BILL ANALYSIS                                                                                                                                                                                                    



                                                                    AB 1644


                                                                    Page  1





          Date of Hearing:  April 12, 2016


                            ASSEMBLY COMMITTEE ON HEALTH


                                   Jim Wood, Chair


          AB 1644  
          (Bonta) - As Amended March 8, 2016


          SUBJECT:  School-based early mental health intervention and  
          prevention services.


          SUMMARY:  Reestablishes and renames the Early Mental Health  
          Initiative (EMHI) as the Healing from Early Adversity to Level  
          the Impact of Trauma in Schools Act, expands the program to  
          serve preschool and transitional Kindergarten students, and  
          establishes an initiative to encourage and support local  
          decisions to provide funding for services offered in that  
          program.  Specifically, this bill:  





          1)Makes findings and declarations regarding the importance  
            preventing and addressing Adverse Childhood Experiences (ACEs)  
            and childhood trauma.


          2)Establishes the School-Based Early Mental Health Intervention  
            and Prevention Services Support Program, administered by the  
            Department of Public Health (DPH), in consultation with the  
            Superintendent of Public Instruction (SPI), the Director of  
            Health Care Services, and the Attorney General to encourage  








                                                                    AB 1644


                                                                    Page  2





            and support local decisions to provide funding for eligible  
            support services. 





          3)Expands the definition of eligible pupils to include preschool  
            and transitional Kindergarten students, and extends program  
            eligibility to charter schools and preschool programs not  
            operated on school sites.


          4)Names DPH and the Director of the DPH as the administrators of  
            the program.


          5)Requires that, in determining which students receive services  
            under the program, local educational agencies (LEAs)  
            prioritize children who have been exposed to childhood trauma,  
            including students in foster care and those who are homeless.   



          6)Includes, as services which may be funded under the program,  
            evidence-based interventions and promising practices intended  
            to mitigate the consequences of childhood adversity and  
            cultivate resilience and protective factors.


          7)Requires DPH to provide outreach to LEAs and county mental  
            health agencies to inform them of the program. 





          8)Requires DPH to provide free regional training on eligible  
            support services, including individual and group intervention  








                                                                    AB 1644


                                                                    Page  3





            and prevention services, parent engagement, teacher and staff  
            conferences and training, referral to outside resources, use  
            of trained and supervised paraprofessional staff, and  other  
            services to improve student mental health, particularly  
            evidence-based interventions and promising practices intended  
            to mitigate the consequences of childhood adversity and  
            cultivate resilience and protective factors.





          9) Requires DPH to provide free regional training on: 



             a)   The potential for the support services to help fulfill  
               state priorities described by the local control funding  
               formula (LCFF) and local control and accountability plans  
               (LCAPs) 



             b)   How educational, mental health, and other funds subject  
               to local control can be used to finance the eligible  
               support services;



             c)   External resources available to support the eligible  
               support services, including workshops, training,  
               conferences, and peer learning networks; and,



             d)   State resources available to support student mental  
               health and positive, trauma-informed learning environments.










                                                                    AB 1644


                                                                    Page  4







          10) Requires DPH to provide technical assistance to LEAs,  
            including assistance in designing programs, training staff;  
            and conducting evaluations; coordination with county mental  
            health agencies and professionals; and leveraging local funds.



          11) Requires DPH to select and support schoolsites as follows: 



             a)   During the first 12 months of the program, DPH to  
               support, strengthen, and expand the provision of eligible  
               services at schoolsites that previously received funding  
               for EMHI and have continued to provide eligible support  
               services;



             b)   DPH to develop a process to identify schoolsites that  
               demonstrate the willingness and capacity to participate in  
               the program; and,



             c)   DPH, during the subsequent 36 months of the program, to  
               select new schoolsites that are not providing eligible  
               support services but that demonstrate the willingness and  
               capacity to participate in the program.  Requires the DPH  
               to work with these schoolsites to deliver eligible support  
               services.




