with desperate parents that need 
psychotropic meds, something to control the behavior of their 
child. So please continue that funding.
    Thank you very much.
    [The prepared statement of Mr. Arch follows:]
                 Prepared Statement of John Arch, FACHE
                                summary
    Boys Town was founded in Omaha, NE in 1917 by Father Edward 
Flanagan. Today, Boys Town provides care to youth in nine States, 
directly serving more than 72,000 children annually. The Boys Town 
mission is ``to change the way America cares for children, families and 
communities'' and shapes everything the organization does, including 
its efforts to address the national concern regarding the appropriate 
use of psychotropic medications in the treatment of children.
    Boys Town's services are organized in two major divisions: youth 
care and health care. Youth Care offers residential care, family 
counseling, foster care, and in-home services and many other programs. 
Health care provides medical care and conducts medical research, 
including studies relating to childhood communication disorders and 
behavioral health. The Health Care division offers Boys Town's highest 
level of behavioral health care at its secure Residential Treatment 
Center facility. The Center provides medically directed intensive 
treatment for troubled children ages 5 to 18. Treatment is based on 
Boys Town's distinctive bio-psychosocial model which coordinates 
medical, psychological and behavioral treatment.
    Approximately 79 percent of the children admitted to the Treatment 
Center are taking multiple psychotropic medications to control their 
behavior at the time of admission. Although effective in treating some 
problems, due to the physical side effects of these medications, more 
research is needed regarding their safety and appropriate use.
    A recent study conducted at the Treatment Center demonstrated the 
success of Boys Town's treatment model, showing a reduction of 33 
percent in the number of children taking any medications and a 38.2 
percent reduction in the average number of medications being taken at 
the time of discharge.
    In furthering their mission, Boys Town has undertaken initiatives 
to study the appropriate use of psychotropic medications in children. 
For example, in 2012, with a grant from The National Institute of 
Mental Health (NIMH), Boys Town hosted a diverse group of scientists, 
physicians, human service providers and child advocates to discuss the 
issue. Going forward, research teams will examine the forces driving 
the high medication rates and define effective management of 
medications. In addition, Boys Town has launched the Center for 
Neurobehavioral Research in Children located at Boys Town National 
Research Hospital. Boys Town's long history of providing effective care 
and the Hospital's successful 40 years of medical research position the 
Research Center to become a collaborative effort that will offer 
evidence-based solutions to the larger mental health community. 
Researchers are currently partnering with NIMH to investigate the 
effects of these medications on brain functioning using imaging 
technology.
                                 ______
                                 
    Good morning Chairman Harkin, Ranking Member Alexander, and members 
of the committee. Thank you for inviting me to speak with you today on 
this critical issue. I am John Arch, executive vice president of Health 
Care at Boys Town, and director of Boys Town National Research Hospital 
in Omaha, NE.
    I would first like to thank Chairman Harkin for his ongoing support 
of the work of Boys Town National Research Hospital over the years, and 
his personal interest in continuing to raise awareness of today's issue 
in Congress and the administration.
    I am honored to represent Boys Town, an institution founded in 
Omaha, NE, in 1917 by Father Edward Flanagan. Boys Town provides care 
to youth in nine States, directly serving more than 72,000 children 
each year. While Boys Town cares for a large number of children, our 
mission is more far-reaching. The Boys Town mission is to ``Change the 
way America cares for children, families, and communities.'' That 
mission shapes everything we do, including our efforts to address the 
national concern regarding the appropriate use of psychotropic 
medication in the treatment of children.
    Boys Town's services are organized in two major divisions: youth 
care and health care. The youth care division offers residential care, 
family counseling, foster care, and in-home services among its many 
programs. The health care division, for which I am responsible, 
provides medical care and conducts medical research, focusing on 
communication disorders in children, and behavioral health. The health 
care division serves 45,000 children annually, including the most 
troubled children cared for by Boys Town in our Residential Treatment 
Center. Since opening the Center in 1996, we have treated children from 
38 States.
    Our Treatment Center provides a secure environment that is designed 
to offer medically directed care for more seriously troubled youth. 
These youth require supervision, safety and therapy but do not require 
inpatient psychiatric care. Each day we care for more than 80 children 
from ages 5 to 18 with an average length of stay of approximately 120 
days.
    These children do not require acute inpatient care but need a very 
structured environment to treat their conditions. Their problems 
commonly include school failures, aggression, self-injury, property 
damage and a history of police and court involvement. The majority of 
the children have not been successful in lower levels of care and have 
experienced multiple placements within the mental health system. 
Without intensive treatment, their futures hold little promise.
    Our medically directed programs base treatment on Boys Town's 
distinctive bio-psychosocial model. This model of care creates a milieu 
where medical, psychological and behavioral treatment of children can 
be coordinated.
    Our model of care is very behavior-focused. Children spend each day 
with specially trained and motivated staff. All staff members actively 
teach appropriate behavior to replace individual problem behaviors 
identified when a child enters the program. Children also are taught 
self-control options to be used in times of stress or in situations 
where they have historically used inappropriate coping behavior.
    Approximately 79 percent of the children who are admitted to our 
Treatment Center are being prescribed multiple psychotropic medications 
at the time of admission, with some taking as many as eight to control 
their behavior. We are very concerned with the lack of scientific 
evidence regarding the safety and efficacy of these drugs in young 
patients, especially the potential long-term effects on their 
development. According to our physicians, these medications, when 
appropriately prescribed, can successfully combat depression, anxiety, 
psychosis, ADHD and many other mental health disorders in children. 
However, children may also experience weight gain, sedation, pre-
diabetes and disruptions in hormones while on these medications. These 
children may also experience developmental problems that affect 
educational achievement and last into adulthood. Our overall treatment 
philosophy is to appropriately use psychotropic medication in 
combination with behavioral and other treatment modalities.
    We treated a young man I will call David a few years ago who had 
been in and out of the mental health system several times. He had 
extreme temper issues and eventually was arrested for assault. The 
judge referred him to our treatment center.
    At the time he was admitted, he weighed more than 300 pounds and 
was taking multiple psychotropic medications prescribed by different 
physicians. During his time with us, he was tapered off several of his 
medications and the level of the other medications was reduced. With 
treatment and appropriate medication he improved and was able to step 
down to one of Boys Town's residential family homes where he went on to 
graduate from high school near the top of his class and enrolled at a 
local university to study engineering.
    With our approach, we have been able to achieve a significant 
reduction in medication among the children we treat.
    A recent study conducted at our Treatment Center, utilizing a 
medication management program within the structure of our strong 
behavioral treatment model, demonstrated a 33 percent reduction in the 
number of youth on any psychotropic medication and a 38.2 percent 
reduction in the average number of medications being prescribed at the 
time of discharge. The study was a part of a nationwide research 
project conducted by Boys Town in collaboration with other 
organizations. I have provided the results of that project to the 
committee.
    Children are succeeding with our treatment model, but our Boys Town 
mission compels us to do more.
    In 2012, Boys Town hosted a diverse group of researchers, 
physicians, human service organizations and other child advocates from 
across the United States for a 2-day conference funded by the National 
Institute of Mental Health to discuss the use of psychotropic 
medications to treat children. Going forward, research teams will 
examine the forces that drive the current high medication rates, 
establish processes for taking children off the medications when 
appropriate, and define effective management of medication use within 
the context of other treatments.
    It was apparent from this conference and other sources that 
additional research is needed in this field. Therefore, Boys Town 
launched a new research initiative with its Center for Neurobehavioral 
Research in Children, located at Boys Town National Research Hospital. 
Our Research Center is building on recent research to develop 
alternative intervention methods. Boys Town's long history of providing 
effective care and the Hospital's successful 40 years of research 
position our Research Center to become a state-of-the-art collaborative 
effort that will offer evidence-based solutions for treatment to the 
larger mental health community.
    To better understand whether these medications do have a 
therapeutic benefit, our Research Center is currently partnering with 
the National Institute of Mental Health to investigate the effects of 
these medications on brain functioning using imaging technology.
    Chairman Harkin, Ranking Member Alexander, and members of the 
committee, I want to thank you for inviting me to testify today.
    We encourage members of the committee to support research funding 
to better understand the effects of psychotropic medication in 
children, to develop effective alternatives to treatment, and to ensure 
that those alternative treatment programs are available to clinicians 
and families in communities across the United States.
    Thank you again for this opportunity to speak to you today.

