BILL ANALYSIS Ó
SENATE COMMITTEE ON HUMAN SERVICES
Senator McGuire, Chair
2015 - 2016 Regular
Bill No: SB 238
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|Author: |Mitchell |
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|Version: |April 7, 2015 |Hearing |April 21, 2015 |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Sara Rogers |
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Subject: Foster care: psychotropic medication
SUMMARY
This bill requires specified certification and training programs
for group home administrators, foster parents, child welfare
social workers, dependency court judges and court appointed
council to include training on psychotropic medication, trauma,
and behavioral health, as specified, for children receiving
child welfare services. This bill requires the Judicial Council
to update court forms pertaining to the authorization of
psychotropic medication for foster youth and ensure specified
changes to those forms, on or before July 1, 2016. Additionally,
this bill requires the California Department of Social Services
(CDSS) to develop an individualized monthly report, a form to
share information and an alert system, to be used by county
child welfare agencies, regarding the administration of
psychotropic medication for a foster youth.
ABSTRACT
Existing law:
1) Provides for the development of a group home
administrator certification program by the California
Department of Social Services (CDSS) in collaboration with
specified stakeholders to ensure certified persons have
appropriate training to provide care and services. Requires
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the certification program to include a minimum of 40 hours
of classroom instruction and provide coverage of a
specified uniform core of knowledge. (HSC 1522.41)
2) Requires every licensed foster parent to complete a
minimum of 12 hours of foster parent training covering
specified topics prior to the placement of a foster child
in the home, and eight hours annually subsequently. (HSC
1529.2)
3) Requires the Judicial Council to develop and implement
standards for the education and training of all judges who
conduct hearings pursuant to Welfare and Institutions Code
Section 300, pertaining to dependent children. (WIC 304.7)
4) Requires court appointed counsel of a child or nonminor
dependent to have specified training, promulgated by the
Judicial Council as rules of the court that ensures
adequate representation of the child or nonminor dependent.
(WIC 317)
5) Provides that only a juvenile court judicial officer
shall have authority to make orders regarding the
administration of psychotropic medications for a minor who
has been adjudged a dependent of the court and removed from
the physical custody of his or her parent. Requires the
Judicial Council to adopt rules of court and develop
appropriate forms. (WIC 369.5)
6) Provides for the development of a statewide coordinated
training program designed specifically to meet the needs of
county child protective services social workers, agencies
under contract with county welfare departments to provide
child welfare services, and persons defined as a mandated
reporter pursuant to the Child Abuse and Neglect Reporting
Act. (WIC 16206)
This bill:
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1) Requires the following trainings to additionally
include the "authorization, uses, risks, benefits,
administration, oversight, and monitoring of psychotropic
medication, and trauma, behavioral health, and other
available behavioral health treatments, for children
receiving child welfare services, including how to access
those treatments."
Group home administrator certification;
Initial preplacement training of licensed
foster parents;
Post training of licensed foster parents;
Training required to be made available to
relative and nonrelative extended family members;
Judicial Council-developed training for judges
who conduct trainings pursuant to Welfare and
Institutions Code Section 300;
Training of court appointed counsel of a child
or nonminor dependent.
Training provided to specified county child
protective services social workers, agencies under
contract with county welfare departments to provide
child welfare services, and persons defined as a
mandated reporter pursuant to the Child Abuse and
Neglect Reporting Act.
1) Requires the Judicial Council, on or before July 1,
2016, in consultation with CDSS, the Department of Health
Care Services (DHCS), and specified stakeholders to
implement and develop updates to the required forms
pertaining to this bill.
2) Requires the above implementation and updates ensure the
following:
The child and his or her caregiver and
court-appointed special advocate, if any, have a
meaningful opportunity to provide input on the
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medications being prescribed.
Information regarding the child's overall
behavioral health assessment and treatment plan is
provided to the court.
Information regarding the rationale for the
proposed medication, including information on other
pharmacological and non-pharmacological treatments
that have been utilized and the child's response, and
an explanation how the psychotropic medication being
prescribed is expected to improve the symptoms.
Guidance is provided to the court on how to
evaluate the request for authorization, including how
to proceed if information, otherwise required to be
included in a request for authorization, is not
included in a request.
