BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 253|
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THIRD READING
Bill No: SB 253
Author: Monning (D), et al.
Amended: 6/2/15
Vote: 21
SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/21/15
AYES: McGuire, Berryhill, Hancock, Liu, Nguyen
SENATE JUDICIARY COMMITTEE: 6-0, 4/28/15
AYES: Jackson, Anderson, Hertzberg, Leno, Monning, Wieckowski
NO VOTE RECORDED: Moorlach
SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15
AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen
SUBJECT: Dependent children: psychotropic medication
SOURCE: National Center for Youth Law
DIGEST: This bill provides that an order of the juvenile court
authorizing psychotropic medication shall require clear and
convincing evidence that administration of the medication is
based on the best interest of the child and a determination of
the court of specified documentation and confirmations from the
prescribing physician. This bill also prohibits the
authorization of psychotropic medications without a second
independent medical opinion under specified circumstances.
Additionally, this bill requires the court to conduct a review
to determine specified information regarding the efficacy of the
child's treatment plan, no later than 60 days after
authorization for psychotropic medication, or at the next review
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hearing, as specified.
ANALYSIS:
Existing law:
1) 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. (WIC 369.5)
2) Requires court authorization for the administration of
psychotropic medication to be based on a request from a
physician, indicating the reasons for the request, a
description of the minor's diagnosis and behavior, the
expected results of the medication, and a description of any
side effects of the medication. Requires the Judicial Council
to adopt rules of court and develop appropriate forms. (WIC
369.5)
3) Requires, within seven court days from receipt, the juvenile
court judicial officer to either approve or deny in writing a
request for authorization for the administration of
psychotropic medication, or to set the matter for hearing.
(WIC 369.5)
This bill:
1) Repeals existing law pertaining to the court authorization of
psychotropic medications under WIC 369.5 as of July 1, 2016,
and enacts the following changes to existing law as of July
1, 2016.
2) Requires the court to ensure, when authorizing administration
of a psychotropic medication, that the medication is only one
part of a comprehensive treatment plan for the child, which
shall specify the psychosocial services the child will
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receive in addition to any authorized medication.
3) Provides that an order of the juvenile court authorizing
psychotropic medication shall require clear and convincing
evidence that administration of the medication is in the best
interest of the child based on a determination that the
anticipated benefits of the psychotropic medication outweigh
the short- and long-term risks associated with the
medications.
4) Provides that an order authorizing psychotropic medication
shall only be granted if the court determines all of the
following:
Documentation has been provided confirming the child's
caregiver and the child have been informed, in an age and
developmentally appropriate manner, about the recommended
medications, as specified, and asked whether either have
concerns, and the nature of those concerns, as specified.
Written consent for a child that is over the age of 14
has been obtained, as specified.
The medication is not being used as punishment, for
the convenience of staff, as a substitute for less
invasive treatments, or in quantities or dosages that
interfere with the child's treatment program.
The prescribing physician confirms specified
information including that a comprehensive examination has
been conducted, as defined; there are no less invasive and
effective treatment options available; the dosage or is
appropriate for the child; the short and long-term risks
associated with the medications do not outweigh the
benefits; and all appropriate lab screenings,
measurements, or tests for the child have been completed
in accordance with accepted medical guidelines.
A plan is in place for regular monitoring of the
child's medication and psychosocial treatment plan, the
effectiveness of the medication and psychosocial
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treatment, and any potential side effects of the
medication.
1) Prohibits the authorization of psychotropic medications
without a second independent medical opinion under specified
circumstances.
2) Requires the California Department of Health Care Services
(DHCS), in collaboration with the Judicial Council to
identify resources, including but not limited to
university-based consultation services, to assist the courts
in securing second medical opinions.
3) Prohibits the authorization of psychotropic medications
unless the court is provided documentation that all of the
appropriate lab screenings, measurements, or tests have been
completed, no more than 30 days prior to the submission of
the request.
4) Requires the court, no later than 45 days following an
authorization for a new psychotropic medication, or at the
next review hearing scheduled, whichever is earlier, to
conduct a review to determine specified information related
to the efficacy and safety of the medication.
5) Requires the court to reconsider, modify, or revoke its
authorization if it determines that the proffered benefits of
the medication have not been demonstrated or that the risks
of the medication outweigh the benefits.
6) Specifies the conditions by which a psychotropic medication
may be administrated without court authorization in an
emergency.
Background
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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 broad,
intending to treat symptoms of conditions ranging from ADHD to
childhood schizophrenia. Some of the drugs used to treat these
conditions are U.S. Food and Drug Administration (FDA)-approved,
including stimulants like Ritalin for ADHD, however only about
31% of psychotropic medications have been approved by the FDA
for use in children or adolescents. It is estimated that more
than 75% 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.
