BILL ANALYSIS                                                                                                                                                                                                    



          SENATE COMMITTEE ON HEALTH
                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 1644             
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          |AUTHOR:        |Bonta                                          |
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          |VERSION:       |May 27, 2016                                   |
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          |HEARING DATE:  |June 15, 2016  |               |               |
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          |CONSULTANT:    |Reyes Diaz                                     |
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           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  :  
          
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          |Assembly Floor:                     |80 - 0                      |
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          |Assembly Appropriations Committee:  |20 - 0                      |
          |Assembly Health Committee:          |18 - 0                      |
          |------------------------------------+----------------------------|
          |Assembly Education Committee:       |  7 - 0                     |
          |                                    |                            |
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          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  








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            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  








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            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.


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