1) Requires CDSS, in consultation with DHCS, the County
Welfare Directors Association (CDWA) and other stakeholders
to develop and provide an individualized monthly report to
each county child welfare services agency that includes the
following for each child receiving child welfare services:
Psychotropic medications that have been
authorized for the child pursuant to Welfare and
Institutions Code Section 369.5.
Data for medications that have been dispensed
to the child, including both psychotropic and
non-psychotropic medication.
Durational information relating to the child's
authorized psychotropic medication, including but not
limited to, the length of time a medication has been
authorized and the length of time for which a
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medication has been dispensed by a pharmacy.
Claims paid for behavioral health services
provided to the child, other than claims paid for
psychotropic medication.
The dosages of psychotropic medications that
have been authorized for the child and that have been
dispensed.
1) Requires CDSS in consultation with DHCS, CDWA and other
stakeholders to develop a form, to be used by a county
child welfare services agency on a monthly basis, to share
with the juvenile court, the child's attorney, and the
court-appointed special advocate, if one has been
appointed, the above information regarding a child
receiving child welfare services authorized to receive one
or more psychotropic medication.
2) Requires CDSS in consultation with DHCS, CDWA and other
stakeholders to develop, or ensure access to, a system that
automatically alerts a social worker of a child receiving
child welfare services when psychotropic medication has
been prescribed that fits the following descriptions:
Is prescribed in combination with another
psychotropic medication and the combination is unusual
or has the potential for a dangerous interaction.
Is prescribed in a dosage that is unusual for
a child of that age.
Is not typically indicated for a child of that
age.
1) Requires a child's social worker, upon receipt of an
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alert, to indicate to the court that the alert has been
received by the child's attorney, the child's caregiver,
and the child's court appointed special advocate, if one
has been appointed, and to include a discussion of the
resolution of the alert in the next court report filed.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
Purpose of the bill:
According to the author, recent newspaper articles have
highlighted the use and overuse of psychotropic medications in
foster care facilities. The author states that reports provided
by the Department of Health Care Services (DHCS) and the
Department of Social Services (CDSS) provide limited information
needed to determine how psychotropic medicine is administered to
foster youth. The author states that the goal of this
legislation is to develop and review data, to develop a system
of red flags, to improve county reporting and to establish
further consultation/second opinion options for cases in which
psychotropic medications and/or antidepressants are being
prescribed for a foster youth.
The County Welfare Directors Association, a sponsor of the bill,
states that "recent reports indicating that psychotropic
medications are over-prescribed in the child welfare system have
prompted a needed look at the procedures by which those
medications are authorized and overseen. The children we serve
have experienced severe trauma that often warrants behavioral
health services such as trauma-informed therapy and other
targeted treatments. We believe it is appropriate for some
children to receive medication, when thoughtfully prescribed as
part of an overall treatment plan that includes
non-pharmacological interventions, as well. With those
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medications, however, must come oversight to ensure that the
treatment plan is in place and that children are responding well
to the authorized medications."
Foster Care Training Requirements
In 2003, the Federal Child and Family Services Review mandated
CDSS to develop and implement standardized statewide training
for child welfare workers including specified curriculum. As a
result of the federal legislation, the California Social Work
Education Center, the Regional Training Academies and the CDSS
developed the Common Core Curricula starting in 2004 with
introduction of the courses in 2005.<1>
AB 3062 (Friedman, Chapter 1016, Statutes of 1996) mandated that
all foster parents obtain education and training prior to a
child's placement and on an ongoing basis. Under current law,
licensed or certified foster parents are required to receive a
minimum of 12 hours of foster parent training prior to placement
of a foster child in the home and are required to complete a
minimum of eight hours of post-placement training annually. Some
counties require significantly more training as a condition of
county licensure. These trainings are generally provided by
California community colleges and in some counties by California
State Universities under the Foster and Kinship Care Education
Program initially established in 1984.
