BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: AB 1644 --------------------------------------------------------------- |AUTHOR: |Bonta | |---------------+-----------------------------------------------| |VERSION: |May 27, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |June 15, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Reyes Diaz | --------------------------------------------------------------- SUBJECT : School-based early mental health intervention and prevention services SUMMARY : Renames the School-based Early Mental Health Intervention and Prevention Services for Children Act of 1991, known as the Early Mental Health Initiative, as the Healing from Early Adversity to Level the Impact of Trauma in Schools Act. Requires the Department of Public Health (DPH) to create a new four-year program, as specified, and requires DPH to perform technical assistance and outreach to local educational agencies about the new program, which will target pupils with adverse childhood experiences, as specified. Existing law: 1)Establishes the School-based Early Mental Health Intervention and Prevention Services for Children Act of 1991, known as the Early Mental Health Initiative (EMHI), subject to the availability of funding each year. Authorizes the Director of the Department of Mental Health (now the Department of Health Care Services [DHCS]), in consultation with the Superintendent of Public Instruction (SPI), to provide matching grants to "local educational agencies (LEAs)," as defined, to pay the state share of the costs of providing school-based EMHI services to "eligible pupils," as defined. 2)Requires priority for the grants to be given to applicants that demonstrate specified criteria, including, but not limited to, serving the greatest number of eligible pupils from low-income families, providing a strong parental involvement component, providing services at a low cost per child, provide programs and services based on existing programs that have been shown to be effective; and provide services to children who are in out-of-home placement or at AB 1644 (Bonta) Page 2 of ? risk of being placed out of home. 3)Defines "LEA", for the purposes of the EMHI program, as any school district or county office of education, or state special school. Defines "eligible pupil" as a pupil who attends a publicly funded elementary school and who is in kindergarten or grades one to three, inclusive. Defines "supportive services" as a service that will enhance the mental health and social development of children. 4)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. 5)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 for periodic screenings to determine health care needs. 6)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. This bill: 1)Renames the EMHI the Healing from Early Adversity to Level (HEAL) the Impact of Trauma in Schools Act (the HEAL Trauma in Schools Act). Requires the Director of DPH, contingent upon an appropriation in the annual budget act, to establish a four-year program, in consultation with the SPI, the Director of DHCS, and the Attorney General to encourage and support local decisions to provide funding for the eligible support services, as specified. 2)Requires DPH to provide outreach to LEAs and county mental health agencies to inform individuals responsible for local funding decisions of the established program. Requires DPH to provide free regional training on all of the following: a) Eligible support services, including individual and group intervention and prevention services; parent engagement through conference or training, or both; teacher and staff conferences and training, as specified; referral to outside resources, AB 1644 (Bonta) Page 3 of ? as specified; use of paraprofessional staff to meet with pupils on a short-term weekly basis, as specified; and any other services that will improve the mental health of eligible pupils, particularly evidence-based interventions and promising practices, as specified; b) The potential for the eligible support services, as defined, to help fulfill state priorities described in the local control funding formula (LCFF), as specified; c) How educational, mental health, and other funds subject to the LCFF can be used to finance the eligible support services; d) External resources available to support eligible support services; and, e) State resources available to support student mental health and resilience, as positive, trauma-informed learning environments, including inclusive multitiered system of behavioral and academic supports, trauma-informed practices, social and emotional learning, and parent-child group supports. 3)Requires DPH to provide technical assistance to LEAs that provide or seek to provide eligible services to include, but not limited to, designing programs, training program staff, conducting local evaluations, and coordinating with county mental health agencies and professionals. 4)Requires DPH, in providing outreach, training, and technical assistance, to select and support school sites that meet specified criteria, including, but not limited to, school sites that previously received EMHI grants and have continued to provide eligible supports after the end of the grant period; school site that are not providing eligible support services but demonstrate a willingness and capacity to participate in the program; and prioritize school sites in communities that have experienced high levels of childhood adversity and that prioritize services to children exposed to trauma, including foster and homeless youth, as specified. 5)Expands the definition of "eligible pupil" to include pupils who attend a preschool program, as specified, and transitional kindergarten. Expands the definition of "LEA" to include charter schools. Specifies in the definition of "supportive AB 1644 (Bonta) Page 4 of ? service" the social-emotional development of children. 6)Makes findings and declarations about the importance of preventing and addressing adverse childhood experiences (ACEs), as specified, and childhood trauma, which can result in negative educational, health, social, and economic outcomes for children, youth, families, and communities. 7)Sunsets the program on January 1, 2022, unless a later enacted statute deletes or extends that date. FISCAL EFFECT : According to the Assembly Appropriations Committee: 1)General Fund (GF) administrative costs to DPH of approximately $300,000 to oversee the program and provide outreach, free regional training, and technical assistance to school sites over four years. DPH would also incur costs related to interim reporting requirements and final evaluation of program. 2)Proposition 98 GF cost pressure, in the millions of dollars, to fund grants pursuant to the HEAL Trauma in Schools Act. Grants are contingent upon an appropriation in the annual budget act. The Assembly Budget proposes $6 million GF for this program. PRIOR VOTES : ----------------------------------------------------------------- |Assembly Floor: |80 - 0 | |------------------------------------+----------------------------| |Assembly Appropriations Committee: |20 - 0 | |Assembly Health Committee: |18 - 0 | |------------------------------------+----------------------------| |Assembly Education Committee: | 7 - 0 | | | | ----------------------------------------------------------------- COMMENTS : 1)Author's statement. According to the author, for 20 years, the EMHI was a highly successful state program that provided matching grants to LEAs to provide school-based mental health supports to young pupils experiencing mild to moderate school adjustment difficulties. EMHI served over 15,000 children per AB 1644 (Bonta) Page 5 of ? year by supporting 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. Despite its success and the demand for services, the program was defunded in 2012. Additionally, with the dissolution of the Department of Mental Health, its oversight and agency was eliminated, effectively ending the program. AB 1644 restores the EMHI program and adds a focus on addressing the impacts of trauma and ACEs for children. Studies such as the Centers for Disease Control and Prevention's (CDC) ACEs Study indicate 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. Restoring and expanding the EMHI program is a significant step towards addressing the harmful and long-lasting effects of ACEs, and will give our children a better shot at success. 