          12) Requires DPH to prioritize school sites in communities that  
            have experienced high levels of childhood adversity, such as  








                                                                    AB 1644


                                                                    Page  5





            adverse childhood experiences and childhood trauma, and  
            schoolsites that prioritize children who have been exposed to  
            childhood trauma, such as students in foster care and those  
            who are homeless.  Requires to DPH prioritize geographic  
            diversity, program effectiveness, program efficiency, and  
            long-term program sustainability.



          13) States that implementation of the support program is  
            contingent upon an appropriation in the annual budget act.



          14) Sunsets the program on January 1, 2022. 
          


          EXISTING LAW: 


          1)Establishes the School-based EMHI Services for Children Act of  
            1991, and authorizes DHCS, in consultation with the SPI, to  
            provide matching grants to LEAs to pay the state share of the  
            costs of providing school-based EMHI services to eligible  
            students, subject to the availability of funding each year. 


          2)Provides for the Medi-Cal program, administered by DHCS, under  
            which eligible low-income individuals receive health care  
            services subject to state and federal laws and funding.


          3)Establishes the Medi-Cal Early and Periodic Screening,  
            Diagnostic and Treatment (EPSDT) program for eligible  
            individuals up to age 21 pursuant to state and federal law.


          4)Defines a LEA as a school district, a county office of  








                                                                    AB 1644


                                                                    Page  6





            education, a nonprofit charter school participating as a  
            member of a special education local plan area, or a special  
            education local plan area and allows LEAs to provide and bill  
            for Medi-Cal services provided to students receiving special  
            education services on Medi-Cal (generally, special education  
            students).


          5)Establishes the Mental Health Services Act, enacted by voters  
            in 2004 as Proposition 63, to provide funds to counties to  
            expand services, develop innovative programs, and integrated  
            service plans for mentally ill children, adults, and seniors  
            through a 1% income tax on personal income above $1 million.

          FISCAL EFFECT:  This bill has not yet been analyzed by a fiscal  
          committee.


          COMMENTS:  


          1)PURPOSE OF THIS BILL.  According to the author, for 20 years,  
            the EMHI Matching Grant Program was a highly successful state  
            program that provided matching grants to LEAs agencies to  
            provide school-based mental health support to young pupils  
            experiencing mild to moderate school adjustment difficulties.   
            EMHI supported Primary Intervention Programs consisting of  
            one-on-one services or services delivered in small groups to  
            address social skills, anger management, friendship groups, or  
            topic-specific issues such as bullying or divorce; and,  
            indirect services such as parent and teacher services and  
            classroom curricula. 



            The author states that EMHI Matching Grant Program served over  
            15,000 children per year and its services were in great  
            demand.  Despite its success and the demand for services, the  
            program was defunded in 2012.  Additionally, with the  








                                                                    AB 1644


                                                                    Page  7





            dissolution of the Department of Mental Health, its oversight  
            and agency was eliminated, effectively ending the program.





            The Centers for Disease Control's (CDC) Adverse Childhood  
            Experiences (ACE) study indicates that childhood exposure to  
            abuse, neglect, and other traumatic experiences has lifelong  
            health impacts.  Left unaddressed, ACEs expose children to  
            toxic stress, keeping them in a constant state of  
            fight-or-flight and taking years off their lives and damaging  
            their health.  The author concludes that restoring and  
            expanding the EMHI Program is a significant step towards  
            addressing the harmful and long-lasting effects of ACEs, and  
            will give children a better shot at success.


          2)BACKGROUND.  


             a)   K-12 Mental Health Services.  There are a number of  
               different funding mechanisms currently available for school  
               districts and LEAs to provide health care services to  
               pupils, as discussed in more detail below.  Between 1991  
               and 2011, the state Department of Mental Health (DMH) also  
               operated a previous version of the EMHI, which provided  
               schools with approximately $15 million annually to serve  
               children in kindergarten through third grade with mild and  
               moderate mental health problems.  With the transfer of  
               responsibilities from the DMH to DHCS in 2012, this program  
               was shifted to local education departments.  Many counties  
               also fund on-campus mental health services for non-special  
               education students through EPSDT and Mental Health Services  
               Act-funded early prevention programs.


