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With that move, which occurred in February 1991, we also developed a plan of hosting a series of workshops to help formulate a research agenda to expand our program on rural mental health, and will

advertise broadly to attract knowledgeable and capable candidates to direct this office.


In fact,

Question. Doctor, I think that we are just beginning to understand the impact that alcohol has on unborn children. there are many mentally disabled adults in residential care today whose impairment is thought to be caused by Fetal Alcohol Syndrome.

The University of California at San Francisco conducted a study to get a handle on how Fetal Alcohol Syndrome affects American productivity and quality of life. They estimate that the total annual cost of this disease is approximately $1.6 billion. This includes the neonatal intensive care, costs of treating growth retardation, as well as care and support services for young people throughout their lives.

I don't see anything in your request that specifically addresses this problem, either in your research or treatment agenda. What is the Institute doing to research, prevent and treat Fetal Alcohol Syndrome?

Answer. A significant part of NIAAA's research addresses the issue of alcohol and pregnancy, including Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). It is the research supported by NIAAA that first led to the identification and description of FAS in the 1970s, and found that heavy maternal drinking was a clear health risk to the infant. NIAAA distributed a health caution to every medical school in the country and informed the public of the research evidence.

Our research in this area has grown from $4.5 million in FY 1986 to over $10 million in FY 1990. In the FY 1992 request, FAS research would be funded at a level of $11.6 million. The goal of fetal alcohol research is the identification of women at risk and the development of therapeutic interventions leading to reduced incidence or even prevention of the effects. A wide range of research studies are supported through investigator-initiated research projects and an alcohol research center focused exclusively on this area. These studies include: possible mechanisms for fetal alcohol damage using animal models; alcohol's affect on placental function; genetic factors of parents and their infants that may contribute to the infants susceptibility to FAS; screening instruments to better identify women who are at high risk of abuse; and measures of development that predict later functional impairments in FAS/FAE children.


Question. Substance abuse is having a devastating impact on American children. Each year, thousands of drug-addicted women give birth to children who suffer physically at birth from drug-exposure and will go on to develop severe emotional and behavioral problems.

The GAO estimates that 100,000 to 375,000 babies are exposed to cocaine each year. It costs an average of $5,500 to treat each infant, compared to $1,400 to care for a health baby. And the GAO reports that this problem is as prevalent among privately insured patients as those on public assistance. But less then 11 percent of the 280,000 pregnant women who need substance abuse treatment are able to get it. How many States are currently receiving funds through OSAP's program for pregnant and post-partum women and infants?

Answer. Under the Pregnant Women and Infants program, OSAP awards demonstration grant funds to organizations within States such as State and local government agencies, community-based organizations, universities, and educational institutions. Currently, organizations in 32 States and the District of Columbia are receiving funds under the Pregnant and Post-Partum Women and Infants program.

Question. How many treatment slots are supported through these OSAP grants, and how many additional slots would your budget allow in

FY 1992?


Answer. OSAP supports various activities devoted to the substance abuse problems of pregnant women and their infants. Principal among these is a demonstration grant program intended to coordinate services systems for linking health promotion and treatment services with substance abusing pregnant women and their small children. Pregnant and Post-Partum Women and their Infants program is designed to provide a full continuum of care, from prevention to early intervention to treatment and rehabilitation. Strategies include: biological/physical, such as substance abuse treatment, detoxification, and nutrition; obstetrical/psychological, such as prenatal care, treatment for anxiety, depression, and low selfesteem; instrumental child care and transportation to facilitate a woman's obtaining services; housing; and informational and educational.

Unlike the treatment programs of the Office for Treatment Improvement, OSAP does not target a given number of slots for support. However, it is estimated that approximately 10, 200 women and their infants will receive services under the demonstration program by the end of FY 1991. Funding increases for FY 1992 will allow for an estimated 1,600 additional women and infants to receive these services.

Additional services are provided for pregnant women and their infants under the ADMS Block Grant to the States. A valid estimate of the number of pregnant women served through the Block Grant does not exist.

Question. How many applications for the OSAP women's program were approved but unfunded in FY 1991?

Answer. Although only one of the two grant review cycles for FY 1991 has been completed to date, estimates based on grant approval and award rates for the first FY 1991 cycle as well as those during FY 1990 indicate that approximately 400 applications are expected to be received during FY 1991. Approximately 172 or 44 percent will be approved, 38 applications (22 percent) will be funded, and 134 (78 percent) will remain unfunded.