    The Chairman. Thank you, Mr. Arch.
    And now Ms. Martinez. Welcome.

STATEMENT OF TIFFANY MARTINEZ, STUDENT, UNIVERSITY OF SOUTHERN 
                      MAINE, PORTLAND, ME

    Ms. Martinez. Good morning, Chairman Harkin, Ranking Member 
Alexander, and members of the committee. Thank you for having 
me here today. My name is Tiffany Martinez. I am currently 
finishing my master's degree in nursing at the University of 
Southern Maine, studying to become a psychiatric nurse 
practitioner.
    When I meet people today, it's hard for them to believe 
that I struggled with mental illness. In 2005, at the age of 
17, I started to exhibit early signs of psychosis. At first, 
they were subtle signs, depression, withdrawing from friends, 
and feeling that something wasn't right.
    When I began my freshman year at the University of Southern 
Maine, the signs intensified. My mind started to play tricks on 
me. I would see shadows and hear noises. I would believe 
someone was whispering in my ear when there was no one next to 
me.
    Eventually, the symptoms were interfering with my daily 
life. I had always been a good student, but I started to 
struggle academically and have bizarre thoughts that seemed 
logical to me. I would fear that the tall trees in the 
courtyard outside my dorm would fall on me. I had thoughts of 
hurting myself.
    Fortunately, my aunt and friends recognized that something 
was wrong. They encouraged me to go to the university health 
center. This was a very hard step. I didn't want to admit I had 
a problem and needed help. I was scared, confused, and 
embarrassed.
    But the school nurse recognized that I needed immediate 
help. She had recently attended a seminar conducted by a staff 
member of PIER. PIER stands for the Portland Identification and 
Early Referral Program. The nurse was trained to recognize the 
early signs of psychosis. She referred me to PIER for an 
evaluation.
    Within 1 week of my referral to PIER, I received a more in-
depth screening and entered into a comprehensive treatment 
program. When they told me I was experiencing early signs of 
psychosis, I became terrified. I have a dad with schizophrenia, 
so I knew what this could mean. He has a hard time functioning 
and is homeless. I thought my life was over.
    Fortunately, the PIER program was the right option for me. 
The staff kept me engaged in my care and on the road to 
recovery, even when things got bumpy. I learned early in 
treatment about early psychosis symptoms and how to deal with 
them, as well as coping skills to reduce stress. I met with a 
counselor and psychiatrist who let me recover at my own pace. 
The extreme paranoia I experienced made it hard to trust 
anyone, but I never felt judged by my clinical team. They 
understood when I was overwhelmed and couldn't do anything on 
my own.
    When I first started treatment and could not leave my dorm 
room, my counselor picked me up and took me to appointments. I 
was also prescribed medication that helped control my symptoms 
and enabled me to function day to day. Initially, I resisted 
this part of treatment. However, my doctor listened to my 
concerns and carefully answered my questions.
    When I took medication, he would ask me about side effects 
and how I was feeling. He would regularly check up on me. After 
consulting with my doctor and evaluating my progress, I ended 
the use of medication in 2009. I have not needed them since.
    One of the key things PIER did to make sure my recovery 
would be successful was to incorporate my family. They engaged 
a cousin who lived nearby and helped educate her on how to 
support me. PIER also worked with the university, which, in 
turn, made accommodations so I could stay in school and 
complete my degree.
    I also became involved with a multicultural center at the 
university. I lived on a reservation while growing up, and this 
allowed me to stay connected to my Native American heritage. 
Participating in activities that were familiar to me helped me 
to feel like myself again.
    The PIER program not only changed my life. It saved my 
life. I had access to a program that could intervene early and 
help me before my condition worsened. As I know too well from 
my father's experience, not everyone has the opportunity I was 
given.
    A few years after I became involved with PIER, the Robert 
Wood Johnson Foundation recognized the promise of the program 
and invested in the Early Detection and Intervention for the 
Prevention of Psychosis Program, or EDIPPP. They funded five 
diverse sites around the country: California, Oregon, New York, 
New Mexico, and Michigan. The program continues to expand in 
Oregon and California. Other States have expressed interest in 
the model.
    I urge the committee to consider how these programs can be 
made available to more people. I am proof that early 
intervention works. If this was cancer, we wouldn't wait to 
prevent it if we could. Why treat mental illness any different?
    I thank the committee for inviting me here today and for 
holding this hearing on such an important issue. Thank you.
    [The prepared statement of Ms. Martinez follows:]
                 Prepared Statement of Tiffany Martinez
                                summary
    Good morning, Chairman Harkin, Ranking Member Alexander and members 
of the committee.
    My name is Tiffany Martinez. I am currently finishing up my 
master's degree in nursing at the University of Southern Maine. In 
2005, at the age of 17, I started to exhibit early signs of psychosis. 
At first, they were very subtle signs--depression, withdrawing from 
friends, and feeling that something wasn't right. Eventually, the 
symptoms intensified and interfered with my daily life. I started to 
struggle academically and have bizarre thoughts that seemed logical to 
me. Fortunately, my aunt and friends encouraged me to go to the 
university health center.
    This was a very hard step. I didn't want to admit I had a problem. 
The school nurse recognized that I needed immediate help and referred 
me to the Portland Identification and Early Referral (PIER) program. 
Within just 1 week of my referral to PIER, I received a more in-depth 
screening and entered into a comprehensive treatment program.
    When I was told I was experiencing early signs of psychosis, I 
became terrified. My father has schizophrenia, so I knew what this 
could mean. He has a hard time functioning and is homeless. I thought 
my life was over.
    Fortunately, the PIER program was the right option for me. The 
program is structured to be patient-centered and supportive. I learned 
early in treatment about early psychosis symptoms and how to deal with 
them, as well as coping skills to reduce stress.
    I was also put on medication that helped control my symptoms. I 
resisted this part of my treatment, but my doctor listened to my 
concerns, answered my questions, asked about side effects, and 
regularly checked-up on me. I ended the use of the medication in 2009 
and have not needed them since.
    The PIER program not only changed my life, it SAVED my life. I had 
access to a program that could intervene early and help me before my 
condition worsened. Not everyone, like my father, has the opportunity I 
was given.
    A few years after I was referred to PIER, the Robert Wood Johnson 
Foundation recognized the promise of the program and invested in five 
diverse sites around the country (California, Oregon, New York, New 
Mexico, and Michigan) to collect solid evidence on the effects of early 
intervention. The program continues to expand in Oregon and California. 
Other States have expressed interest in the model.
    I urge the committee to consider how early intervention programs 
can be made available to more people. I am proof that early 
intervention works. If this was cancer, we wouldn't wait to prevent it. 
Why treat mental illness any different?
                                 ______
                                 