          Schools are the main providers of mental health services for  








                                                                    AB 1644


                                                                    Page  8





          children in California. The federal Individuals with  
          Disabilities Education Act (IDEA) was adopted in 1975 to  
          guarantee children with disabilities a right to public education  
          in the least restrictive setting.  In California, the federal  
          IDEA mandate to provide special education services is  
          administered by local school districts and local education  
          agencies. Special education students may be eligible for health  
          care services, including mental health services, in specific  
          IDEA disability categories. Mental health services provided to  
          special education students include counseling and guidance,  
          psychological services, parental counseling and training, and  
          residential placement, among others.  While federal law requires  
          mental health services to be provided to students who have been  
          identified for special education services, there are little to  
          no services available to the general student population.


          
             b)   County Mental Health Plans (MHPs).  Prior to 2011,  
               special education students who had a severe emotional  
               disturbance condition documented in their individual  
               education plans (IEPs) were referred by their schools to  
               county mental health agencies for treatment.  In 2011, the  
               Legislature repealed the state mandate on county mental  
               health agencies to provide IDEA-related mental health  
               services and shifted this financial responsibility to the  
               California Department of Education (CDE).  LEAs and local  
               county MHPs were required to develop new agreements  
               defining agency responsibilities that reflected the changes  
               in state law.  MHPs remain responsible for providing EPSDT  
               services for students who are Medi-Cal beneficiaries with  
               IDEA-related individualized education, if they meet medical  
               necessity criteria.





          AB 114 (Committee on Budget), Chapter 43, Statutes of 2011,  








                                                                    AB 1644


                                                                    Page  9





          transferred the responsibility for providing mental health  
          services for students with individualized education programs  
          (IEPs) from county mental health departments to LEAs.  A 2016  
          state audit on the effect of AB 114 on mental health services  
          for these students reported, among other findings:





               i)     Although the most common types of mental health  
                 services offered and the service providers generally did  
                 not change, LEAs removed mental health services from  
                 student IEPs in the two years after AB 114 took effect;



               ii)    Although most service reductions were not related to  
                 AB 114, such as those prompted by a student graduating,  
                 IEP teams did not always record in the IEP document their  
                 rationale of why a service was removed;



               iii)   For 40% of the students who had a change to their  
                 mental health services or their educational placement  
                 within two years of AB 114's implementation, the IEP  
                 teams did not document the rationale for the changes;  
                 and,



               iv)    For 13 of the 44 students reviewed who had a mental  
                 health service removed from their IEPs, either the LEAs  
                 could not satisfactorily explain why the services were  
                 removed or the removal was related to AB 114.  In three  
                 cases, the LEA had no assurance that removing services  
                 would not adversely affect access to education.
             c)   EPSDT.  EPSDT is a federally mandated Medi-Cal benefit  








                                                                    AB 1644


                                                                    Page  10





               for individuals up to the age of 21 who have full-scope  
               Medi-Cal eligibility.  This benefit allows for periodic  
               screenings to determine health care needs and based upon  
               the identified health care need and diagnosis, treatment  
               services are provided.  EPSDT services include all services  
               otherwise covered by Medi-Cal and EPSDT beneficiaries can  
               receive additional medically necessary services.  EPSDT  
               mental health services are Medi-Cal services that correct  
               or improve mental health problems that have been determined  
               by a physician, psychologist, counselor, social worker, or  
               other health or social services provider.  EPSDT provides  
               eligible children access to a range of mental health  
               services that include, but are not limited to mental health  
               assessment, collateral contracts, therapy, rehabilitation,  
               mental health services, medication support services, day  
               rehabilitation, day treatment intensive, crisis  
               intervention and stabilization, targeted case management,  
               and therapeutic behavioral services. 



             d)   The Adverse Childhood Experiences Study.  The ACE study  
               is a landmark investigation into associations between  
               childhood maltreatment and later-life health and  
               well-being.  The ACE study is a collaboration between the  
               CDC and Kaiser Permanente's Health Appraisal Clinic in San  
               Diego. 



