BILL ANALYSIS Ó SB 238 Page 1 Date of Hearing: July 14, 2015 ASSEMBLY COMMITTEE ON HUMAN SERVICES Kansen Chu, Chair SB 238 (Mitchell) - As Amended July 1, 2015 SENATE VOTE: 40-0 SUBJECT: Foster care: psychotropic medication. SUMMARY: Requires training for various individuals in the child welfare system to cover aspects related to psychotropic medications and adopts measures to increase oversight of the authorization and administration of psychotropic medications for foster youth. Specifically, this bill: 1)Specifies that training for group home administrators, foster parents, specified judges and appointed counsel, relative and nonrelative extended family member caregivers, mandated child abuse reporters and members of the child welfare delivery system, and public health nurses shall include, but not be limited to: the authorization, uses, risks, benefits, administration, oversight, and monitoring of psychotropic medications, and trauma, behavioral health, and other available behavioral health treatments, for children receiving child welfare services, including how to access those SB 238 Page 2 treatments. 2)Requires, by July 1, 2016, the Judicial Council, in consultation with specified entities, to develop implementation updates and related forms and adopt or amend related rules of the court regarding that authorization and administration of psychotropic medications to dependent children who have been removed from the physical custody of their parents, including minors who have been adjudged a ward of the court. Further requires these implementation updates to: a) Ensure all of the following: the opportunity for the child and his or her and court-appointed special advocate to provide input on the medications being prescribed; that specified information regarding a child's behavioral health assessment and treatment plan and the rationale for the proposed medication is provided to the court; and that guidance is provided to the court on how to evaluate requests for authorization; and b) Include a process for periodic oversight by the court of orders regarding the administration of psychotropic medications that includes specified information, is facilitated by appropriate county staff, and that is conducted in conjunction with other regularly scheduled court hearings and reports. 1)Requires the following in order to ensure oversight of psychotropic medication prescribed to foster children: SB 238 Page 3 a) The Department of Social Services (DSS), in consultation with other designated entities, to develop and provide an individualized monthly report to each county child welfare services agency that includes, for each foster child for whom one or more psychotropic medications has been authorized, specified information related to the authorization and administration of psychotropic and nonpsychotropic medication and provision of other behavioral health services; b) County child welfare services agencies to use a form developed by DSS and other stakeholders to share the aforementioned information, as specified; c) DSS to develop or ensure access to a system that automatically alerts a child's social worker when that child has been prescribed a psychotropic medication that either: is prescribed in unusual and/or potentially dangerous combination with another psychotropic medication, is prescribed in an unusual dosage for that child's age, has the potential to interact dangerously with other medications prescribed to the child, or is not typically indicated for a child of that age; d) The child's social worker to, upon receipt of an alert from the system described above, notify specified entities that the alert has been received and to include a discussion of any alerts and their resolutions, if any, in the next court report filed in the child's case; and e) DSS to, in consultation with stakeholders, develop training that may be provided to various entities who work with children receiving child welfare services regarding SB 238 Page 4 the authorization, uses, risks, benefits, administration, oversight, and monitoring of psychotropic medications, and trauma, behavioral health, and other available behavioral health treatments, for children receiving child welfare services, including how to access those treatments. EXISTING LAW: 1)Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to be at risk or have been abused or neglected, as specified. (WIC 202 et seq.) 2)Allows a juvenile court to adjudge a child a ward or a dependent of the court for specified reasons, including but not limited to if the child has been left without any provision for support, as specified. (WIC 300) 3)Permits the juvenile court to retain jurisdiction over a ward or dependent of the court until he or she reaches the age of 21. (WIC 303) 4)Establishes circumstances under which a minor may be adjudged a ward of the juvenile court, including, but not limited to, being beyond the control of his or her parents, guardian, or custodian, or violating any city, county, state, or federal laws, except for certain serious violations that warrant prosecution under the general law in a court of criminal jurisdiction, as specified. (WIC 601 and 602) 5)States that only a juvenile court judicial officer has the authority to make orders for the administration of psychotropic medications for a minor who has been adjudged a dependent or ward of the court. (WIC 369.5 and 739.5) SB 238 Page 5 6)Defines "psychotropic medication" or "psychotropic drugs" as those medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. Further states that these medications include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants. (WIC 369.5 (d)) 7)Requires the director of DSS to develop a certification program for the adminstrators of group home facilities, and states that this program shall require a minimum of 40 hours of training in specified areas of knowledge. (HSC 1522.41) 8)Requires every licensed foster parent to complete