    Good morning, Chairman Harkin, Ranking Member Alexander and members 
of the committee.
    Thank you for the opportunity to share my story with you today.
    My name is Tiffany Martinez. I am currently finishing up a masters 
of nursing program at the University of Southern Maine, studying to 
become a psychiatric nurse practitioner. I also work as a nurse at a 
local prison and at a program that serves adults with developmental and 
behavioral challenges.
    When I meet people today, they see me as a hard-working young adult 
with friends and a full life. It's hard for my classmates and 
colleagues to believe that I struggled with mental illness.
    There was a time too, when I would not have imagined that I would 
be able to sit here today and share my story.
    In 2005, at the age of 17, I started to exhibit early signs of 
psychosis. At first, they were very subtle signs--depression, 
withdrawing from friends, and feeling that something wasn't right.
    When I began my freshman year at the University of Southern Maine, 
the signs intensified. My mind started playing tricks on me. I would 
see shadows and hear noises: I would believe someone was whispering in 
my ear when there was no one next to me.
    Eventually, the symptoms interfered with my daily life. I had 
always been a good student, but I started to struggle academically and 
have bizarre thoughts that seemed logical to me. I would fear that the 
tall trees in the courtyard outside my dorm would fall on me. Over 
time, just leaving my dorm room became difficult. I began having 
thoughts of hurting myself. Fortunately, my aunt and friends from 
school recognized that something was wrong. They encouraged me to go to 
the university health center.
    This was a very hard step. I was a young adult. I didn't want to 
admit I had a problem and needed help. I was scared, confused, and 
embarrassed. I didn't know how to begin to verbalize all that I was 
experiencing.
    But the school nurse quickly recognized that I needed immediate 
help. She had recently attended a seminar conducted by a staff member 
of PIER. PIER stands for the Portland Identification and Early Referral 
program and it is based at the Maine Medical Center. The nurse was 
trained to recognize the early signs of psychosis, such as patients 
seeing or hearing things that are not there; having persistent 
illogical or irrational thoughts that do not disappear; and being 
unable to think straight, focus, or speak coherently. After she met 
with me, she referred me to PIER for an evaluation.
    Within just 1 week of my referral to PIER, I received a more in-
depth screening and entered into a comprehensive treatment program that 
included counseling, psychoeducational support, and medication.
    When they told me I was experiencing early signs of psychosis, I 
became terrified. I have a dad with schizophrenia so I knew what that 
could mean. He has a hard time functioning and is homeless. I thought 
my life was over.
    Fortunately, the PIER program was the right option for me. The 
program is structured to be patient-centered and supportive. The staff 
kept me engaged in my care and on the road to recovery, even when 
things got bumpy.
    I learned early in treatment about early psychosis symptoms and how 
to deal with them, as well as coping skills to reduce stress.
    I met with a counselor and psychiatrist who let me recover at my 
own pace. A nurse also provided care for me early in the program to 
track vital signs and other physical conditions. The extreme paranoia I 
experienced made it hard to trust anyone, but I never felt judged by my 
clinical team. They understood when I was overwhelmed and couldn't do 
anything on my own. When I first started treatment and could not leave 
my dorm room, my counselor picked me up and took me to appointments.
    The strong support I received helped me form a connection that 
built trust and kept me on a path to recovery.
    I was also prescribed medication that helped control my symptoms 
and enabled me to function day-to-day. I resisted this part of 
treatment. But instead of forcing me to take my medication, my doctor 
acted more like a partner. He listened to my concerns and carefully 
answered my questions. When I took medication, he asked me about side 
effects and how I was feeling. He would regularly check up on me to 
make sure I was keeping to my medication schedule.
    And after consulting with my doctor and evaluating my progress, I 
ended use of the medication in 2009. I have not needed them since.
    One of the key things PIER did to make sure my recovery would be 
successful was incorporate my family. My immediate family lived about 4 
hours away from the university, so it was hard for them to participate 
in my care. The PIER team engaged my cousin, who lived nearby, to play 
a role in my treatment. PIER educated my family about my condition and 
taught them how to respond.
    PIER also worked with the university to make sure I could stay in 
school and complete my degree. Thanks to those efforts, the university 
helped me manage my workload and deadlines so that I could continue 
going to classes while in treatment.
    I also became involved with the multicultural center at the 
university. This allowed me to stay connected to my Native American 
heritage. I lived on a reservation from the time I was 6 until I left 
for college; the Native American culture is a large part of who I am. 
During my recovery, participating in activities that were familiar 
helped me begin to feel normal and like myself.
    The PIER program not only changed my life, it SAVED my life. I am 
one of the lucky ones. I had access to a program that could intervene 
early and help me before my condition got worse. As I know too well 
after witnessing my father's experience, not everyone has the 
opportunity I was given.
    I wouldn't be here today if it weren't for a program like PIER. I 
want you to know that programs like this can make a tremendous 
difference to people's lives and their futures.
    A few years after I became involved with PIER, the Robert Wood 
Johnson Foundation recognized the promise of a program that focused on 
treating young people before they experience their first full-blown 
psychotic episode. Building on the PIER model, the Foundation invested 
in the Early Detection and Intervention for the Prevention of Psychosis 
Program (EDIPPP). They funded five diverse sites around the country--
California, Oregon, New York, New Mexico, and Michigan--to collect 
solid evidence on the effects of early intervention for mental illness. 
The program continues to expand in Oregon and California. Other States 
have shown interest in implementing the program.
    I urge the committee to consider how these programs can be made 
available to more people. Through my own studies to become a nurse 
practitioner, my colleagues and classmates are interested in programs 
that help them recognize the early warning signs so they too can 
prevent people from developing early problems.
    Nine years after I was first referred to PIER, I am proof that 
early intervention works. Mental illness is a disease. With early 
intervention, it can be managed and treated. If this was cancer, we 
wouldn't wait to prevent it if we could. Why do we treat a disease like 
mental illness any different?
    I thank the committee for inviting me here today and for holding 
this hearing on such an important issue.