Anti-psychotic medications, used to treat more severe mental
health conditions, have very 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. 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 "cardiometabolic and endocrine side-effects"
as well as significant weight gain. 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. Protecting the
health and well-being of children who are taking one or more
psychotropic medications 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.
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Recent media 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. A series published in the San Jose
Mercury News detailed significant challenges in accessing
pharmacy benefits claims data held by DHCS, eventually overcome
through a Public Records Act request and lengthy negotiations,
and it demonstrated that prescribing rates, dosages and regimens
were far higher and more concerning 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:
The reasons for the request;
A description of the child's diagnosis and behavior;
The expected results of the medication; and
A description of any side effects of the medication.
In accordance with this statute, the Administrative Office of
the Courts established a series of court documents generally
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.
Oversight concerns. A broad range of stakeholders have expressed
concerns with the efficacy of current oversight mechanisms
citing the limited scope of information that is available on the
JV-220 and a lack of access to medical experts able to assist in
evaluating medical information. Further, due to frequent
placement changes of dependent youth, important medical history
may not accompany the youth such that prior, or current
medication regimens, may not be disclosed to a judge,
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prescribing physician, social worker or caregiver. Additionally
important information related to alternative non-pharmacological
treatments that may have been tried may not be available and
this important information is often left blank on the JV-220.
The JV-220 form has been criticized for offering 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 medically important
metabolic screenings.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Senate Appropriations Committee:
One-time costs of $77,000 (GF - Trial Court Trust Fund)
associated with Judicial Council's updating of forms and rules
of court.
Annual costs ranging from $0.9 million to $1.8 million (GF -
Trial Court Trust Fund) for review hearings for approximately
9,000 requests for psychotropic medication authorizations each
year (based on match of CWS/CMS data with DHCS pharmacy claims
from FFY 2013).
Annual costs of about $1 million (GF - Trial Court Trust Fund)
for approximately 9,000 requests for psychotropic medication
authorizations per year associated with managing documents.
Annual costs of about $1.3 million (Federal Funds/General
Fund) for social workers to identify cases that require a
second opinion, make arrangements for the youth to be examined
by the second medical practitioner, ensure the child's
screenings, lab tests, and measurements have occurred no more
than 30 days from the date of the request to the court, and
attend the additional review hearings.
Potentially major increase in Medi-Cal program costs in the
low millions of dollars (FF/GF) annually to the extent the
provisions of this bill result in additional medical
examinations for second opinions, as well as an increase in
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lab screenings, measurements, and tests completed that
otherwise would not occur under existing law.
Potentially significant offsetting decrease in Medi-Cal
program costs (FF/GF) to the extent the enhanced oversight and
monitoring results in reduced use of psychotropic medications
for these youth. To the extent the reduced utilization of
these medications is replaced with alternative treatment
options/psychosocial services, this bill could result in
additional offsetting costs.
SUPPORT: (Verified6/1/15)
National Center for Youth Law (source)
Advokids
Alameda County Board of Supervisors
Alameda County Foster Youth Alliance
Attorney General Kamala Harris
American Federation of State, County and Municipal Employees
California Alliance of Child and Family Services
California CASA Association
California CASA Association, Santa Cruz County
California Youth Connection
Children's Advocacy Institute
Children's Law Center of California
Children's Partnership
Dependency Legal Group of San Diego
East Bay Children's Law Offices
East Bay Community Law Center
First Focus Campaign for Children
Humboldt County Transition Age Youth Collaboration
John Burton Foundation
Legal Advocates for Children and Youth
Peers Envisioning and Engaging in Recovery Services
Youth Law Center
11 individuals
OPPOSITION: (Verified6/1/15)
None received
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ARGUMENTS IN SUPPORT: According to the author, nearly one in
four children placed in foster care receive powerful
psychotropic drugs, and that of these children, 52% are given
antipsychotics, drugs that include risk factors that can lead to
life-long disabilities such as tremors, obesity, and diabetes.
Additionally, the author states that 48% of foster children are
given antidepressants that include an FDA black box warning for
use by children.
The author states that frequent monitoring of children given
psychotropic medications is required as part of the health care
guidelines of the American Psychiatric Association, the American
Diabetes Association and the American Association of Child and
Adolescent Psychiatrists. However, the required baseline lab and
blood tests were completed for fewer than four in ten children
administered a psychotropic drug. The author states that this
bill will provide courts with key factors to consider when
making these potentially life-changing medical decisions.
Prepared by:Sara Rogers / HUMAN S. / (916) 651-1524
6/2/15 20:20:31
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