a minimum of 12 hours of training before any foster children are placed with him or her, and also requires a minimum of 8 hours of foster parent training annually. Further specifies the topics to be covered in these trainings. (HSC 1529.2) 9)Requires the Judicial Council to develop and implement standards for the education and training of all judges who conduct dependency hearings, as specified, and further requires certain topics to be covered. (WIC 304.7) 10)Requires the Judicial Council to promulgate rules establishing training requirements for appointed counsel for children in the dependency system, as specified. (WIC 317) 11)Requires each community college district with a foster care education program to make available training covering specified topics for relative and nonrelative extended family SB 238 Page 6 member caregivers. (WIC 16003) 12)Provides for statewide coordinated training for county child protective services social workers and other members of the child welfare delivery system, as specified. (WIC 16206) 13)Requires the Department of Social Services (DSS) to establish and maintain a public health nursing program in the child welfare services system, as specified, whereby counties are required to use the services of foster care public health nurse. Further states that the purpose of this program is to identify, respond to, and enhance the physical, mental, dental, and developmental well-being of children in the child welfare system. (WIC 16501.3) FISCAL EFFECT: According to the May 28, 2015, Senate Appropriations Committee analysis, this bill may result in the following costs: 1)Potentially significant one-time costs (General Fund) to DSS for the development of the training component for licensed foster parents, group home administrators, relative and nonrelative extended family members, court-appointed counsel, child protective services staff, and mandated reporters. 2)One-time costs of $77,000 (General Fund) related to developing and/or updating Judicial Council forms. SB 238 Page 7 3)One-time costs of $150,000 ($100,000 General Fund) for DSS to develop the individualized report and associated form, to the extent DSS and the Department of Health Care Services (DHCS) are able to utilize pre-existing data from their respective databases to develop the report. 4)Unknown, but potentially major one-time costs potentially in the millions of dollars (General Fund) for DSS to develop or ensure access to a system that automatically alerts social workers when psychotropic medication has been prescribed to youth, subject to specified conditions. 5)Major costs potentially in the low millions of dollars (General Fund) annually for increased costs incurred by county social workers, public health nurses, and other county staff for time to attend additional training, complete more comprehensive court forms, respond to automatic alerts, provide notifications, and provide additional follow-up. (Proposition 30 exempts the State from mandate reimbursement for realigned programs, however, legislation that has an overall effect of increasing the costs already borne by a local agency for realigned programs, including child welfare services, apply to local agencies only to the extent that the State provides annual funding for the cost increase.) COMMENTS: Psychotropic medications and foster youth: Psychotropic medications include drugs prescribed to manage psychiatric and mental health disorders or issues including depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and others. These medications include antipsychotics such as Seroquel, SB 238 Page 8 antidepressants like Prozac, mood stabilizers including Lithium, and stimulants like Ritalin. There continues to be significant concern over the use of psychotropic medications for children, due to a vast array of side effects (which can include aggressive behavior, hostility, seizures, significant weight gain, and more) and due to the fact that the long-term effects for children using these drugs are largely unknown. Additionally, many psychotropic medications are prescribed to children "off label" - that is, they are used to treat symptoms other than those for which the FDA originally approved each drug. While off-label use is not illegal, there are concerns about how well-understood these medications and their uses are by prescribers and patients. Over 75% of psychotropic drug use among children and adolescents is believed to be off-label. One class of psychotropic medications, antipsychotics, raises particular concern; these are potent drugs with a high potential for side-effects, and there is little known about their impact on growth, development, and children's neurological systems. Research has repeatedly indicated that children and youth in foster care face higher levels of inappropriate or excessive medication use, and that those foster youth placed in group home settings are particularly vulnerable to over-prescription and misuse of psychotropic medications. Data provided by the Department of Health Care Services (DHCS) indicate that, in fiscal year 2013-14, almost 15% of all foster youth in California ages 0 to 20 years old were prescribed at least one psychotropic medication; looking specifically at all foster youth ages 12 through 20, this rate was almost 25% and for youth placed in group homes, it was 50%. In late 2011, the U.S. Department of Health and Human Services issued a letter to states encouraging them to coordinate with partners who worked with foster youth to address enhanced SB 238 Page 9 efforts to appropriately prescribe and monitor psychotropic medication among children placed in out-of-home care. As a result, DHCS and DSS developed the Quality Improvement Project to strengthen the state's Medicaid and child welfare services system by, among other things, improving safe and appropriate prescribing and monitoring of psychotropic drugs; this project has enabled the state to access the