    The Chairman. Thank you, Ms. Martinez. I thank you for 
being so courageous to talk about your own personal situation 
like this. I think this gives courage to others to not try to 
hide it and cover it up but to talk about it openly and to seek 
the help that they need. So I really thank you for that very, 
very much.
    I thank you all. We'll begin a round of 5-minute questions.
    Dr. Cooper, according to the American Academy of 
Pediatrics, approximately 70 percent of children and 
adolescents who are in need of mental health treatment do not 
receive services. Of the remaining 30 percent who do seek 
treatment, only one in five obtain mental health specialty 
services, such as those provided by a psychologist or a 
psychiatrist. Fifty percent to seventy-five percent of the care 
for children with mental health conditions occurs in primary 
care settings, family practice, pediatricians, and others.
    I was alarmed to find this out. I guess I just never 
thought about it. But primary care doctors and pediatricians 
can prescribe psychotropic drugs. I don't know why that never 
occurred to me. So they read the medical journals. They do a 
preliminary diagnosis. And perhaps the family or someone has 
read something or seen an ad, and they say, ``I think my kid 
needs Paxil. That's what it all says, and I think they need 
that.'' So the doctor or the pediatrician might say, ``Well, 
OK. I'll prescribe that.''
    How can we make sure that more pediatricians--I focus 
especially on pediatricians--have adequate training in 
assessment, diagnosis, and treatment of various mental health 
conditions? I'm just really concerned about the over-medication 
of kids and how much they're giving medication, which we don't 
even know if it works or not.
    So what do we do with this? How do we get more 
pediatricians to understand that there are other modalities, 
other than just prescribing a psychotropic drug?
    Dr. Cooper. Senator Harkin, I think you highlight a really 
critical issue here that's echoed by all the panelists today, 
and that is the notion that we really have to think about the 
right treatment for the right child. There's a lot of things 
that probably contribute to that. One of those things is 
ensuring that pediatricians and other primary care doctors or 
professionals have appropriate training and education in what 
is appropriate to diagnose a child and what the appropriate 
treatments are, ensuring that there's communication.
    One of the challenges is that--as highlighted by some of 
the cases that were presented today--oftentimes, when the right 
diagnosis is made and the right plan is put in place, there's a 
lack of access to resources. So it is absolutely critical that 
these medications, if they're needed, are used in conjunction 
with other therapies, behavioral therapies or other 
psychotherapies.
    The Chairman. Since most of these illnesses manifest 
themselves in the school setting, that's kind of the first 
place that it's--teachers say something to the school counselor 
or something like that. This is the Education Committee. Do we 
need to be taking a closer look at how many psychologists we 
have, for example?
    I, again, was alarmed to find out that school 
psychologists--these are people actually trained in psychology, 
child psychologists. The national average is 1,500 to 1, 1,500 
kids to 1. In Iowa, it's 1,294 to 1, not much better. There'll 
be a shortage of almost 9,000 school psychologists in the 
United States by 2010--we've already passed that--and an 
accumulated shortage of almost 15,000 by 2020. Should we be 
taking a look at that?
    Dr. Cooper. I think so. I think Mr. Fernandez is a nice 
example of sort of how excellence can be achieved there. In our 
practice, we routinely partner with our education colleagues. 
So it takes time. You have to call the teacher. You have to 
call the school psychologist to talk about what's going on with 
that child and what's going on in their life that helps you to 
form the best treatment plan for that child. And that's really 
a critical step.
    The Chairman. Mr. Fernandez, you said here--and I didn't 
know this--our focus, you say in your testimony, is what 
intervention and supports will help the student best, 
regardless of the cause. Then you went on to say that in terms 
of medication, schools do not recommend or prescribe 
medication. In fact, many States have laws prohibiting school 
personnel from even raising it in conversation with families.
    Are you suggesting that school personnel be allowed to 
discuss perhaps different interventions with the family? I 
don't understand what you meant by that statement. They can't 
discuss with family interventions, or just medical 
interventions?
    Mr. Fernandez. Mainly the prescribing of medication, 
because, many times, I'll be in meetings, or I have been in 
meetings in the past, where the teacher will say, ``Well, your 
child just needs Ritalin'' or ``Your child needs that.'' I'm 
not a physician. I'm not trained in prescribing medication and 
neither is the teacher. So I think some of those regulations 
and rules are in place because of that.
    The Chairman. Right.
    Mr. Fernandez. We can certainly talk about the variety of 
interventions and services and initiatives we have in school 
with a parent, and when those questions come up to us, we 
encourage them to talk to--sometimes there are clinical 
psychologists who can link them to a psychiatrist. But we 
definitely try to encourage them to talk to a medical 
professional about the specifics of prescribing medication. So 
that's what I meant in my testimony.
    The Chairman. I'll come back to that. My time is up. But 
I'll make a generalized statement here that nonprofessional 
people sometimes tend to say, ``Well, there's a drug that will 
take care of that. Just take that drug.'' And that's not a 
professional way, but a parent might listen to that.
    Senator Alexander.
    Senator Alexander. Thanks, Mr. Chairman. Let me approach it 
almost from a layman's point of view, which I am, and I think 
the way a great many Americans would look at this. This reminds 
me a little bit of the hearings we've had on food allergies, 
which, in the experience of most of us when we were young, we 
didn't ever hear about them, and all of a sudden, here they 
are, and we wonder where they came from. I know that's an 
entirely different situation.
    But, Dr. Cooper, let me start with you, and let me use this 
personal example. My mother, for 35 years in Maryville, TN, had 
25 3- and 4-year-olds in the morning and 25 5-year-olds in the 
afternoon in her preschool program. Now, 50 years ago, 40 years 
ago, how many of those kids would have been considered to have 
attention deficit disorder? Was that known then? Was that 
understood then? Do you have any idea how many children in 
their early childhood ages were diagnosed with ADHD 30 and 40 
and 50 years ago? How many of them had medication prescribed?
    Today, we're told that 20 percent of boys, by the time 
they're 17 or 18, are diagnosed with this problem, and 70 
percent have medication. So, first, what was going on 30 or 40 
or 50 years ago? Was it just not present, or was it just not 
noticed?
    Dr. Cooper. I think that's an important question. In 
thinking about your mother's classroom and my mother's 
classroom--she taught second grade and had a similar 
experience--and I recall back 30 years ago when I was in 
school--40 years ago, I guess, when I was in first grade. There 
are children that have had some of these behaviors for years, 
and they were not necessarily given a diagnosis of ADHD. So 
whether the increase that we're seeing is because there's an 
increase in----
    Senator Alexander. Excuse me. But, in plain English, we're 
really talking about a difficulty with highly focused attention 
in ADHD. Is that a correct way to say that? How would you 
describe that?
    Dr. Cooper. ADHD is sort of a balance of things that--they 
have an attention--also may have hyperactivity. You would 
describe these kids as being driven by a motor, and when they 
show up in my exam room, I can tell what's going on with this 
child, because they're bouncing from the exam room to the 
chair. They're knocking the ear specula off the wall. So you 
can often tell.
    But what happens is for a child to have a diagnosis of 
ADHD, it has to be disruptive. It has to interfere with their 
functioning. So a child's job is to go to school and grow and 
be healthy. And when these behaviors or these symptoms 
interfere with their functioning, that's when we need to put 
things in place.
    Senator Alexander. Has this condition multiplied greatly in 
the last 20 or 30 or 40 years? Or is it just being noticed more 
often?
    Dr. Cooper. I don't think we know. I think probably it's a 
combination of several factors. It certainly is being noticed 
more often, and for some children that may be a good thing. I 
think if we think about whether or not there's too much 
diagnosis--and there may be some times where there's other 
things that can be done to help these children. Behavioral 
therapies are highly effective. We find that they can really 
make a difference for these kids.
    I had a child a few months ago that we were treating, and 
we did several behavioral interventions, but they weren't 
working. We started the medication, and he said, ``It's kind of 
like my mind was being driven by a motor. The medications 
allowed me to slow down enough for the behavioral therapies to 
work.''
    Senator Alexander. I've got about a minute left here. But 
let me shift a little bit to say you've done a lot of research 
and studies, as have others who are here. Have you come to any 
conclusions of your own about why there's so much diagnosis 
compared to earlier?
    Is it something in the environment? Is it the fact that 
both parents may be working, or the only parent may be working, 
and there's less time for a child? Is it that schools, as some 
have suggested, receive more money when a child goes into 
special education? Is it because high testing is putting 
pressure on children?
    Have you come to any conclusions yourself about the growth 
and why we have 20 percent of boys by age 17 or 18 with this 
diagnosis?
    Dr. Cooper. It's really perplexing, isn't it? And I don't 
think we know the answer. I think we need to do more research 
to understand and figure out if it's an increase, or if it's 
increased recognition, or some of these other external factors 
maybe at play.
    Senator Alexander. So we just don't know.
    Dr. Cooper. We don't know.
    Senator Alexander. Little boys bounce around a lot. How do 
you make the distinction between a disorder and just the 
familiar characteristic of boys growing up?
    Dr. Cooper. I raised one. I can tell you they do. What we 
find is that if they are able to go to school, if they're able 
to function, if they're able to function with their peers and 
have friendships, then some of these symptoms may be managed 
just by helping the parents with behavioral management. But in 
times where it interferes with their job--go to school, grow, 
have friends--that's when we need to think about whether 
there's something else at play.
    Senator Alexander. Thank you.
    Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator Alexander.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman. I want to thank 
you and the Ranking Member for keeping the focus of this 
committee on this important topic, mental health, treatment 
options and trends.
    I wanted to spend my question time focusing in on a 
particular treatment option for particularly vulnerable 
children and bipartisan legislation that I've recently 
introduced concerning that treatment option. What is known as 
either therapeutic foster care or treatment foster care can be 
a ray of hope for children who have serious medical, 
psychological, behavioral, emotional, and social needs.
    Under this therapeutic or, as it's sometimes known, 
treatment foster care model, foster parents are given special, 
fairly intensive training to address the needs of youths with 
major mental or physical health challenges. And then children 
receive intensive in-home services to sustain them in the 
community. Therapeutic foster care provides critical services 
to what we estimate to be about 40,000 across the Nation at any 
given time and about 1,000 in my home State of Wisconsin.
    Mr. Arch, I understand that Boys Town has helped pioneer 
what we now know as therapeutic foster care or treatment foster 
care, and that you've nurtured this model and have been 
providing these services to at-risk youth for many years. I'd 
like you to share for the committee the Boys Town experience 
with treatment foster care and the ways in which high-quality 
services of that model can benefit these children.
    Mr. Arch. Yes, we have operated treatment foster care. Boys 
Town very much believes in a continuum of care. I spoke about 
the Residential Treatment Center, which is the highest level of 
that care within Boys Town. The treatment foster care would be 
a step below that, and it is for those kids. The Residential 
Treatment Center provides an essential place where a child can 
step down.
    A child may not be ready to make the jump from a 
