BILL ANALYSIS Ó
SB 253
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Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Kansen Chu, Chair
SB
253 (Monning) - As Amended July 8, 2015
SENATE VOTE: 40-0
SUBJECT: Dependent children: psychotropic medication.
SUMMARY: Modifies juvenile court practices and requirements
regarding the authorization of psychotropic medications for
foster youth.
Specifically, this bill:
1)Requires the court, as of July 1, 2016, whenever it authorizes
the administration of a psychotropic medication, to ensure
that such administration is only one part of a comprehensive
treatment plan for the child, as specified.
2)Requires, as of July 1, 2016, an order authorizing the
administration of a psychotropic medication to be granted only
upon the court's determination that there is clear and
convincing evidence that such administration is in the best
interest of the child, as specified. Further prohibits
authorization of administration of a psychotropic medication
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if it is determined to be for purposes of punishment or staff
convenience, or in lieu of less invasive treatments or in
quantities or dosages that interfere with a child's treatment
plan.
3)Requires, as of July 1, 2016, an order authorizing the
administration of a psychotropic medication to be granted only
if the court determines all of the following:
a) The court is provided documentation including the
written assent or refusal of any child age 12 or older and
reflecting that, as specified: the child's caregiver and
the child have been informed about the recommended
medications and alternative treatments, the child and
caregiver have been given the opportunity to express
concerns, and the child has been informed of his or her
right to object to the authorization of psychotropic
medications;
b) The prescribing physician submitting the request for
psychotropic medication has conducted a comprehensive
examination of the child, as specified;
c) The prescribing physician confirms that there are no
less invasive treatments available, the dosage is
appropriate, the short-and long-term risks do not outweigh
the reported benefits to the child, and all appropriate
laboratory screenings, measurements, or tests for the child
have been completed in accordance with accepted medical
guidelines; and
d) A plan is in place for regular monitoring, as specified,
of the child's medication and psychosocial treatment plan,
the effectiveness of such treatments, and potential side
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effects.
1)States that, as of July 1, 2016, the person or entity
submitting the request for authorization of the administration
of psychotropic medication is responsible, and shall bear the
burden of proof, for providing the necessary documentation of
the clinical appropriateness of the proposed medication.
2)Prohibits, as of July 1, 2016, a court from issuing an order
authorizing the administration of psychotropic medications for
a child without a second independent medical opinion if the
request for a psychotropic medication: is for a child under
the age of 6, would result in a child being administered three
or more psychotropic medications concurrently, is for the
concurrent administration of any two drugs from the same
class, as specified, or is for a dosage exceeding that
recommended for children.
3)Requires the Department of Health Care Services (DHCS), in
collaboration with Judicial Council, to identify resources to
assist the courts in securing a second review and second
opinions, as specified.
4)Prohibits, as of July 1, 2016, the court from authorizing the
administration of psychotropic medication unless the court is
provided with documentation indicating that all appropriate
laboratory screenings, measurements, or tests have been
completed no more than 45 days prior to the submission of the
request to the court, as specified.
5)Requires the court, as of July 1, 2016, to conduct a review
hearing regarding the authorization of a new psychotropic
medication, as specified, to determine whether the child is
taking the medication(s), whether components of a child's
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treatment plan have been provided, the extent to which
symptoms have been alleviated, whether more time is needed to
evaluate the effectiveness of medication(s), any adverse
effects the child has suffered and what steps have been taken
to address those effects, the date(s) of follow-up visits with
the prescribing physician, and whether the appropriate
follow-up laboratory screenings have been performed and their
findings. Further, requires the court, if the benefits of the
medication have not been demonstrated or the risks outweigh
the benefits, to reconsider, modify, or revoke its
authorization for administration of the medication.
6)Requires, as of July 1, 2016, the child's social worker to
submit a report to the court and to counsel for the parties
prior to the review hearing that includes information from the
child, the child's caregiver, the public health nurse, and any
court appointed special advocate.
