classification systems. better classification for tbi, predictive markers for dementia and a host of other activities that can only really be achieved through that type of collaboration. so i think that this is -- the acronym is the federal interagency traumatic brain injury research database. i think it's going to be a real facilitator for the type -- >> so you're working to improve access to databases -- >> right. >> -- and electronic information on the funded research. mr. ditto, how are the states working with returning service members or veterans and how do states coordinate these services with the veterans organizations? >> well, actually, the state -- actually the states have had an interesting opportunity over the last several years. the veterans administration actually established a program

in conjunction with the department of health and human services that is called consumer directed home and community based veterans services. and it was modeled after a program that was done in a number of states in which individuals were given an individual budget and then allowed to decide how to use that money to meet their specific needs. and so the states have gotten involved, and it's a slow process, but it's taking off, in getting involved in understanding that the returning service people, once they have had the acute care, and, you know, they go through the acute rehabilitation phase through veterans affairs that they then need a sort of a stepdown after that. they're not ready to just go back into their communities and live. they need an environment, a therapeutic environment, not as intense as intense physical

rehab is, but something that is more a day-to-day living kind of getting adjusted program. so i think we're making headway with that because before, to be perfectly blunt, in most states the department of defense was placing individuals in long-term care facilities, in nursing homes. so we're getting away from that. i think also the states are reaching out to their veterans administration agencies to network with them and to become involved with them and to open up the doors to what the state may have to offer in terms of helping out with this. many times veterans, employees are just not aware of the scope of brain injury programs and, frankly, because this has become the signature injury of this war. this the first time that people started looking about at these other programs that were out there dealing with people who had acquired their brain injuries in a digfferent way other than combat.

>> thank you. dr. ashley, you describe the very ability and post-acute care for tbi patients. what are the factors that cause this variability, and also, would you -- i only have so much time -- describe the difference in rehab, rehabilitation of children versus adults. >> well, yes, sir. the first part of your question is what accounts for the variability begins with a lack of understanding of the condition, itself. as i mentioned earlier in the general medical community and in the payer community, there's not good understanding of the neu neurophisiologic as a recovery of brain injury. today we understand what we do in the environment by creating appropriately structured demand reprograms existing cells to take over function or induces growth in the brain for new

development of -- or excuse me, development, new structures to take on function. so without the proper knowledge in the medical community or in the payer community that underlies this, it's treated as though it's a broken bone. broken bone takes six weeks to heal, and we get two weeks or so in rehabilitation for the brain. inappropriate. we also have rehabilitation policy in insurance plans that was designed for muscular se skeletal and orthopedic, four decades ago when it first came into being. it has not morphed into covering the reblgts needs that we see with surviving neurologic injuries. we spend a great deal of money to keep a person alive and basically spend no money to give them any quality of life afterward. the injustice here is we actually have the ability to do it. we're simply withholding this

care, calling it something other than medical treatment and constraining it in policy by either licenseure restriction or benefit restriction. one or both. i apologize, the second part of your question -- oh. the difference between children and adults. >> yeah. >> it's -- euphemistically it's said that children are not little adults. i think dr. winston touched on it very nicely when she indicated that the path of physiology of a child's brain is substantially altered with an injury and differs substantially from adults. one of the areas that we have to really investigate has to do with the onset of lifelong disease processes that arise from the changes in the brain metabolically and neurophysiologically. once altered it's difficult to know if the changes actually revert to normal or not.

there's great suspicion, for example, in pediatric injury, that abnormalities contribute to the system to further mature appropriately. as a consequence, we have to really call into question the role of even a cult brain injury much more more obvious brain swrur in conditions that might lead to dyslexia, difficulties with reading, writing, math, and so on, that we bundled under learning disabilities, as an example. and further, as we see the difference in children, we have, excuse me, medication differences, foarm clojic interventi interventions, put children at risk that could be used in adults. we have the real social dilemma in terms of how we treat these children. it's difficult to amass them in a single environment and take them out of their cultural surroundings, family, school, et

cetera. and so unfortunately because of the vagaries of rehabilitation coverage, the schools do end up being the de facto rehabilitation setting. it's not what they're trained for. it's not what they're prepared for. they certainly have stepped up and tried to address the problem. but the medical rehabilitation of children really ought to be left to medical professionals. >> chair thanks the gentleman and recognizes the ranking member, five minutes for questions. >> thank you, mr. chairman. i wanted to ask dr. winston, you described how the majority of research is focused on traumatic brain injury in adults and that the scientific foundation for pediatric brain injury is limited. and you mentioned the need for focused research investments for better policies to better prevent and reduce the severity among children. it seems that, you know, you believe there's an important role for nih and other federal