Residential Treatment Center, a very highly structured 
environment, to immediately go home or to another placement at 
a lower level of care. This is a great transition for that 
child, where there is still continued structure. The other 
thing it does is it provides more opportunity to continue to 
watch the effects of psychotropic meds.
    One of the difficulties in managing and reducing 
psychotropic meds in an outpatient setting, from what the 
physicians have told me, is that it's difficult because you're 
not watching that behavior. So you can manage, but the mom 
comes in and says, ``I need help. I'm desperate. We're afraid. 
The child is really tearing up the home and we need help.''
    So in a treatment foster care setting, you again have that 
longer view of behavior in a structured environment where you 
can step that down. So, yes, we're very much in support. And, 
of course, the States have a very different definition of that 
treatment foster care.
    Senator Baldwin. I was going to mention that in followup, 
that despite the clear benefits of this treatment option for 
children with significant mental health, behavioral, and 
sometimes medical needs, current law does not provide any sort 
of standard definition of treatment or therapeutic foster care 
under the Medicaid program, in particular. And though these 
services are provided across the country and are often 
reimbursed through the Medicaid program and certainly other 
child welfare funding streams, the lack of a Federal standard 
definition has, in the evidence that I've gathered, affected 
both quality and access across the country.
    So I wanted to reference the bipartisan legislation that I 
recently introduced, along with my colleague, Senator Portman 
of Ohio, that establishes a Federal definition for Medicaid of 
therapeutic or treatment foster care. And I was pleased to see 
that Boys Town was 1 of 265 national organizations that last 
week sent a letter to House and Senate leadership endorsing the 
legislation.
    Can you speak to how the passage of the Quality Foster Care 
Services Act would improve care for youth, given the need for 
high-quality therapeutic foster care services across the 
country?
    Mr. Arch. I think by standardizing that definition, that 
goes a long way. And by providing the opportunity for the 
States to use Medicaid dollars--because it is different in 
various States. Some do use Medicaid dollars. Others do not. By 
allowing that, it provides, as I said, that intermediate level 
of care, and not necessarily long-term care, where the child 
would stay there for an extended period of time, but as a 
transition to step down to that lowest level of care that would 
be appropriate for that child.
    Senator Baldwin. Thank you.
    The Chairman. Thank you, Senator Baldwin.
    We're due to have votes at about 11:15, but I want to cover 
a few other things here. I forget which testimony it was--maybe 
it was Mr. Fernandez--stating, ``Our focus is always on what 
intervention supports will help the student best, regardless of 
the cause.'' That bothers me a little.
    Have any of you ever read this book, Manufacturing 
Depression, by Gary Greenberg?
    [No verbal response.]
    None of you have read it? Might I suggest that you would 
read it? I would really appreciate that, and I would appreciate 
your writing me and getting in touch with me and telling me 
what you think of it.
    One of the things he points out in there is that if we 
don't look at the cause of certain mental illnesses, then we 
think it is only a medical problem and, therefore, has a 
medical solution. Now, in some cases, that might be true--
bipolar, schizophrenia, things like that that do require 
certain medications. But in a lot of other areas, maybe it's 
due to something else.
    So to not look at the cause, the underlying background of 
what a child may have gone through--I mean, what may be 
manifested, maybe some years of abuse, abandonment, 
bereavement, someone has died. Different things can happen to 
kids in their lives. They have tough lives.
    Maybe it's because of things that people have suggested--
and I don't know if it's true or not--that society has changed. 
Kids today, from the earliest time, eat more fat, starches, and 
sugars and salt--fat, starches, sugar, and salt. Kids from the 
earliest age are eating a lot more than what we did 50 years 
ago, or when I was a kid. And kids are not just little adults. 
They have different metabolism rates and everything else.
    And then they don't get as much exercise as what we did, 
plus they're bombarded from the earliest time with everything. 
Life is fast, the fast pace. They see all the ads on 
television, and there's more games. There's more things like 
this, but not enough exercise. Society has changed greatly in 
the almost 70 years since I was a kid.
    So it seems to me that to say we're not going to look at 
the cause tends to move you more toward medical, medicine, 
antidepressants, psychotropic drugs, rather than 
psychologically--not psychiatrically, but psychologically 
looking at the whole child and thinking, ``Well, maybe we need 
to know more about what's going on there.''
    I digress a little bit. But we started a program in Des 
Moines a long time ago. It was called Smoother Sailing. I was 
able to get some money through Appropriations. We co-partnered, 
I think, with McDonald's, of all things, to get more trained 
child psychologists in elementary school, at the earliest 
possible time.
    What was discovered over about a several year period of 
time was that a lot of these kids brought to school--as someone 
said in their testimony--more than just their back packs and 
their school lunches. But they're bringing a lot of problems 
from home.
    And once these school psychologists went home with the 
child and talked with the family and found out what was going 
on and was able to work with the family, things changed. Now, 
barring that, that kid might have been given Ritalin or 
something, which may have caused other kinds of problems, like 
diabetes.
    Was that you that pointed out the increase in diabetes?
    I say all this because I was concerned about that 
statement, about we don't look at the cause. We just treat the 
child. Shouldn't we be looking at the cause in these children, 
thinking about what the background of this--what's all that 
background noise that's going on that may cause that child to 
act out?
    Am I just misreading what you said?
    Mr. Fernandez. Yes. I probably could have worded that a 
little bit better. I think we do very much look at all the 
variables and factors that impact a student. But working in the 
public schools, we have to support every child that walks 
through the door, regardless of what they bring to us, whether 
it be emotional, behavioral, or social issues.
    So regardless of what comes to the door, we are charged 
with addressing those needs and supporting those students. But 
we very much do look at the various causes and reasons that may 
be impacting a student, because I think it's important that we 
are providing the right interventions, and that when we 
collaborate with outside professionals, we are able to provide 
that information to them as well.
    We work very hard to build relationships with families. 
Schools can't function in a vacuum. The best work, the best 
support, and the most success for students can be seen with 
that collaborative relationship with school and family. So I 
guess my point in that was regardless of who walks through our 
doors, we have to support them.
    The Chairman. So you're not saying don't go into their 
backgrounds and what's happening with their families.
    Mr. Fernandez. No. That's correct.
    The Chairman. Oh, that's my misreading of it.
    Mr. Fernandez. Yes, because there are a lot of things on 
the surface, and if you just look at symptoms that are 
presented or behaviors that are presented, you can think, ``Oh, 
that's ADHD.'' But when you take a step back----
    The Chairman. Yes. My time has run out. But I want to ask 
Ms. Martinez to think about my next question, because it's 
going to be: What would you suggest to other young people about 
how they overcome their internal fears? But we'll have to wait 
until my next time.
    Senator Alexander.
    Senator Alexander. Thank you, Mr. Chairman.
    Mr. Arch, let me pursue Senator Harkin's line of 
questioning and ask you some of the same questions I asked Dr. 
Cooper. For a lay person who looks at this, the straightforward 
way to look at it is to say if you have a problem where, 
suddenly, you read that 20 percent of boys are diagnosed with 
this attention disorder, the first place you'd go to find out 
why--the cause--is home. The second place you'd go is the 
school. The third place you'd go is the environment in which 
the child lives, watching several hours of screens a day with 
violent images and all that you see. And the next place you'd 
go would be the doctor or other medical personnel that the 
child sees.
    My first question is: Has there been a big increase in the 
actual condition over the last 30 or 40 years? Boys Town is the 
most celebrated outfit in the country, I guess, in looking at 
this. And now you look at it in so many States and so many 
settings. Has there been a big increase in the number of boys, 
let's say, who have attention deficit disorders? And based on 
the children you see, do you see lots of examples of--well, why 
is that? And, three, do you see lots of examples of over-
medication to deal with it?
    Mr. Arch. Senator, like you, I am also a lay person. So I'm 
not a physician and not a clinician. However, I can tell you 
that for children that are admitted to the Residential 
Treatment Center below the age of 12, Ritalin is the No. 1 most 
prescribed medication. Now, that doesn't prove cause-effect, 
obviously, and I think the struggle that we all have in 
answering that question is what is the cause. It's not an 
experimental design that we can study. So it's more 
observation.
    I can also tell you that in discussions with the 
psychiatrists, they certainly have seen an increase in 
diagnoses of that. They believe that they are seeing that, but 
that's anecdotal. So, like Dr. Cooper, I'd say more research is 
needed.
    Senator Alexander. But Boys Town has been around since 
1917. Surely, in 1917, 1947, 1957, 20 percent of boys didn't 
have attention deficit disorder, did they? Or did they?
    Mr. Arch. Maybe that's another question for Dr. Cooper. But 
I'm not sure when ADHD was actually added to the list of 
diagnoses. I don't know the answer to that question, Senator. 
I'm sorry.
    Senator Alexander. But over-medication--you see many boys 
coming into your system. What about over-medication?
    Mr. Arch. We definitely see that, and that's a big concern. 
I say over-medication--multiple psychotropic meds being 
prescribed. And as I say, some of that has to do with just the 
coordination of care. A medical home, the ability to have a kid 
with special needs that's being overseen by a single physician, 
would go a long way toward that, more medical home treatment, 
so that there is a coordination of that, of the prescribing of 
those psychotropic meds instead of going from physician to 
physician. And that sometimes happens, especially as these kids 
move from placement to placement.
    Senator Alexander. I know our time is short, Mr. Chairman. 
I'll give my time to Senator Baldwin.
    The Chairman. Senator Baldwin.
    Senator Baldwin. Thank you.
    Dr. Cooper, in your testimony, you spoke about health care 
providers often being unaware of the best practices, frankly, 
and guidelines for treating children with behavioral and mental 
health issues. And, often, that results in inappropriate 
treatment with medications.
    What would be the best way to close this gap and ensure 
that both providers and families have clear information and 
various treatment options? And could you comment on the 
significant holes that I think exist in current research on 
treatments for children that we ought to be addressing? If you 
could focus us in on what those key gaps are, that would be 
great.
    Dr. Cooper. Senator Baldwin, I think that's a really 
critical point, because it turns out that there are excellent 
tools. There are treatments that are available. But the 
challenge is education of community-based providers, including 
that early on in the training course so that as people are 
going through their medical training or their professional 
training, they receive appropriate guidance on those things.
    One of the things that actually works really well is a 
model of identifying those behaviors or those providers who are 
sort of out of line and providing them with information, sort 
of an academic detailing model by peers. So in Tennessee, for 
example, the State of Tennessee has foster care centers of 
excellence.
    And one of the critical roles that those centers of 
excellence play is to identify children in the foster care 
system who are receiving multiple medications or receiving 
medications that are not consistent with therapy, helping then 
to give that information back to the health care provider who's 
having that practice and saying,