7)States that, as of July 1, 2016, the order for authorization
is effective until terminated or modified by the court or
until 180 days following the date of the order, whichever is
earlier.
8)Provides for, as of July 1, 2016, the administration of
psychotropic medications without court authorization in an
emergency, as specified, and requires court authorization to
be sought as soon as practical but no more than two court days
after the emergency administration of medication.
9)States that, as of July 1, 2016, no person has the authority
to administer psychotropic medication to a child who has
refused and that a child cannot be forced to take such
medication unless otherwise explicitly permitted by statute.
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10)Requires the Judicial Council to adopt rules of court and
develop appropriate forms for the implementation of the
changes contained in this bill by July 1, 2016.
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)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))
4)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 of the court. (WIC 369.5)
FISCAL EFFECT: According to the May 28, 2015, Senate
Appropriations Committee analysis, this bill may result in the
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following costs:
1)One-time costs of $77,000 (General Fund) related to
developing/revising Judicial Council forms and rules of court.
(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.)
2)Annual costs ranging from $0.9 million to $1.8 million
(General Fund) for review hearings for approximately 9,000
requests for psychotropic medication authorizations each year.
3)Annual costs of around $1 million (General Fund) for document
management related to approximately 9,000 requests for
psychotropic medication authorizations per year.
4)Annual costs of about $1.3 million (Federal Fund/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.
5)Potentially major increase in Medi-Cal program costs in the
low millions of dollars (Federal Funds/General Fund) annually
to the extent the provisions of this measure result in
additional medical examinations for second opinions, as well
as an increase in lab screenings, measurements, and tests
completed that otherwise would not occur under existing law.
While the estimated costs for second medical opinions may be
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less than $1 million annually as it will not impact the entire
caseload, the requirement to have all appropriate lab
screenings and tests within 30 days prior to submission of the
request to the court will be required for each authorization.
6)Potentially significant off-setting decrease in Medi-Cal
program costs (Federal Funds/General Fund) to the extent the
enhanced oversight and monitoring process results in reduced
utilization of psychotropic medications for this population of
youth. To the extent the reduced utilization of these
medications are replaced with alternative treatment
options/psychosocial services could result in additional
offsetting costs.
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,
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 Federal Drug
Administration originally approved each drug. While off-label
use is not illegal, there are concerns about how well-understood
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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 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
efforts to appropriately prescribe and monitor psychotropic
medication among children placed in out-of-home care. As a
result, DHCS and the Department of Social Services (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.
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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.
According to the author:
"Since 1999, juvenile courts have been the decision-makers,
the gatekeepers for authorizing psychotropic medications for
children in foster care. But we have not given the courts
standards by which to guide their decision-making and the
support necessary to make an informed decision.
California law upholds the rights of convicted felons confined
to our state prisons and county jails, sexually violent
predators, and those adjudicated not guilty by reason of
insanity to refuse the administration of antipsychotic
medications unless specific circumstances exist and due
process is afforded them. Among other protections, they are
entitled to counsel, to be present at the hearing and to have
decisions made on clear and convincing evidence. Certainly we
can and must afford our foster children even greater
protections against the misuses of these medications.
[This bill] ensures our juvenile court judges are given the
information they need to make informed decisions before
authorizing these medications, provides criteria to guide the
decision-making, and safeguards our foster children's health
and safety by overseeing the effects of these medications."
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The sponsor of this bill, the National Center for Youth Law,
states that, "When more than twenty-five percent of older
children and adolescents in foster care are given one or more
psychotropic medications, and thousands of children are taking
multiple drugs at the same time, when fifty percent of those
foster children receiving a psychotropic medication are
administered an antipsychotic, it is clear that the current
system is failing our children. A more rigorous process is
needed to protect the health and welfare of our foster children.
We believe [this bill] will improve decision-making for our
children and provide the protections they are entitled to before
being given medications that have profound effects upon their
well-being."