          The ACE study uses a score to represent the degree to which a  
          person has experienced traumatic events.  One point is recorded  
          for each type of trauma exposure in the areas of abuse, neglect,  
          and household dysfunction, and the points add up to a score  
          ranging from 0 to 10.  The higher an ACE score, the greater  
          one's risk of a broad range of health, mental health, and  
          at-risk behaviors. 










                                                                    AB 1644


                                                                    Page  11








          The ACE Study has shown that ACEs are major risk factors for the  
          leading causes of illness and death, as well as poor quality of  
          life.  Related research has also demonstrated a strong  
          association between high ACE scores and poor performance in  
          school, including a higher risk of learning and behavior  
          problems.  Other research into the effects of chronic stress  
          (often caused by ACEs) on children, has identified a profound  
          effect on the developing brain, which in turn affects school  
          performance and behavior.





          Recognition of the impact of these childhood experiences has led  
          to the development and increasing use of "trauma-informed"  
          approaches in a variety of fields, including education.  Broadly  
          speaking, trauma-informed practices in schools are those which  
          involve:  i) a realization of the widespread prevalence and  
          impact of trauma; ii) recognition of signs of traumatic  
          exposure; iii) responses grounded in evidence-based practices;  
          and, iv) resisting the re-traumatization of students [definition  
          from the federal Substance Abuse and Mental Health Agency].   
          Examples of such practices in schools include professional  
          development for educators on the role of trauma in learning,  
          classroom management practices and discipline policies focused  
          on conflict resolution and restorative practices, and even  
          instructional modifications which address the specific learning  
          needs of students exposed to trauma.





          Trauma-informed practices are specifically cited in the new  
          federal education law, the Every Student Succeeds Act (ESSA).   








                                                                    AB 1644


                                                                    Page  12





          Several provisions of the law reference staff development "based  
          on trauma-informed practices that are evidence-based?" and  
          "effective and trauma-informed practices in classroom  
          management." 





          3)SUPPORT.  Children Now and Time for Kids, sponsors of this  
            bill, state that state that the rationale for creating the  
            EMHI program in 1991 still resonates today:  "It is in  
            California's best interest, both in economic and human terms,  
            to identify and treat minor difficulties that our children are  
            experiencing before those difficulties become major barriers  
            to later success."  For 20 years, the EMHI Matching Grant  
            Program was the solution:  a highly successful program that  
            provided matching grants to LEAs to provide school-based  
            mental health supports to young pupils experiencing mild to  
            moderate school adjustment difficulties such as isolation,  
            anxiety, and bullying.



          The California Medical Association and others state in support  
            that this bill would build on the success of the EMHI program  
            by authorizing the provision of non-financial supports to help  
            LEAs maximize the use of funds that are under local control  
            for EMHI programs.  The proposed program would benefit young  
            children from preschool through third grade with  
            evidence-based and developmentally appropriate services and be  
            both cost effective and consistent with the principles of  
            local control. 

          The Steinberg Institute and Autism Deserves Equal Coverage,  
            state in support that this measure would create a prevention  
            and early intervention pilot program to help students from  
            preschool to third grade through the delivery of EMHI  
            services, which have a long track record of success in  








                                                                    AB 1644


                                                                    Page  13





            California.
          4)RELATED LEGISLATION.  SB 463 (Hancock) of 2015 requires the  
            CDE to designate a county office of education to be the  
            fiduciary agent for the Safe and Supportive Schools Train the  
            Trainer Program.  SB 463 is pending in the Assembly Education  
            Committee.