agencies in congress to build upon existing on pediatric brain injury. could you share your perspective on specific pediatric research questions that could be further or should be further explored? >> thank you very much for asking that question. i think that we need to build up our scientific foundation so that we can improve and be more efficient in how we deliver our care. i like to think about it in five categories. first, to prevent -- to improve the prevention strategies we need to understand the who, what, where, when, how, and why of pediatric injury. we need to -- using biomechanics, behavioral science, epidemiology and the like. we need to improve our methods and measures for studying, diagnosing and following the course of tbi. biomarkers are also important. we need to conduct work to know what works and what doesn't. what -- how to improve on therapies that are currently

done, how to deliver it in the best ways possible. we need to know how to get state of the art to the field. to the frontline. and we need to support innovation research for the development of new safety products, biomarkers, and therapeutics. we must not forget to train our next generation to be our scientists of pediatric injury. there are two resources that i call the committee's attention to that would be able to give you more complete answers. trying to be brief here. the first is a very exciting initiative that i was part of, actually both i was part of, that will be released by the cdc i think next month. it's a national action plan for child injury prevention. it provides action steps in research, data, education, health systems, communication, to prevent child injuries from occurring. it also seeks to incorporate child injury prevention into existing systems and strategies at the national, state, and

local level. a second very exciting initiative is the national institute of child health and development, is interested in child injury. and i applaud leadership for their interest in this. the society for the advancement of violence and injury research under the direction of the president, dr. fred rivera, tapped into experts in the field and enumerated important next steps in child injury research. and i recommend that you get ahold of that as well. so from a personal perspective, there's a range, a wide range of what we need to do, but i think we can prioritize and we should. >> all right. thank you very much. let me ask, i know we're running out of time again, but dr. ashley, in your testimony, i'm struck by the continuing care that's needed for people with traumatic brain injury. you stated, for those americans who have experienced moderate to severe traumatic brain injury,

their recovery often extends beyond their hospitalization, requires ongoing extensive rehab. you also testify it's a start of a disease causative and disease accelerative process. can you elaborate on an extent to which more serious brain injuries are lifelong conditions? i know you mentioned that. if you want to talk about it a little more. >> yes, sir. the difficulty that we see, of course, is that anything and everything that a human being does is mediated by the brain. so when the brain is injured, the potential for impacting any and every organ system in the body and its function exists. at the most basic level, when a brain cell is injured and you have 100 billion of them, that begins a neurodegenerative process, the end of which we're not sure exists. in fact, a few hours after an injury to the brain, we'll see inflammatory processes around the body initiated. in about a third of all individuals late in life will

see those same processes reinitiate. we change how the brain's biochemistry works. the brain functions in various degrees of bioenergetic crisis following a brain injury. almost indefinitely. as a result, what happens is the metabolic demand creates tremendous stress within the system that triggers a number of degenerative processes. so we're beginning to reconsidering lifelong diseases, diseases we've known lifelong like parkin's, multiple sclerosis, so on, as disorders that may have an origin in alterations in the brain's neurophysiology after a brain injury. you see this made manifest in the recent press over retired athletes with repetitive concussions, from the sports

legacy institute and the work being done at boston university on the donated brains of retired professional another heats. we see changes in the brain and a condition called chronic traumatic encephalopathy that's been identified as a single example of these lifelong conditions and progressive conditions. >> thank you. thank you, mr. chairman. >> chair thanks the chairman. recognizes the gentleman from illinois. five minutes for your question. >> i thank the panel for being here. i apologize for not being here for opening statements. i was giving a tour to wounded warriors in the capitol. they just left. it gave any time to get back here. so in that venue, obviously some of my questions will already be asked. dr. strickland, you know, we think it's applaud bl for us to try to organize these agencies

and try to maximize the focus. we know that you got the federal interagency community, the federal clearinghouse, or tbi, federal interagency for tbi research database, center for ye neurosciences and regenerative medicine. how are you going to try to coordinate these groups? i think everyone knows, and the president's also said, we have to get efficient, we have to pare down redundancies. how are you going to go about doing that. >> the interagency community that hersa is convening is really not to achieve that interagency -- >> do you think that's an important thing to do? >> i think it's a very important thing to do within each agency. ours is more of an informal group so we can be aware of what other agencies are doing and better align what we're doing with our scarce resources with the resources of others. there's certainly still a need