Concerns raised: Various parties, some representing health care
providers, have registered concerns with this bill, claiming
that some of its provisions may actually have the impact of
restricting timely access to medically necessary medications for
children. Specifically, one chief concern they have raised is
the requirement that a prescribing physician confirm that he or
she has conducted a comprehensive examination, taking into
account a number of factors, including the child's trauma and
health care history and medical records as well as multiple
sources of information including, but not limited to, the child,
the child's parents, relatives, teachers, caregiver(s), past
prescriber of psychotropic medication, or other health care
providers. The parties registering concern claim that these
requirements represent an ideal standard of care that may in
actuality be difficult to achieve.
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Another concern raised is that the requirement that physicians
confirm that there are no less invasive or effective treatment
interventions available is difficult to operationalize, that
physicians may often prescribe a combination of both medications
and psycho-social interventions, and that the availability of
psycho-social interventions are not under the control of the
prescribing physician.
Staff comments: While structures and practices may not
currently be in place in the state's child welfare system to
always ensure the ready availability of a youth's entire medical
history and useful supplementary information, this is arguably
not a reason for the state to simply permit the prescription of
potentially dangerous drugs to children based on imperfect and
incomplete information. The excessive and inappropriate
prescription of psychotropic medication to foster youth in
California, and the negative impacts this can have on their
lives both in the short- and long-term, is a serious problem
that has triggered a number of approaches to reforming the
system of psychotropic drug authorization and administration.
As various pieces of this reform are adopted and implemented,
the hope is that improved collection and sharing of medical and
related data will be one result. In the interim, this bill's
allowance for emergency administration of psychotropic
medications can facilitate immediate access to such medications
when warranted and medically necessary.
This bill, in seeking to reform the way psychotropic medications
are authorized in California, arguably has at its core at least
three of the guiding principles of DSS's and DHCS's recently
released "California Guidelines for the Use of Psychotropic
Medication with Children and Youth in Foster Care":
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"Integration: These inclusive health care needs
[inclusive of physical, emotional/behavioral, and dental
health] of a child/youth are expected to be integrated into
a health care services plan that provides integrated,
coordinated services that are individualized and tailored
to the strengths and needs of each child and their family.
Collaboration: The State and its counties recognize the
importance of collaboration with treatment providers,
particularly prescribing providers, to ensure the success
of these Guidelines and psychotropic medication management
reform for children and youth in out of home care served by
child welfare and/or probation.
Limitations: Psychotropic medication is never the sole
intervention but should be part of an overall treatment
strategy. Medication also carries the risk of adverse
(side) effects, so careful monitoring by the prescriber is
essential."
RELATED LEGISLATION:
SB 238 (Mitchell), 2015, requires DSS to develop expanded
training for foster parents, social workers, group home
administrators, and others involved in the care and oversight of
dependent children on issues related to psychotropic
medications. Further requires Judicial Council to, in
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consultation with other entities, update court forms related to
the authorization of psychotropic medications, and requires DSS
to establish an individualized monthly report and other tools
for use by county welfare agencies to monitor the administration
of psychotropic medications to foster youth.
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 Board of Supervisors
Alameda County Foster Youth Alliance (FYA)
American Federation of State, County and Municipal Employees
(AFSCME), AFL-CIO
California CASA Association
California Department of Justice
California Youth Connection
Children's Advocacy Institute
Children's Defense Fund - California (CDF-CA)
Children's Law Center of California
Children's Partnership
Consumer Watchdog
County Welfare Directors Association of California (CWDA)
Dependency Legal Group of San Diego
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First Focus Campaign for Children
Humboldt County Transition Age Youth Collaboration
John Burton Foundation for Children without Homes
National Association of Social Workers, CA Chapter (NASW-CA)
National Center for Youth Law, sponsor
Peers Envisioning and Engaging in Recovery Services (PEERS)
The Children's Partnership
The Jamestown Community Center
9 individuals
Opposition
None on file.
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Analysis Prepared by:Daphne Hunt / HUM. S. / (916)
319-2089