Question. I'm told that the most successful programs of all are those that combine residential treatment and prenatal care. In Iowa, for example, the Iowa Methodist Medical Center teaches mothers to care for their babies during a short-term treatment program followed by at-home care. Programs like these work, but they are scarce and often under-funded. Would increasing the ADMS Block Grant, with its 10 percent set-aside for women's treatment programs, expand every State's .capacity to treat pregnant women?

Answer. Increasing the Glock Grant would make additional funds available for women's treatment programs. However, additional funds alone will not add more capacity for treating pregnant women. We have found that many States need program development guidance including clinical protocols, model staffing patterns and appropriate facility types, and other program standards.

To meet these needs OTI is co-sponsoring with the Alcohol and Drug Problems Association a National Meeting on Women's Treatment Needs in Portland, Oregon May 5-8, 1991, and ensuring that every State drug authority sends at least one staff person.

Also, recent staff field work has made us aware that several States have not interpreted the set-aside requirement to require programs dedicated to women and their children with the appropriate mix of services. To address this problem, an expanded federal oversight role and significant revision to provisions of the DHHS Block Grant Regulation (45 CFR Part 96) that cover State's reporting requirements and State's interpretation of Block Grant statutes will be required. The regulations are currently under review within the Department and oversight is being expanded through the State Systems Development Program.


Question. With our Nation continuing to suffer the effects of substance abuse, it's disappointing to see that the budget proposes level funding--not even an increase to cover inflation--of the Alcohol, Drug Abuse, and Mental Health Services Block Grant. The only increase proposed for substance abuse treatment is the $99 million "capacity expansion" grant, targeted to drug abuse but not, it appears, to combat the Nation's number one substance abuse problem, alcohol.

Dr. Goodwin, do you think it is the best policy to target funds to drugs only, or should we be taking into account the fact that many addicts use both drugs and alcohol?

Answer. Although the Capacity Expansion Program focuses on effective and comprehensive drug abuse treatment, the extensive overlap of alcohol and other drug abuse problems in the same individuals dictates that almost all service providers address the treatment of the dually diagnosed. The 1989 National Drug Abuse Treatment Utilization Survey reported that the percent of drug patients who have secondary alcohol problems ranged from 12 percent in Maine to 100 percent in Nebraska and Pennsylvania. Eighteen States reported in excess of 45 percent of drug patients with secondary alcohol problems.

Question. If the Committee consents to provide these funds, how would the Department assure an equitable distribution of funds between urban and rural areas, where alcohol remains the primary drug of choice?

Answer. The Capacity Expansion Program will assist States and communities in expanding the capacity of their drug abuse treatment programs for specific population subgroups that are facing critical health and socio-economic difficulties as a result of their drug abuse. This new capacity expansion program will focus on adolescents, racial and ethnic minority populations, and residents of public housing projects. ADAMHA is particularly interested in funding projects that address the population subgroups of drug abusers who are homeless, have a co-occurrence of drug addiction and other health disorders, or are in a rural area.


The award criteria for grants under the announcement described above will be based, in part, on the application's technical merit and its focus on the program's target populations and subgroups. making awards, consideration will also be given to the balance among target populations. In this way, OTI will ensure a reasonable distribution of funds to rural areas.

The CEP grants will target rural areas, particularly those where 1) demand for drug treatment services exceeds capacity, 2) there is a high prevalence of drug abuse, and 3) there is a high incidence of drug related criminal activities. The smaller towns and communities in rural States that face these problems will be served by this program when they are included as sub-recipients in the application from the State.


Question. Dr. Goodwin, a recent editorial in the Journal of the American Medical Association reports that 37 percent of people suffering from alcohol abuse are also diagnosed as having mental disorders. For people with other drug disorders, 53 percent are suffering from mental illness. This study suggests that "mental disorders must be addressed as a central part of drug abuse prevention efforts in this country."

Clearly, the ADMS Block Grant is by far the best vehicle the Institute has to implement this kind of new and innovative program focus. Given the success of the Block Grant so far, and the possibility it holds for new programs, why haven't you included an increase for it in FY 1992?

Answer. The structure of the ADMS Block Grant makes it nearly impossible to target funding to specific programs without a revision to the enabling legislation. This was intentionally built into the Block Grant when it was established by the Omnibus Budget Reconciliation Act of 1981 so that the States would have greater flexibility in controlling resources and addressing service needs within the State. Currently, the ADMS Block Grant funds are distributed to the States by a complex, congressionally-mandated allocation formula that uses urban population, age-weighted program factors, and total taxable resources.