for agencies to coordinate their activity activities within their own agencies and dedicated activities of similar interest and similar focus. >> i think we're going to try policy wise and budgetary wise to really streamline this process of not just in this area but health care research dollars. because we do seem to have sometimes multiple agencies doing similar things but they're not coordinated and they're not feeding back the same information and there's not one clearinghouse. we're getting a return on that investment. the question is, are we get a bigger return on investment as we should? and that's not even in your own agency. some of the health care research is in the department of defense, as you know, and the like. let me go to mr. ditto. how many states are working with returning service members or

veterans? >> give me a quick number. probably about 15 or 20 from what we're aware of. now, some states are very advanced in this. the state of massachusetts, for instance, has a very involved, e elaborate program they've been working on for years. they had a lot of commitment of resources at the state level that helped to bring this collaboration together and work on. what wooim worried about from the standpoint of our organization and representing state governments is sththat we just don't have every state working on this but every state has returning service people. so right away we're in sort of a difficult position because we're really not necessarily reaching people. the other thing is, and i'm sure it's no surprise to you, most of the public entitlement programs across the country, especially like medicaid, become the payer for long-term care services for people with various disabilities

including brain injury. and most states are seeking to reduce and decrease their expenditures under the medicaid program for various reasons. for obvious reasons. and it worries me because what's happening is in some respects people with brain injuries are just being mixed in or lumped in in states with other groups of people with disabilities, and yet as you've heard from the experts, the treatment and the management of these individuals is quite different. we're looking at quite a different approach to doing something. and it -- because it's a lifelong disability and because the impairments persist over time, over a long period of time, it really requires a lot of resources. and states are not -- i don't think states don't want to do the right thing. i just think they're having a very difficult time with the funding and, you know, with constrictions in programs and with the small amount of money that hrsa gets to support, you

know, through the tbi act what needs to be done, this is, you know, this system is not -- the amount of money that is being given to hrsa is not reflective of the magnitude of the problem of brain injury. that's the simplest way i can say. >> and we appreciate that. what about, in your coordination with states, and how are the veterans organizations linked in at all? >> well, veterans and organizations are linked in, and, in fact, we've had some very excellent -- we had some very interesting developments in a number of states where the national guard came to the state and said, we'd like to do something with the people we're sending out, you know, to combat, and so they were pretested before they left on assignment with a base measure of their brain function, et cetera, and then when something happened to them, and they returned home again, they were retested and because of the baseline, there was an ability to determine whether or not any

brain damage had been sustained and if so then planned appropriate treatment for them. so both the local service organizations, as well as the state veterans service organizations, as well as the federal veterans department, veterans affairs, i think are all very guested in this. and nrsa has tried to work with these organizations and encouraged our states to work with them, but when we ended up with 21 states getting grants from hrsa, it made it difficult for the rest of the states to get replacement funding from the legislature and the governor to fill the void of trying to continue the momentum of this. >> and my time's expired. i appreciate the answers. i'll just finish on this, that, i mean, in fact, especially your last point, because as members of congress, one of the things that we do numerous times is we do constituent service and we do a lot of veterans affairs issues. and have a baseline on

disability and percentages and be able to get through that system sooner rather than later and instead of reinventing the wheel, in some of the lag times, it's just really abysmal. that would be helpful, too. so, appreciate your testimony. thank you, chairman. >> chair thanks the gentleman. dr. winston, i didn't get to you. i have one follow-up, if you would. in your testimony, you discussed the importance of the golden window in acute trae kucute tre. are you aware of any studies of treatment of children with tbi during the golden window? >> yes. so the question is about the goaden window. it used to be called the golden hour. we're now learning it's important to have aggressive care for a longer period of time, as we heard terrific testimony on. you know, the fact is that it is very difficult to do acute care

research, and i think that there are -- there's work out there to try to start bridging together emergency departments and hospitals to try to build networks where this kind of research can be done. just beginning. i personally, i could get back to you on specific information, but i know a very exciting study with adults found, just came out from the university of pennsylvania, found that early aggressive, expensive care, had important long-term consequences. i think that we give, and i think you would agree, too little, too late, and sometimes too late, to little, even late. you know, like we give -- we really need to get in there, particularly for very serious injuries. we need to get in there and work with the brain's ability to heal and reduce the secondary injuries that might occur from

high pox ya, low blood flow and the rest. for mild traumatic brain injury, the window is a little bit longer. it's 48 hours. i applaud the cdc and others to try to get that awareness out there. that early recognition response is needed. but i want to challenge, if i may, i give you a challenge that we're experiencing. the growing awareness for earlier recognition has really turned into some real challenges by parents who want some sound answers. they want to know things like, after how many concussions should my child be removed from contact sports? for how long are injured brains vulnerable to a second impact? does the risk differ by age? and why did my child get a concussion when they were wearing a helmet? our science, today, does not answer these questions. clinicians on the front lines are also asking questions. i think you might find this interesting, visits for

