BILL ANALYSIS                                                                                                                                                                                                    Ó




           ----------------------------------------------------------------- 
          |SENATE RULES COMMITTEE            |                        SB 253|
          |Office of Senate Floor Analyses   |                              |
          |(916) 651-1520    Fax: (916)      |                              |
          |327-4478                          |                              |
           ----------------------------------------------------------------- 


                                UNFINISHED BUSINESS 


          Bill No:  SB 253
          Author:   Monning (D), et al.
          Amended:  8/4/16  
          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

           SENATE FLOOR:  40-0, 6/3/15
           AYES:  Allen, Anderson, Bates, Beall, Berryhill, Block,  
            Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,  
            Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,  
            Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,  
            Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner,  
            Stone, Vidak, Wieckowski, Wolk

           ASSEMBLY FLOOR:  75-0, 8/18/16 - See last page for vote

           SUBJECT:   Juveniles:  psychotropic medication


          SOURCE:    National Center for Youth Law
          
          DIGEST:   This bill requires that, beginning January 1, 2018, an  
          order authorizing the administration of psychotropic medications  
          to a dependent child or a delinquent child in foster care be  
          granted only upon the court's determination that the  
          administration of the medication is in the best interest of the  








                                                                     SB 253  
                                                                     Page 2



          child and that specified requirements have been met, including  
          laboratory screenings, as specified. This bill also requires  
          that under specified conditions the court be prohibited from  
          authorizing psychotropic medications until a pre-authorization  
          review has been conducted by a child psychiatrist or behavioral  
          pediatrician, as specified. This bill imposes additional court  
          oversight requirements, as specified, and includes chaptering  
          amendments to resolve conflicts with SB 999 (Pavley).


          Assembly Amendments replace the requirement for a second opinion  
          with a preauthorization review and narrow the criteria  
          triggering such a review.  Amendments revise the requirement  
          that physicians collect specified information on a child being  
          prescribed psychotropic medications and replaces it with  
          language that requires the physician be provided that  
          information. They add the requirement that the Judicial Council  
          adopt rules and create forms to implement this bill in  
          consultation with the state and various stakeholders, and that  
          the rules include a process for periodic court oversight, as  
          specified. Amendments additionally extend the implementation  
          date and include chaptering out language with SB 999.


          ANALYSIS: 


          Existing law:


           1) Establishes a system of juvenile dependency for children who  
             are or are at risk of being physically, sexually or  
             emotionally abused, being neglected or being exploited to  
             ensure their safety, protection and physical and emotional  
             well-being, and further establishes a juvenile court's  
             jurisdiction over a child when that child has committed acts  
             that trigger delinquency jurisdiction.  


           2) Authorizes the court to make any and all reasonable orders  
             for the care, supervision, custody, conduct, maintenance and  
             support of a dependent child, including medical treatment.  








                                                                     SB 253  
                                                                     Page 3





           3) Authorizes the court to allow a social worker or probation  
             officer to authorize medical, surgical, dental or other  
             remedial care for a ward or dependent child who has been  
             placed by the court under the custody or supervision of a  
             social worker or probation officer, if it appears there is no  
             parent or guardian capable of authorizing or willing to  
             authorize medical, surgical, dental or other care.  


           4) Authorizes a minor who is 12 years of age or older to  
             consent to mental health treatment or counseling services if,  
             in the opinion of the attending professional person, the  
             minor is mature enough to participate intelligently in the  
             mental health treatment or counseling services.  


           5) Establishes that only a juvenile court judicial officer has  
             authority to make orders about the administration of  
             psychotropic medications for a minor who has been adjudged a  
             dependent or ward of the court and removed from the physical  
             custody of his or her parent.  Defines "psychotropic  
             medicine" as medicines used to treat psychiatric disorders or  
             illnesses, as specified.


           6) 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, within seven court  
             days, the juvenile court to either approve or deny in writing  
             a request for authorization for the administration of  
             psychotropic medication, or to set the matter for hearing.  


           7) Requires the Judicial Council to adopt rules of court and  
             develop appropriate forms to ensure the child and caregiver  
             have an opportunity to provide input on the medications being  
             prescribed, that information about the child's overall mental  








                                                                     SB 253  
                                                                     Page 4



             health assessment and treatment plan is provided to the  
             court, including the rationale for the proposed medication  
             and guidance about how to evaluate the request for  
             authorization and oversight mechanisms.


