[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.]