In lieu of increasing the ADMS Block Grant in 1992, the Administration is proposing to establish a Capacity Expansion Program that will continue the expansion of comprehensive drug abuse treatment slots as a means of closing the gap between the need for drug treatment services and current treatment capacity. The Block Grant mechanism does not allow us to target funds specifically for the expansion of drug abuse treatment capacity. Although the Capacity Expansion Program focuses on effective and comprehensive drug abuse treatment, the extensive overlap of mental health problems and alcohol and other drug abuse problems in the same individuals dictates that almost all service providers address the treatment of the co-morbid and the dually diagnosed. The Capacity Expansion Program will concentrate on the delivery of comprehensive treatment services designed to address the full spectrum of a patient's biological, psychological, and social needs. It is expected that a substantial number of patients will receive services that address their mental health problems as well as their alcohol and drug abuse problems.


Question. Both the newly authorized Projects for Assistance in Transition from Homelessness (PATH) and your own proposed Consolidated Homeless Program would support expanded services to homeless individuals who suffer from mental illness and related disorders. How will you assure that these services, such as case management, housing assistance, and referral to other necessary community services, will be provided by the grantees?

Answer. Assurances of compliance with service guidelines will be achieved by a thorough review of PATH applications, coordinated technical assistance, and monitoring by NIMH staff. Section 528 of the PATH legislation, "Requirement of Reports by States", specifically requires each State to submit a report containing information necessary for: (1) securing a record and a description of the purposes for which amounts received under section 521 were expended during the preceding fiscal year and of the recipients of such amounts; and (2) determining whether such amounts were expended in accordance with the provisions of this part. The Act goes on to specify that the Comptroller General in cooperation with the NIMH will evaluate these expenditures at least once every three years. addition, extensive voluntary reporting guidelines for the collection


of detailed information including services provided will be reviewed by NIMH.

The request for Consolidated Homeless Program applications will specify the range of services, to include case management, housing assistance, and referral to' other necessary community services, for which funding will be provided. The initial review group will assess the scientific merit of the proposals and the rationale for services provided will be closely scrutinized. If selected for funding, program and grants management staff at the NIMH will provide oversight on compliance with the proposal. The projects will be required to send interim reports to the program staff for review.

Question. The budget proposes to eliminate the Community Youth Activity program in OSAP, part of which goes to each State; but to expand the High-Risk Youth program and other competitively-bid prevention grant programs. Is every State likely to receive funds under this change?

Answer. The new funds available for the High Risk Youth programs as well as other competitive grant programs within OSAP will provide for at least 137 new awards to organizations within States such as State and local government agencies, community-based organizations, universities, and educational institutions. Although States will not be receiving these FY 1992 funds directly, they nevertheless benefit through support of organizations within the their States. Currently, OSAP has over 600 grants within 48 States, the District of Columbia, and Puerto Rico.


Question. How will ADAMHA assure geographic dispersion of the


Answer. All grant funding decisions within OSAP are based on award criteria set forth in the grant announcements. These criteria include, among other things, geographic distribution which is intended to ensure a reasonable distribution of OSAP programs to ensure that OSAP programs reach all populations. Specifically, within the Community Partnership program, grants are funded in the following three categories by population and relative rural/urban character: small communities and/or rural areas; medium sized communities; and larger communities. In addition, the OSAP sponsors technical assistance grant workshops at geographically disbursed locations throughout the U.S. encouraging applications from organizations located in all States.


Question. Your Agency requested an increase in the Block Grant set-aside last year to give the Office of Treatment Improvement extra funds to work on the State Systems Development Program, which will assess State treatment programs and develop a State-by-State data base on the drug abuse problem.

But ADAMHA spends most of the set-aside funds on services research, which can be funded through the Institutes. I think out of the $63 million set-aside, you should be able to find a few million for the State Systems Development Program. We asked for a report on the SSDP last year, due January 14th.

When will the Agency's report on the set-aside be completed?

Answer. The ADAMHA Report to Congress, "ADMS Block Grant SetAside" was delivered to the Chairman of the Subcommittee on Labor, Health and Human Services and Education on March 13, 1991.

Question. What is the status of the State Systems Development Program?

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