          ``For some reason, you appear to be practicing out of 
        the norm with your peers. You're prescribing at this 
        rate, whereas your peers are prescribing at another 
        rate.''

    There's been a tremendous benefit from that level of 
detail. That's intensive, but that's been really helpful. I 
think that's an area where we could think about closing that 
gap.
    Senator Baldwin. I'll yield. I know you wanted an 
additional round of questions.
    The Chairman. Thank you. We've got time. We've got plenty 
of time.
    Ms. Martinez, this is all well and good. But it all comes 
down to the individual who has suffered some form of mental 
illness, and especially young children. I was intrigued by your 
testimony and--intrigued--that's the wrong word. I was 
encouraged by your testimony and what you did as you looked at 
yourself. You said, ``Fortunately, my aunt and friends 
encouraged me to go to the university health center.''
    So this started to manifest itself in university. And, at 
least, from my reading, a lot of these mental health disorders 
exhibit themselves when kids go away from home for the first 
time and they go to college. I've had hearings in the past with 
this committee on eating disorders and was alarmed to find that 
the single largest cause of young women dropping out of college 
is an eating disorder, and that eating disorders then continue 
to evolve into other forms of mental health problems.
    I guess what I'm wondering is in your experience--you 
obviously did something very courageous. You self-diagnosed. 
You talked to friends. You took the right course of action. But 
I'm sure you must know others of your peers that didn't take 
that course of action.
    Is there anything we should be doing in terms of young 
people, when they--I'm thinking now of college. Before, I've 
been talking about grade school and elementary school--but when 
they go to college, that they get some kind of counseling right 
away so that they can recognize these early symptoms. Should we 
be thinking along those lines?
    Ms. Martinez. In my experience, I was not a stranger to 
counseling. All my life, I had been in some sort of mental 
health treatment, but not to this extreme. But when I went away 
to school, then there were sort of these exacerbations--just 
not feeling like myself--and people started to notice that 
around me. So other people were able to speak up and say, 
``This is how you're presenting. This isn't normal.''
    I had support around me in that really critical and 
vulnerable time period, which I'm so thankful for. I went and 
saw the counselor, who then was smart enough to refer me to the 
practitioner, who just happened to have had this seminar and 
this training on this model, the PIER program, and was able to 
identify my signs and symptoms early.
    It does take a lot of courage, I think, especially for 
people that aren't used to being treated and talking about 
mental health issues. It's very scary and shameful and 
embarrassing. So trying to have as much support as possible, 
especially when you move away to college, is crucial.
    The Chairman. Tell me a little bit more about this PIER 
program. I'm not familiar with it. You said it saved your life.
    Ms. Martinez. Right. It's a model. It's a preventative sort 
of model. They replicated this model in different areas of the 
country. But, basically, once you get a referral and you sort 
of meet criteria for this research program, they start 
treatment right away. I can just speak about my own experience 
with it.
    But, basically, the treatment was fast and it was early. So 
the model really stresses prevention, trying to catch it sooner 
rather than later and not waiting for having a first episode, a 
psychotic episode, to happen, doing something before that 
episode. It really--it stops that progression of a major mental 
illness, and that's what happened in my case. I was treated 
very early on because of really good assessment and evaluation 
and treatment.
    The Chairman. Some of which had gone back to your earlier 
life, right--I mean, younger, when you were much younger.
    Ms. Martinez. I had treatment for other things earlier in 
life, yes, but not in this model, though, not this way.
    The Chairman. Thank you.
    Mr. Arch, you said approximately 79 percent of the children 
admitted to the treatment center are taking multiple 
psychotropic medications to control their behavior at the time 
of admission. Although effective in treating some problems, due 
to the physical side effects of these medications, more 
research is needed regarding their safety and appropriate use.
    You said that you had reduced by 33 percent the number of 
kids taking any medications and a 38 percent reduction in 
medications being taken at the time of discharge. So you do try 
to get kids off of medication, then.
    Mr. Arch. That's right. We try to reduce--as the 
psychiatrist has said to me--he says,

          ``I'm not sure what I'm looking at when a child is 
        first admitted. I'm not sure if I'm looking at the 
        drugs, the effects of the psychotropic meds, or if I'm 
        looking at the behavior.''