Group home facility administrators are required to be certified
through CDSS developed and approved programs that include 40
hours of classroom instruction. Group home administrators are
further required to renew their certification every two years
through 40 hours of classroom or online instruction. The
required curriculum includes training in business operations;
staff management and supervision; psychosocial, physical and
educational needs of the facility residents; community and
support services; administration, storage, misuse and
interaction of medication used by facility residents;
instruction on cultural competency and sensitivity relating to,
and best practices for, providing adequate care to lesbian, gay,
bisexual and transgender youth in out-of-home care; non-violent
emergency intervention and reporting requirements; basic
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<1> http://calswec.berkeley.edu
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admission, retention and assessment procedures including
specified non-discrimination rights of a foster child; and
school environment anti-harassment laws.
Existing law additionally requires the Judicial Council to
develop training requirements for dependency court judges and
dependency attorneys, providing the Council with broad
discretion to define the scope of the training. California Rules
of Court, Rule 5.660 requires attorneys to complete a minimum of
eight hours of initial training or education in the area of
juvenile dependency, or have sufficient recent experience in
dependency proceedings, and to also complete at least eight
hours of continuing education every three years. Rule 5.660
requires the superior court of each county to amend its local
rules, and many local courts have established training
requirements far exceeding the above minimum requirements.
Psychotropic Medication Use in Children
Concern over the use of psychotropic medications among children
has been well-documented in research journals and the mainstream
media for more than a decade. The category of psychotropic
medication is fairly broad, intending to treat symptoms of
conditions ranging from ADHD to childhood schizophrenia. Some of
the drugs used to treat these conditions are FDA-approved,
including stimulants like Ritalin for ADHD, however only about
31 percent of psychotropic medications have been approved by the
U.S. Food and Drug Administration (FDA) for use in children or
adolescents. It is estimated that more than 75 percent of the
prescriptions written for psychiatric illness in this population
are "off label" in usage, meaning they have not been approved by
the FDA for the prescribed use, though the practice is legal and
common across all manner of pharmaceuticals.<2>
Anti-psychotic medications, used to treat more severe mental
health conditions, include powerful brand-name drugs such as
Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very
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<2>https://www.magellanprovider.com/mhs/mgl/providing_care/clinic
al_guidelines/clin_monographs/psychotropicdrugsinkids.pdf
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limited approval by the FDA for pediatric use beyond rare and
severe conduct problems that are resistant to other forms of
treatment, such as Tourette's syndrome, behavioral symptoms
associated with autistic disorder, childhood schizophrenia, and
bipolar disorder.<3> However, the off-label use of these
anti-psychotics among children is high, particularly among
foster children. According to a study published in 2011,
children who took antipsychotic medications were likely to
suffer ill health effects including "cardio metabolic and
endocrine side-effects" as well as significant weight gain.<4>
The authors recommended that collaboration between child and
adolescent psychiatrists, general practitioners and
pediatricians is essential to "reduce the likelihood of
premature cardiovascular morbidity and mortality."
Compounding the potential for unintended side effects is the use
of combinations of psychotropic medications, which foster youth
are particularly likely to be prescribed, despite limited
evidence of clinical efficacy.<5> Protecting the health and
well-being of children who are taking one or more psychotropic
medication requires extensive and ongoing health and metabolic
screenings to identify potential adverse effects quickly,
however in practice many children many fail to receive ongoing
screenings and adverse effects may go undetected causing
permanent injury or death.
Drugging our Children Media Series
A recent series of stories published in the San Jose Mercury
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<3> Harrison, et al, "Antipsychotic Medication Prescribing
Trends in Children and Adolescents," Journal of Pediatric Health
care, March 2012.
<4> DeHert, Dobbelaere, Sheridan, et al "Metabolic and endocrine
adverse effects of second-generation antipsychotics in children
and adolescents: A systematic review of randomized, placebo
controlled trials and guidelines for clinical practice,"
European Psychiatry, April 2011, pgs 144-58.
<5> http://www.ncbi.nlm.nih.gov/pubmed/25022817
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News<6> and most recently in the Los Angeles Times, highlighted
growing concerns that psychotropic medications have been relied
on by California's child welfare and children's mental health
systems as a means of controlling, instead of treating, youth
who suffer from trauma-related behavioral health challenges. The
series detailed significant challenges in accessing pharmacy
benefits claims data held by the California Department of Health
Care Services (DHCS), eventually overcome through a Public
Records Act request and lengthy negotiations, and demonstrated
that prescribing rates were far higher than had been anticipated
by child welfare system experts.