knowledge and perspectives of various experts, and has continued to hold various workgroup meetings and set and accomplish objectives related to its mission. Additionally, this Spring, DHCS and DSS released state guidelines for the use of psychotropic medication with children and youth in foster care. Need for this bill: This is one of four bills proposing a set of reforms aimed at curbing excessive and inappropriate authorization and administration of psychotropic medications among foster youth. This bill requires DSS, and other stakeholders, to develop monthly data reports to facilitate the matching of authorization and pharmacy dispensing data for a child for whom one or more psychotropic medications have been authorized; this data would be shared with county child welfare agencies, and these agencies would in turn share the data with relevant parties, including the court and a child's attorney. This bill also creates an alert system that would notify a county child welfare agency any time psychotropic medications are prescribed in a potentially dangerous combination or dosage; again, this data would be shared with relevant parties. Additionally, this bill calls for updates to court processes and forms, providing the important opportunity for children and other key stakeholders to provide information and feedback regarding the child's overall behavioral health treatment plan. Lastly, this bill requires topics related to psychotropic medications and other behavioral health supports to be included in training for group home administrators, foster parents, specified judges and appointed counsel, relative and nonrelative extended family member caregivers, mandated child abuse reporters, and public health nurses. SB 238 Page 10 A number of professionals and individuals come into contact with a child in the state's child welfare services system. This bill seeks to strengthen the potential of this support network to protect a child from the administration of psychotropic drugs that are unwarranted or potentially dangerous by increasing workers' and caregivers' knowledge about psychotropic medications and their alternatives, and by fostering crucial communication across the system. The sponsor of this bill, the County Welfare Directors Association of California, states that "we are not seeking the authority for county staff, attorneys or judges to take the place of the trained medical professionals who serve our children. Rather, we want to arm these other practitioners with the necessary tools and training to ask the right questions and probe further when psychotropic medications are prescribed and when potentially harmful interactions could occur. This bill represents a critical piece of the response to this important issue." According to the author, this bill, "will ensure that the department and legislature are receiving the reports that we need to monitor our foster youth, that triggers are in place to make sure the children are not being over medicated, and that those who are in trusted with the youth's well-being receive adequate and appropriate training." RELATED LEGISLATION: SB 253 (Monning), 2015, modifies juvenile court practices and requirements regarding the authorization of psychotropic medications for foster youth by, among other things, requiring clear and convincing evidence that administration of the medication is in the best interest of the child and, in SB 238 Page 11 specified circumstances, prohibiting the authorization of psychotropic medication administration for a child unless a second opinion is obtained from a child psychiatrist or behavioral pediatrician. SB 319 (Beall), 2015, adds to the duties of foster care public health nurses, including monitoring each child in foster care who is administered one or more psychotropic medications. SB 484 (Beall), 2015, requires DSS to compile and post on its Internet Web site specified information regarding the administration of psychotropic medications to children placed in group homes and to establish a methodology for identifying group homes with high levels of psychotropic drug use. Further establishes certain requirements for those group homes. SECOND COMMITTEE OF REFERENCE . This bill was previously heard in the Assembly Judiciary Committee, on June 30, 2015 and was approved on a 10-0 vote. REGISTERED SUPPORT / OPPOSITION: Support Abode Services Advokids SB 238 Page 12 Alameda County Foster Youth Alliance (FYA) Alameda County Social Services Agency American Federation of State, County and Municipal Employees (AFSCME), AFL-CIO Accessing Health Services For California's Children In Foster Care Task Force California Alliance of Child and Family Services California CASA Association California Department of Justice California State Association of Counties (CSAC) California State Conference of the NAACP California Youth Connection (CYC) Children Now Children's Advocacy Institute Children's Defense Fund SB 238 Page 13 Children's Law Center of California Consumer Watchdog Contra Costa County Board of Supervisors County Welfare Directors Association of California (CWDA), co-sponsor Dependency Legal Group of San Diego Family Voices of California First Focus Campaign for Children (FFCC) First Place for Youth Humboldt County Transition age Youth Collaboration John Burton Foundation for Children without Homes National Center for Youth Law, co-sponsor North American Council on Adoptable Children (NACAC) SB 238 Page 14 Peers Envisioning and Engaging in Recovery Services (PEERS) Public Counsel's Children's Rights Project San Joaquin County Human Services Agency (HSA) Santa Clara County Board of Supervisors Stanislaus County Community Services Agency The Children's Partnership The Jamestown Community Center The Mockingbird Society Urban Counties Caucus (UCC) Ventura County Board of Supervisors Youth Law Center (YLC) Opposition SB 238 Page 15 None on file. Analysis Prepared by:Daphne Hunt / HUM. S. / (916) 319-2089