    But in a structured environment, such as our Residential 
Treatment Center, we're able to wean the kids down to what the 
psychiatrist believes is an appropriate level of medication.
    The Chairman. And, obviously, you've found that when they 
transition--do they stay at that level? I mean, once you've 
taken them off that, do they stay at that level then?
    Mr. Arch. I don't know the answer to that question. I don't 
know that our research did that--a 6-month followup on that. I 
could check on that, but I'm not sure.
    The Chairman. Senator Alexander.
    Senator Alexander. I don't have anything else.
    Senator Baldwin.
    [No verbal response.]
    Nothing else. Well, I've got a lot of questions. This is 
something that interests me greatly. I don't mean to prolong 
it. But I just want, again, for all of you here--Dr. Cooper, 
you've published several articles about the off-label use of 
antipsychotic medications for treatment of conditions such as 
ADHD and depression in both adults and children.
    What does that mean? What does off-label mean?
    Dr. Cooper. The labeling requirements for medications 
require that there be proven efficacy for a medication in a 
certain condition. So antipsychotics have been proven to work 
and are approved for use in certain children for schizophrenia, 
for autism, and, in some settings, severe bipolar disorder. 
When it's used for another diagnosis or another indication, 
that's technically off-label.
    The prescribing regulations allow a health care 
professional to make decisions about what might make sense for 
an individual patient. And while that's important, in these 
settings, over half of the antipsychotic prescriptions that we 
studied were for ADHD and other behavioral things. We don't 
know if they work in these settings. Now we've done some 
research that shows that they actually can be harmful.
    The Chairman. I mentioned the ratios here for school 
psychologists. The national average is 1,500 to 1. The 
recommended ratio is 700 to 1. School counselors--ratio of 
students is 457 to 1, twice the recommended ratio of 250 to 1.
    School social workers--some States have 2,500 to 1. The 
School Social Workers Association determined that the maximum 
ratio is 800 to 1. The Department of Education uses a ratio of 
800 to 1. The recommended ratio of school social workers is 250 
to 1.
    I guess the question I would ask is do we need more school 
psychologists--I mean, someone trained as a child 
psychologist--and counselors and school social workers in our 
elementary schools? What would you think? Do we have enough? 
I'm just asking. Yes or no?
    Dr. Cooper. I don't think we have enough. What I find is 
that for these children who have these chaotic social 
situations, lack of access, mental illness, mental illness in 
their family, all these things, there are so many challenges 
that they face, and school is the primary point of contact.
    When we try to interface with schools as health care 
providers, it's often challenging to find the right person to 
help this child get access. We really believe in collaborative 
partnerships to help ensure that the right child gets the right 
treatment every time.
    The Chairman. Mr. Fernandez, do you think we need more 
school psychologists or social workers?
    Mr. Fernandez. I do. I agree with what Dr. Cooper was 
saying. The access point for a lot of students with mental 
health and behavioral concerns is the school, and there's not 
enough of us to address all the needs that walk through our 
doors.
    The Chairman. Mr. Arch, what do you think?
    Mr. Arch. I think research is pretty clear that early 
intervention is a big key to this, and school is where a lot of 
this behavior is manifested. So if that will help, yes.
    The Chairman. Ms. Martinez, from your experience?
    Ms. Martinez. Yes, definitely. I think access to the 
resources is a key thing and just doing it, being more 
collaborative. That's how my care went, and that's what worked.
    The Chairman. Our bells have rung. I just want to ask this. 
We have all your testimony. You gave your statements here. 
We've asked questions. Is there anything that any one of you 
wants to say to us before we gavel this down that maybe we 
haven't raised or you really think that we should know or 
consider? Is there something that you think, ``I wish they had 
asked this or looked at this.'' Is there anything? Maybe we 
have. I don't know.
    Dr. Cooper.
    Dr. Cooper. I think the critical thing is that you're 
having this conversation, and that's what's really important. 
We have to be aware of these issues. We have to be aware of the 
challenges that mental health disorders create for children and 
ensure that we continue to talk about this and identify ways to 
identify children early, intervene, get these right treatments 
for the right child, and ensure that we're moving forward in 
the right way for these kids.
    The Chairman. Mr. Fernandez.
    Mr. Fernandez. We've all spoken today about the 
collaborative work. We can't address student needs in 
isolation. Working with outside providers, medical 
professionals, clinical psychologists, school counselors--all 
these people come together as a much larger team to support the 
needs of a student. I think that's probably one point I 
definitely would like to make sure that everyone knows.
    The Chairman. Mr. Arch.
    Mr. Arch. Like you, Senator Harkin, I come from a rural 
State, and what we see in the rural State is a lack of child-
adolescent psychiatrists. That is the reality. I don't think 
that's going to change. I would encourage Congress to take a 
look at some possible creative funding mechanisms that can 
allow a child psychiatrist in an urban setting to support a 
rural family practice doctor or a pediatrician as they're 
wrestling with some of the issues regarding psychotropic meds.
    Right now, there's just not that ability. If a child 
psychologist doesn't see that patient, there's no way for that 
child psychiatrist to be reimbursed for their time. But 
something like that might be a little creative to help some of 
the family practices and pediatricians.
    The Chairman. Ms. Martinez.
    Ms. Martinez. I think what you can take away from my 
testimony today is really being an ally to supporting these 
programs like PIER and EDIPPP that use prevention against major 
mental illness--recovery, if possible, for us. So that's the 
big take-home.
    The Chairman. Thank you all very much. I would just say 
this in my closing. I'll ask Senator Alexander if he has any 
closing remarks. And this is my own view. I only speak for 
myself, obviously.
    But we spend a lot of time here, and we have over the last 
30 years that I've been here, looking at elementary and 
secondary education. We have tests and No Child Left Behind, 
and now we have this and now we have that. We're looking at all 
the different ways of measuring kids' achievements.
    I don't know that we've spent enough time looking at the 
other part of the child in school. I think--and, again, I speak 
for myself. I tend to think of a more bucolic time. When I was 
younger, we had nuclear families. We lived in small 
communities. We had church groups. We had all these things we 
did. We weren't bombarded with television and all these games. 
We exercised. We ate good food.
    I wish we had that, but times have changed. I'm just 
wondering if maybe we've focused too much on tests and scores 
and things like that, but not enough on the whole child in 
terms of our elementary and secondary education. That's just my 
thoughts.
    Senator Alexander, did you want to say anything else?
    Senator Alexander. No.
    The Chairman. I request that the record be kept open for 10 
days for statements and questions for the record. And, again, I 
thank you all very much, and please read Manufacturing 
Depression by Gary Greenberg and let me know what you think.
    Thank you all very much for being here. I know some of you 
came a long distance, and I appreciate it very much.
    The committee stands adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

       Response to Question of Senator Harkin by Tiffany Martinez
    Question. Ms. Martinez, thank you for the testimony you provided 
regarding how the Early Detection and Intervention for the Prevention 
of Psychosis Program (EDIPPP) helped you in your own journey with a 
mental health condition. Can you tell us more about the EDIPPP 
program's locations, goals and the research findings generated by the 
program? How can Federal agencies like SAMHSA and NIMH benefit from 
knowledge gained through EDIPPP programs? In particular, what are the 
implications for prevention efforts aimed toward reducing severity of 
mental illness?
    Answer. Thank you for your questions and for inviting me to speak 
before the committee. If I had not been referred to the Portland 
Identification and Early Referral (PIER) program, the model for EDIPPP, 
I would not be getting ready to graduate next month with my master's 
degree to become a nurse practitioner from the University of Southern 
Maine. When I first found out I was experiencing the early signs of 
schizophrenia, I thought my life was over. PIER gave me hope and helped 
me to live a fulfilling and meaningful life. EDIPPP, a national study 
funded by the Robert Wood Johnson Foundation from 2006-13 provided this 
opportunity to thousands of other young people ages 12-25. EDIPPP was 
designed to replicate PIER in five sites (Sacramento, CA; Salem, OR; 
Albuquerque, NM; Queens, NY; and Ypsilanti, MI) around the country, 
each with unique geographic, socio-cultural, and environmental 
characteristics.
    The goal of EDIPPP is to identify and curb the early signs of 
psychotic illness before they develop into severe mental illness. The 
program focuses on educating families and those who routinely interact 
with at-risk youth--teachers, mental health professionals, and 
doctors--about key signs to look for in young people to identify those 
with early signs that might lead to psychosis and thus prevent 
psychosis before it starts. Once a person is identified, the program 
provides an evaluation of an individual's current mental health status 
and treatment needs. Those who meet the criteria for the program are 
engaged in treatment, which includes family engagement. They also learn 
new skills--to complement professional support--that help them 
recognize symptoms, manage stress, and decrease the risk of movement to 
full-blown psychosis. All treatment is based on an individual treatment 
plan, which includes counseling, supported education or employment 
services, and, if necessary, medication.
    The results of EDIPPP are promising. A recent article published in 
Psychiatric Services suggests that PIER-reduced hospitalizations for 
initial psychotic episodes by 26-34 percent in a mid-sized city. In 
addition, a large peer-reviewed study of EDIPPP found:

     The conversion to psychosis was 6.3 percent at 2 years, 
within a narrow range (4.3 percent-7.7 percent) across six cities.
     84 percent of the at-risk youth already had a DSM-IV major 
disorder, alleviating some of the concern about treating those who do 
not develop a psychotic disorder. Early intervention for psychosis can 
thus be early intervention for a wider spectrum of psychiatric illness 
during its early phase.
     83-84 percent of at-risk youth and those experiencing very 
early onset psychosis were in school or working at baseline; this 
remained stable or increased at 2 years with 83-90 percent in school or 
working.