Court oversight mechanisms
SB 543 (Bowen, Chapter 552, Statutes of 1999) mandated that,
once a child has been adjudged a dependent of the state, only
the court may authorize psychotropic medications for the child,
based on a request from a physician that includes the
following:<7>
The reasons for the request;
A description of the child's diagnosis and behavior;
The expected results of the medication;
A description of any side effects of the medication.
Under the statute, psychotropic medications are defined as those
"administered for the purpose of affecting the central nervous
system to treat psychiatric disorders or illnesses. These
medications include, but are not limited to, anxiolytic agents,
antidepressants, mood stabilizers, antipsychotic medications,
anti-Parkinson agents, hypnotics, medications for dementia, and
psychostimulants."
In accordance with this statute, the Administrative Office of
the Courts established a series of court documents generally
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<6> Drugging our Kids. Karen De Sa. San Jose Mercury News.
<7> WIC 369.5
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referred to as "the" JV 220, which includes a statement
completed and signed by the prescribing physician that includes
the child's diagnosis, relevant medical history, other
therapeutic services, the medication to be administered, and the
basis for the recommendation.
In addition, a form must be included indicating notice has been
provided to the parents or legal guardians, their attorneys of
record, the child's attorney of record, the child's guardian ad
litem, the child's current caregiver, the child's Court
Appointed Special Advocate, if any, and if a child has been
determined to be an Indian child, the Indian child's tribe.<8>
The procedure for notification varies by county - the
responsibility may fall primarily to the child welfare agency,
or it may be shared with the juvenile court clerk's office that
may be responsible for notifying the attorney and the Court
Appointed Special Advocate.
Within four court days after notification, a parent or guardian,
the child, the attorney for either, the guardian ad litem, or
the Indian child's tribe may file an objection to the
application. Following this period, the court files a final
order.
Oversight Concerns
Stakeholders have expressed widespread concerns about the
efficacy of the current oversight mechanisms, given that in many
counties the court lacks access to medical experts to assist in
evaluating medical information. Child welfare advocates and
clinicians report that in many instances a prescribing physician
who fills out the JV 220 form may not have a history of treating
the child, and thus may not be aware of prior medications or
alternative treatments that have (or have not) been tried. Such
information is frequently left blank on the JV 220.
Additionally, as noted by the author, the California Drug Use
Review recently found that fewer than four in ten children had
received the required baseline laboratory screenings prior to
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<8> See also 25 U.S.C. § 1903(4)-(5); Welf. and Inst. Code, §§
224.1(a) and (e) and 224.3.
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being administered a psychotropic medication. In theory, a
health and education passport - a paper file of the youth's
medical history - is supposed to be provided to a new caregiver,
who might provide important information to a prescribing
physician; however it is common for a child to move between
placements without the requisite records, leaving the foster
parent also unaware of the child's medical history.
DHCS and CDSS have drafted, but not finalized, a Guidelines for
the Use of Psychotropic Medication with Children and Youth in
Foster Care report which states that "the use of psychotropic
medication for children and youth is considered a non-routine
intervention, used under specified circumstances and as only one
strategy within a larger, more comprehensive treatment plan to
provide for that child's safety and well-being."
The JV 220 form offers little opportunity for input from the
community of representatives and caregivers involved with the
youth except to offer a short window of opportunity to formally
object. Furthermore, the form does not include information
related to baseline or ongoing screening, it does not require
consideration of alternative treatments (though it provides a
field inquiring about them), nor does it offer substantive
opportunities for relevant parties to weigh in with important
information that may be worthy of consideration by the court.
Currently, CDSS and DHCS, are collaborating on the Quality
Improvement Project: Improving the Use of Psychotropic
Medication among Children and Youth in Foster Care, which is
intended to improve oversight and monitoring of psychotropic
medication use and to develop data tools to identify "quality
concerns" described as overutilization of medication,
inappropriate prescribing, gaps of service including
insufficient monitoring or not making decisions on evidence
based care. Together, DHCS and CDSS hold quarterly and monthly
meetings with various stakeholders to negotiate the parameters
of the data for use in agreed-upon indicators. For this purpose,
foster care data from the Child Welfare System/Case Management
System is matched with a dataset containing fee-for-service and
Medi-Cal managed care pharmacy paid claim records for
psychotropic medication for children in foster care to identify
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prescribing patterns.