concussion, because of awareness, have skyrocketed at the children's hospital of philadelphia's care network, increasing 458% since 2009. we're struggling to meet the demand. we need research and leadership to provide evidence-based recommendations. it won't be this broad brush because we just can't afford it and we don't have enough trained providers. i know that chairman pitts, you have been very, very helpful in trying to make sure that we shore up the training that's necessary for this specialized care that children need. thank you very much for that. we need better standards for safety equipment, biomarkers for traumatic brain injuries so that we can follow the course of care, better tools to use in the field and in the clinics. evidence based and tested protocols. these don't exist right now. and then just to reiterate, for the young athlete, in particular, their job is not

playing on the field. it's actually learning. and we can't forget that. we need to make sure that we protect their brains so that they can become the leaders in society that many of them hope to become. >> thank you. and that effort for the children's hospital, gme, training for pediatrician, was bipartisan. my colleague was a great advocate of that as well. do you have any follow-up? >> no, mr. chairman, i just wanted to, first of all, thank you for what you just said, and your comment about concussions in sports. i agree. but i just wanted to, if i could, ask unanimous consent to submit the statement of our ranking member, mr. waxman. >> without objection. that concludes our hearing. the members may give you questions. we ask that you respond to those

questions once you get them, promptly. and i remind members they have ten business days to submit questions for the record. and that means they should submit their questions by the close of business on monday, april the 2nd. excellent hearing. wonderful testimony. we thank our expert panel for your very important testimony and answers to our questions. without objection, the subcommittee's adjourned. a busy week ahead in

congress. the house convenes tomorrow to consider spending for agriculture, transportation, and housing programs. and also a vote on holding attorney general eric holder in contempt of congress. republicans want the attorney general to turn over more documented related to the fast and furious gun tracking operation. live coverage from the house floor on c-span. and over in the senate, lawmakers gavel in today at 2:00 eastern with two bills on the agenda. the flood insurance program and user fees the fda collects from drug companies and medical device makers. you can watch that on c-span2. and there's a july 1st deadline hanging over congress. without congressional action, student loan rates will double on the 1st, and money runs out for the nation's highway and mass transit programs. here's a look at president obama's schedule this week. today, the president travels to boston and to portsmouth, new hampshire, for campaign events. he's back in washington tomorrow and will meet with the crowned

prince of abu dayby and later in the day host a picnic at the white house for members of congress. when did clean energy become a dirty word? i mean, you know, what is wrong with clean energy? you can believe, you know, what you want about our existing energy resources but why couldn't you also believe there's an opportunity for clean energy? >> i think we need to create demand in the next five to ten years for renewables to offset all the advantages that fossil fuels have had and i think it's clearly happening on a state-by-state basis. it would be much more effective if it was a federal policy. >> roughly three times as much of our energy is consumed in mobility as it is in heating our homes and our offices. and natural gas, again, north america is the only continent where we don't have widespread vehicles coming off the assembly line that can use compressed natural gas. there are still a ton of people out there that honestly believe compressed natural vehicle -- cars, trucks, are more likely to

burst into flames during a crash. >> developing alternative energy sources, including wind and biofuels, were all part of a next generation energy forum hosted by the "atlantic" magazine. watch their conversations online at the c-span video library. wednesday on "washington journal" sally krawcheck, former president of bank of america, recently wrote an article in the harvard "business review" titled "four ways to fix banks." find an article on our website c-span.org. she'll take your phone calls wednesday morning at 9:15 eastern on c-span. sunday, award winning author and historian david pietrusza is our guest on "book tv." his passion for u.s. presidents and the great american pastime, baseball, has resulted in a dozen books including "1920," the year of the six presidents.

"1960: lbj vs. jfk vs. nixon." joins live with your calls, e-mails and tweets for david pietrusza, sunday, noon eastern, book tv's "depth" on c-span2. veterans affairs department estimate ps 18 veterans commit suicide every day. at a recent conference on military suicide, head of the mental health services administration and health and human services secretary kathleen sebelius spoke about suicide prevention efforts. >> veterans administration and all the parts of the military working on issues that we care a lot about at samsa. we are very interested in the issue of suicide nationwide and in preventing that issue. and i want to take just a minute to sort of set a larger context. i suspect after three days or two days at a conference like this, you may have heard much of this, but let me just tell you a little bit about ho