    NIMH and SAMHSA can benefit from the lessons learned by EDIPPP as 
they 
develop guidelines for early identification and intervention in serious 
mental illness under the 5 percent set-aside in the Community Mental 
Health Services (CMHS) Block Grant. The EDIPPP findings should help to 
inform the guidelines on how to incorporate evidence-based strategies 
for early intervention for psychosis at a stage prior to the onset, as 
well as at a first episode of psychosis. For the majority of people who 
develop psychotic disorders the onset is gradual and preceded by a host 
of identifiable risk indicators. These indicators include significant 
declines in cognitive function, social and role (school and work) 
functioning, as well as the development of other diagnosable mental 
health problems such as anxiety and depression. By 
engaging a person and their family early and providing appropriate 
support, we can either prevent the illness from becoming acute or 
reduce how long the illness 
remains at an acute level. Already, Oregon and California are in the 
process of 
expanding the program. In Oregon, through its Early Assessment and 
Support Alliance (EASA), services similar to EDIPPP have been made 
available to 81 percent of the population. Once people are in EASA 
there was a major and immediate drop in hospitalizations and most 
people remain actively involved in school and work. Other States have 
shown an interest in EDIPPP implementation.
    As you know, psychotic disorders often first appear in the mid-late 
teens or early 20s, and exact a tremendous cost to individuals, their 
families, and communities. The findings from EDIPPP and a large growing 
body of research should help to change the way mental health services 
are delivered. We have an opportunity to move our mental health system 
from a costly system that is disability-oriented to one that focuses on 
easy access, strengths, self-determination and developmental progress. 
Communities that are willing to commit to making early identification 
and intervention supports available to teenagers and young adults will 
increase these individuals' ability to stay in school, maintain 
employment, and live healthy, productive lives.
    Thank you for your questions. I am happy to provide any other 
information that may be helpful.
 Response to Questions of Senator Murray by Benjamin Fernandez, M.S., 
                                  Ed.
                             mental health
    Thank you for attending the HELP Committee hearing and sharing your 
experience with the committee.
    As you are well aware, there is an urgent need to improve mental 
health care all across the country. Stigma associated with mental 
illness remains widespread, and often results in individuals feeling 
isolated and afraid--causing them to forego the treatment or support 
they need. An estimated one in five Americans will suffer from a mental 
or neurological disorder at some point in their lives, yet two-thirds 
of people with a known mental disorder never seek treatment.
    Question 1. What can we do to instill in children from a very early 
age that mental health is just as important as physical health? How can 
we work to reduce stigma associated with mental health, and educate 
individuals, families, and schools?
    Answer 1. For starters, we need to infuse the importance of mental 
health into health curricula that discusses the importance of physical 
health. Currently, we focus on physical health and mental health as two 
completely separate issues. However, physical health can impact one's 
mental health, and vice versa, so we need to be more explicit in the 
inclusion of mental health in health curricula. Additionally, we need 
to provide education regarding mental health and wellness for all 
children, beginning when they are toddlers. Adults need to teach our 
young people that sharing their feelings, seeking help when they need 
it, and caring for others who need help is just as important as getting 
fresh air, eating fruits and vegetables, and playing outside. 
Additionally, as a country we need to intentionally start discussing 
mental illness openly and honestly. In school, students learn about 
various physical diseases (e.g., cancer, heart disease) and how to 
prevent them, but rarely are mental illnesses, such as depression, 
mentioned. Mental illness is a disease. In some cases it is 
preventable, in all cases it is treatable. Children who have asthma, or 
diabetes think nothing of sharing their story, showing their inhaler, 
or telling a friend they have to go to the school nurse once a day to 
get a shot. However, students who are receiving treatment for an 
emotional, behavioral, or mental health issue are often less open about 
their treatment. Students who need to seek counseling should not have 
to hide it. We need to do a better job of engaging in an open dialog 
about mental illness--what causes it, how to prevent it and how to 
treat it--in the same manner that we discuss physical ailments. With 
intentional public outreach, we can reduce the stigma associated with 
mental illness.
    There are also a number of ways that schools can assist in reducing 
the stigma regarding mental illness and instill the importance of 
mental wellness through a student's academic career. Students can learn 
about the concepts of mental wellness through lessons such as 
Mindfulness (a cognitive behavioral process teaching students to self-
regulate emotion, behavior, and attention) and key concepts related to 
resiliency and positive behavior can be incorporated within the school 
day and environment. In Loudoun County Public Schools, eighth grade 
middle-school students learn about mental health as part of the general 
health curriculum via the ``Exploring Mental Health'' program. 
``Exploring Mental Health'' is conducted by school psychologists, 
school social workers, and school counselors to educate students about 
mental health and positive ways to maintain mental wellness. At the 
high school level, all ninth grade health classes receive Depression 
Awareness/Suicide Prevention education. School psychologists, in 
conjunction with the school social worker and school counselor, teach 
students the signs and symptoms of depression, clarify the facts and 
myths associated with depression and suicide, and teach students how to 
identify the warning signs and risk factors associated with suicide. 
Importantly, this program teaches students how to address a situation 
where a friend or someone they know may be in danger of harming 
themselves. Students are taught to seek out a trusted adult in school 
and/or at home to share their concerns and ensure that the student 
receives help. Additional outside resources specific to their community 
are also provided for students. Delivery of this type of education has 
helped to create an environment where students feel comfortable going 
to trusted adults to get help and has helped to reduce the stigma of 
depression. Additionally, a Depression Awareness Booster session has 
been conducted in a number of the high schools. This presentation 
reinforces concepts from the initial Depression Awareness/Suicide 
Prevention presentation but focuses on how students can seek the help 
they may need as they transition to college or career.

    Question 2. What more needs to be done to educate individuals and 
families to recognize early signs of behavioral health issues? How can 
we ensure families understand their options and know where to turn when 
they need access to mental health services?
    Answer 2. Much more needs to be done in terms of education on how 
to recognize behavioral health issues and where to go for help. For 
example, parenting books and parenting classes need to include more 
information regarding typical behavior vs. atypical behavior across the 
life span. Parents have a wealth of information about where to turn for 
help when their young child may not be meeting developmental milestones 
such as walking or talking later than typical. However, information for 
parents who are concerned about the behavioral or mental health of 
their child is lacking. Schools can also be more proactive in this 
effort. Schools frequently send home information on how to help a 
student struggling to learn, how to deal with homework difficulties, 
and how to help a child become more organized. However, with help from 
school-employed mental health professionals (e.g., school 
psychologists) schools can also provide information to parents on 
strategies to support mental wellness and how to seek help if they have 
concerns about their child's mental health. Many school systems wait 
until a problem has reached a critical point before sharing this type 
of information with parents. Mental health supports should be viewed as 
equally important to the academic support services made available for 
kids.
    In Loudoun County, school employed mental health professionals 
routinely attempt to engage parents. To help parents better understand 
mental wellness and mental illness, the content and topics covered in 
``Exploring Mental Health'' and ``Depression Awareness'' education 
programs are available for parents to review. In many schools, these 
presentations are given in their entirety for parents. Parents have the 
right to ``opt-out'' their child from these education programs if they 
feel it is necessary. Additionally, schools psychologists are available 
to discuss these topics with parents and answer any questions related 
to mental health and supports available. Below are a few examples of 
how LCPS school psychologists, in conjunction with other school-
employed mental health professionals, provide education on mental and 
behavioral health:

     A preschool psychologist and one of our school 
psychologists run a series of parenting classes that provide parenting 
skills as well as addressing developmental issues with children.
     Hosting workshops and parent coffees on topics related to 
anxiety, eating disorders, and drug abuse.
     Parents as Educational Partners meetings for ELL families 
after school hours offering workshops on anxiety, depression awareness 
and suicide prevention, family reunification, dating violence, gang 
prevention and intervention.

    Question 3. Can you share best practices on how government agencies 
and the community where you practice have worked together to find 
effective solutions to these issues?
    Answer 3. Loudoun County has several partnerships with other local 
government and community agencies. Below are a few examples:
 restorative justice/practices--department of juvenile justice and lcps
     Restorative Justice (RJ) emphasizes values of empathy, 
respect, honesty, acceptance, responsibility, and accountability. It 
provides ways to address undesirable behaviors, offers alternatives to 
suspensions and expulsions, incorporates learning, and improves safety 
by preventing future incidents.
     LCPS staff, Loudoun County Juvenile Court Services, and 
Fairfax County Public Schools are collaborating to bring training for 
facilitators in order to fully implement these services.
     student assistance program (sap)--loudoun county mental health
     A collaborative program between Loudoun County Mental 
Health and Loudoun County Public SAP provides a Loudoun County Mental 
Health therapist who will be available to conduct a free assessment at 
school for students who are having significant difficulties due to 
behavior problems, emotional problems, family difficulties, peer 
relationships, or other outside issues. This person sees the student 
for three sessions and provides the school and the family with 
recommendations regarding what, if any, further treatment is warranted.
               community provider meet and greet sessions
     Each year LCPS holds a Meet and Greet session with private 
mental health providers and community agencies. This gives school-
employed mental health staff, school psychologists, school social 
workers, and school counselors) the opportunity to personally meet 
these outside providers and to learn about services offered.
     A list of providers is then compiled with provider name, 
expertise, insurance taken, and services provided. This list is made 
available to the schools for future reference.

    Local school/community partnerships are certainly important in 
addressing the behavioral and mental health needs of students during 
and after school. However, it is imperative that the Federal Government 
continue to provide explicit funding to assist these endeavors. There 
is a shortage of school employed mental health professionals (school 
psychologists, school social workers, and school counselors). These 
professionals are specially trained to provide behavioral, social, 
emotional, and mental health supports within the context of learning 
and the school system as a whole. These professionals are critical 
partners with community resources and agencies and can help ensure that 
students have access to the supports they need in the community, and 
can provide critical supports during the school day. Currently, the 
Elementary and Secondary School Counseling Program is the only Federal 
grant that can be used to implement or expand school counseling 
programs--including hiring school psychologists, school social workers, 
and school counselors. These funds can help schools better provide 
mental and behavioral supports to children, while forming the 
partnerships with communities needed to meet the comprehensive needs of 
all students.
    Thank you for your dedication to the mental wellness of our 
students.

    [Whereupon, at 11:24 a.m., the hearing was adjourned.]

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