Related legislation:
SB 253 (Monning, 2015) provides that an order of the juvenile
court authorizing psychotropic medication shall require clear
and convincing evidence of specified conditions. Furthermore
this bill prohibits the authorization of psychotropic
medications without a second independent medical opinion under
specified circumstances. It also prohibits the authorization of
psychotropic medications unless the court is provided
documentation that appropriate lab screenings, measurements, or
tests have been completed, as specified. Furthermore it requires
the court, no later than 45 days following an authorization for
psychotropic medication, to conduct a review to determine
specified information regarding the efficacy of the child's
treatment plan.
SB 484 (Beall, 2015) requires the CDSS to publish and make
available to interested persons specified information regarding
the administration of psychotropic medication in residential
facilities serving dependent children. Additionally, it requires
CDSS to inspect facilities at least once per year, as specified,
if the facility is determined to have a higher than average rate
of psychotropic medication authorization for children residing
in the facility and to monitor corrective action plans, as
specified.
SB 319 (Beall, 2015) expands the duties of the foster care
public health nurse to include monitoring and oversight of the
administration of psychotropic medication to foster children, as
specified. It also requires counties to provide child welfare
public health nursing services by contracting with the community
child health and disability prevention program established by
the county.
Prior Legislation:
AB 3015 (Brownley, Chapter 557, Statutes of 2008) required
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training programs for group home administrators, licensed foster
parents and relative caretakers to include basic instruction on
the safety of foster youth at school and school environment
anti- harassment protections.
AB 2675 (Strickland, Chapter 421, Statutes of 2006) permitted no
more than half of the required 40-hour continuing education
requirement to be satisfied through online courses.
AB 458 (Chu, Chapter 331, Statutes of 2003) established and
required provider training regarding the right of foster
children to fair and equal access to all available services,
placement, care, treatment, and benefits, and to not be
subjected to discrimination or harassment on the basis of actual
or perceived race, ethnic group identification, ancestry,
national origin, color, mental or physical disability, or HIV
status.
AB 1694 (Committee on Human Services, Chapter 918, Statutes of
2002) required California Community Colleges that provide foster
parent training programs to make those programs available to
non-relative extended family members.
AB 2307 (Davis, Chapter 745, Statutes of 2000) required
California Community Colleges that provide foster parent
training programs to make those programs available to relative
and kinship care providers.
SB 543 (Bowen, Chapter 552, Statutes of 1999) mandated that once
a child has been adjudged a dependent of the state only the
court may authorize psychotropic medications for the child,
based on a request from a physician including specified
information.
AB 3062 (Friedman, Chapter 1016, Statutes of 1996) mandated all
foster parents to obtain pre- placement and post-placement
training.
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SB 2003 (Royce, Chapter 1597, Statutes of 1984) established the
Foster Care Education Program under the office of the Chancellor
of the California Community Colleges.
COMMENTS
This bill has considerable overlap with SB 253 (Monning) which
would enact specified changes to the court authorization process
also referenced in this bill. Staff notes that the direction of
this bill is to provide general direction to the Judicial
Council, while SB 253 provides more specificity regarding
changes to the court authorization process. Should the bills
pass this committee, staff recommends the authors and sponsors
of the two bills work to eliminate apparent conflicts between
the two bills.
POSITIONS
Support:
National Center for Youth Law
Advokids
Alameda County Foster Youth Alliance
California Alliance
California Court Appointed Special Advocates (CASA)
Children's Advocacy Institute
Children's Partnership
County Welfare Directors Association of California
Dependency Legal Group of San Diego
First Focus Campaign for Children
Humboldt County Transition Age You Collaboration
Legal Advocates for Children and Youth
Peers Envisioning and Engaging in Recovery Services
Public Counsel's Children's Rights Project
Urban Counties Caucus
Youth Law Center
7 individuals
Oppose:
None.
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