BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                     SB 238


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          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  








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            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:








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             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  








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               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)








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          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  








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            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.












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          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,  








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          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  








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          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.









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          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  








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          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










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          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








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          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)










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          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










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          None on file.








          Analysis Prepared by:Daphne Hunt / HUM. S. / (916)  
          319-2089