2)Background. Between 1991 and 2011, the state Department of Mental Health (DMH) operated the EMHI, providing schools with approximately $15 million annually. With the transfer of responsibilities from 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 prevention and early intervention programs. Schools are the main providers of mental health services for children in California. The federal Individuals with Disabilities Education (IDEA) Act 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 LEAs. 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 AB 1644 (Bonta) Page 6 of ? to the general student population. 3)EPSDT. The EPSDT benefit provides comprehensive screening, diagnostic, treatment, and preventive health care services for children under age 21 who are enrolled in Medi-Cal, and is key to ensuring that children who are eligible for EPSDT services receive appropriate preventive, dental, mental health, developmental, and specialty services. Federal Medicaid law defines the EPSDT benefit to include a comprehensive array of preventive, diagnostic, and treatment services for low-income children under age 21. States are required to provide coverage of any services listed in a section of the federal Medicaid Act to children who are eligible for EPSDT services when the services are determined to be medically necessary to correct or ameliorate any physical or behavioral conditions. The EPSDT benefit is more robust than the Medi-Cal benefit package provided to adults and is designed to ensure that eligible children receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible. 4)A shift in responsibilities and its effects. 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), transferred the responsibility for providing mental health services for students 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: a) Although the most common types of mental health AB 1644 (Bonta) Page 7 of ? 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; b) 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; c) 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, d) 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. 5)The ACEs Study. The ACEs study is an investigation into associations between childhood maltreatment and later-life health and well-being. The ACEs study is a collaboration between the CDC and Kaiser Permanente's Health Appraisal Clinic in San Diego. The ACEs 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 ACEs score, the greater one's risk of a broad range of health, mental health, and at-risk behaviors. The 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 ACEs 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. According to the federal Substance Abuse and Mental Health Services Agency, trauma-informed practices in schools can include those that involve: a realization of the widespread AB 1644 (Bonta) Page 8 of ? prevalence and impact of trauma; recognition of signs of traumatic exposure; responses grounded in evidence-based practices; and resisting the re-traumatization of students. 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 instructional modifications that address the specific learning needs of students exposed to trauma. 6)Double referral. If this bill passes out of this committee, it will be referred to the Senate Education Committee. 7)Prior legislation. 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. AB 1025 (Thurmond of 2015), would have required 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. 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 offices of education to provide technical assistance and develop statewide resources to assist LEAs in establishing and aligning systems of learning and behavioral supports. 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 and transferred that responsibility to school districts. 8)Support. Supporters of this bill argue that childhood trauma and exposure to violence can have a lasting impact on the AB 1644 (Bonta) Page 9 of ? ability of a child to grow and thrive, resulting in negative impacts on educational, health, social, and economic outcomes for children and their families. Supporter state that this bill is modeled on the success of the EMHI, in which 79% of participating students exhibited improvements, and that this bill will not only improve the lives of young people but the public safety and well-being of the state for years to come. NAMI California states that almost half of all cases of mental illness begin by age 14 but only 20% of children with diagnosable mental illness are identified and receive treatment and services each year, with Asian and Latino children being the least likely to have had a mental health visit. 9)Opposition. California Right to Life Committee, Inc. (CRLC) opposes with concerns about intervention services for pre-school and transitional kindergarten-aged children. CRLC questions who determines at what level ACEs warrant governmental intervention, what local decision-makers will be included, and who determines what ACEs are, among other things. SUPPORT AND OPPOSITION : Support: Attorney General Kamala D. Harris (cosponsor) Children Now (cosponsor) Time for Kids, Inc. (cosponsor) Abriendo Puertas/Opening Doors Alameda Unified School District/Woodstock Child Developmental 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 Council of Community Behavioral Health Agencies California Pan-Ethnic Health Network California School-based Health Alliance California School Nurses Organization AB 1644 (Bonta) Page 10 of ? California State PTA Californians for Safety and Justice Center Joint Unified School District Center for Leadership, Equity, and Research Center for Youth Wellness Chico Unified School District Children's Defense Fund California Children's Specialty Care Coalition City of Oakland Common Sense Kids Action County Behavioral Health Directors Association of California Early Edge California East Bay Agency for Children East Bay Asian Youth Center Family Voices of California Fight Crime: Invest in Kids First Place for Youth Full Court Press Communications Girls Leadership Institute Human Impacts Partners Inland Congregation United for Change LEMONADE Creative Consulting 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 Association of California Mental Health & Autism Insurance Project Montclair Physical Therapy NAMI California National Association of Social Workers, California Chapter [Nonprofit] Communications Nurse-Family Partnership Oakland Natives Give Back Playworks Public Counsel Rape Counseling Services of Fresno Regional Asthma Management and Prevention Resource Development Associates Sacrament ACT (Area Congregations Together) Santa Clara County Board of Supervisors Street Level Health Project The Children's Partnership AB 1644 (Bonta) Page 11 of ? The MADE thriveSF Fitness United Ways of California Violence Prevention Coalition of Greater Los Angeles Wellness Together Western Center on Law and Poverty Young People's Policy Solutions Youth UpRising Numerous individuals Oppose: California Right to Life Committee, Inc. -- END --