          5)PREVIOUS LEGISLATION.


             a)   AB 1133 (Achadjian) of 2015 would have established a  
               program substantially similar to the one proposed by this  
               bill.  Would have established a four year pilot program,  
               the School-Based Early Mental Health Intervention and  
               Prevention Services Support Program, to provide outreach,  
               free regional training, and technical assistance for LEAs  
               in providing mental health services at school sites.  AB  
               1133 was held in the Assembly Appropriations Committee.



             b)   AB 1025 (Thurmond) of 2015 would have required the CDE  
               to establish a three year pilot program to encourage  
               inclusive practices that integrate mental health, special  
               education, and school climate interventions following a  
               multitiered framework.  AB 1025 was held in the Senate  
               Appropriations Committee.



             c)   AB 114 (Committee on Budget), Chapter 43, Statutes of  
               2011, a companion measure to the 2011-12 Budget bill,  
               relieved county mental health departments of the  
               responsibility to provide mental health services to  
               students with disabilities (AB 3632 program) and  








                                                                    AB 1644


                                                                    Page  14





               transferred that responsibility to school districts.


             d)   AB 104 (Committee on Budget), Chapter 13, Statutes of  
               2015, among other things, appropriates $10 million to the  
               SPI to be apportioned to a designated county office of  
               education to provide technical assistance and develop  
               statewide resources to assist local educational agencies to  
               establish and align systems of learning and behavioral  
               supports.


          6)DOUBLE REFERRAL.  This bill was double referred to the  
            Assembly Education Committee, where it passed unanimously.


          REGISTERED SUPPORT / OPPOSITION:


          





          Support


          California Attorney General Kamala D. Harris (sponsor)


          Children Now (sponsor)


          Time for Kids, Inc. (sponsor)


          Abriendo Puertas/Opening Doors
          Alameda Unified School District, Woodstock Child Development  








                                                                    AB 1644


                                                                    Page  15





          Center
          Alliance for Education Solutions


          American Academy of Pediatrics


          Amethod Public Schools
          BANANAS


          Bay Area Urban Debate League
          Beats Rhymes and Life
          Bicycle Coffee


          Brighter Beginnings
          California Alliance of Child and Family Services


          California Black Health Network
          California Center for Public Health Advocacy
             California Children's Hospital Association
          California Council of Community Mental Health Agencies
          California Medical Association
          California Pan-Ethnic Health Network
          California School Nurses Organization 


          California School-Based Health Alliance


          California State PTA


          Californians for Safety and Justice


          Center for Community Health and Engagement








                                                                    AB 1644


                                                                    Page  16







          Center for Leadership, Equity, and Research
          Center for Youth Wellness


          Center Joint Unified School District 


          Chico Unified School District


          Childhood Injury Prevention Network


          Children's Hospital & Research Center Oakland


          Children's Specialty Care Coalition


          Children's Defense Fund-California
          Children's Partnership
          Common Sense Kids Action


          Early Edge California


          East Bay Agency for Children


          East Bay Asian Youth Center
          Family Voices of California


          Fight Crime: Invest in Kids California
          First Place for Youth









                                                                    AB 1644


                                                                    Page  17






          Folsom Cordova Unified School District


          Full Court Press Communications


          Futures Without Violence


          Girls Leadership Institute


          Human Impact Partners
          Inland Congregations United for Change


          Lemonade Creative Consulting
          Liberty School District
          Los Angeles County Office of Education


          Los Angeles Trust for Children's Health


          Lucile Packard Children's Hospital Stanford


          Mental Health America of California


          Mental Health and Autism Insurance Project
          Mental Health Association of California
          Montclair Physical Therapy
          National Alliance on Mental Illness California
          National Association of Social Workers, California Chapter
          Nonprofit Communications
          Nurse-Family Partnership
          Oakland City Council








                                                                    AB 1644


                                                                    Page  18







          Oakland Natives Give Back 


          Playworks


          Public Counsel


          Rape Counseling Services of Fresno


          Regional Asthma Management and Prevention
          Resource Development Associates
          Sacramento Area Congregations Together


          Santa Clara County Board of Supervisors


          Santa Cruz City Schools


          Street Level Health Project


          The Children's Partnership


          The MADE


          ThriveSF Fitness


          Time for Kids, Inc.









                                                                    AB 1644


                                                                    Page  19






          United Ways of California


          Violence Prevention Coalition of Greater Los Angeles


          Waugh School District


          Wellness Together


          Western Center on Law and Poverty


          Young People's Policy Solutions


          Youth UpRising


          Numerous individuals




          




          Opposition


          None on file.











                                                                    AB 1644


                                                                    Page  20






          Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097