          This bill:


           1) Requires the court to verify when authorizing administration  
             of a psychotropic medication that the medication is only one  
             part of a comprehensive treatment plan for the child, which  
             must include and specify the psychosocial, behavioral and  
             alternative services the child will receive in addition to  
             any medication.


           2) Prohibits the juvenile court from authorizing psychotropic  
             medication to a ward or dependent unless it determines 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.  


           3) Prohibits authorizing the administration of psychotropic  
             medication if the court determines it is being used as a  
             punishment, for purposes other than treatment of a diagnosed  
             mental health condition, as a substitute for less invasive  
             treatments, or in quantities that interfere with the child's  
             treatment program.  


           4) Permits an order authorizing psychotropic medication to be  
             granted only if:


              a)    The court is provided documentation confirming the  
                child's caregiver and the child have been informed, in an  
                age and developmentally appropriate manner, about the  
                recommended medications and side-effects and asked about  
                their concerns, and the child has been informed of his or  








                                                                     SB 253  
                                                                     Page 5



                her right to object to the authorization and request a  
                hearing.
              b)    The court is provided with the written consent or  
                refusal to assent from a child who is 12 years of age or  
                older. 
              c)    The court determines that the prescribing physician  
                was provided a copy of the child's health and education  
                summary or passport, and confirms that there are no less  
                invasive and effective treatment options available to meet  
                the child's needs; the dosage is appropriate for the  
                child; the short- and long-term risks do not outweigh the  
                benefits of the medication; and all appropriate lab  
                screenings for the child have been performed or ordered.
              d)    The court determines that a plan is in place for  
                regular monitoring of the child's medication and  
                psychosocial treatment plan, the effectiveness of the  
                medication and treatment, and any potential side effects  
                of the medication.


           1) Prohibits the authorization of psychotropic medications  
             without a preauthorization review, as defined, from a child  
             psychiatrist or behavioral pediatrician if the child is five  
             years old or less, or the request would result in the child  
             receiving three or more psychotropic medications  
             concurrently, or the request is for concurrent medication of  
             two antipsychotic medications, unless the request is for  
             medication tapering, as specified. 


           2) Establishes that preauthorization review, as specified, does  
             not require a face-to-face assessment of the child for whom  
             the psychotropic medications are prescribed, but permits the  
             court to order that assessment to be completed before  
             deciding whether or not to approve the request to authorize  
             the medication, as specified. 


           3) Prohibits the court from authorizing the administration of  
             psychotropic medications unless it is provided documentation  
             that the appropriate lab tests have been completed, as  
             specified.








                                                                     SB 253  
                                                                     Page 6





           4) Requires the court, no later than 60 days following an  
             authorization for a new psychotropic medication, or at the  
             next review hearing scheduled no earlier than 45 days after  
             the authorization, to conduct a review hearing to determine: 


              a)    Whether the child is taking the medication or  
                medications.
              b)    Whether psychosocial services and other aspects of the  
                child's treatment plan have been provided to the child.
              c)    To what extent the symptoms for which the medication  
                or medications were authorized have been alleviated and  
                what, if any, adverse effects the child has suffered and  
                any steps to address those effects. 
              d)    Whether more time is needed to evaluate the  
                effectiveness of the medication or medications.
              e)    The date or dates of follow-up visits with the  
                prescribing physician since the medication or medications  
                were authorized and whether appropriate follow-up  
                laboratory screenings have been performed, and their  
                findings.


           1) Requires the social worker to submit a report prior to the  
             review hearing.  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.  


           2) Allows a psychotropic medication to be administrated without  
             court authorization in an emergency, provided that court  
             authorization is sought as soon as practical, as specified,  
             and all of the following are true:


              a)    The physician finds that the child requires the  
                medication to treat a psychiatric disorder or illness;
              b)    The medication is immediately necessary for the  
                preservation of life or prevention of serious bodily harm  








                                                                     SB 253  
                                                                     Page 7



                for the child or others; and 
              c)    It is impractical to obtain court approval prior to  
                administering the medication.


           1) Establishes that nothing in the bill grants anyone the  
             authority to administer psychotropic medication to a child  
             who refuses to take the medication.  Provides that no person  
             may threaten, coerce, withhold privileges or otherwise  
             penalize a child for refusing to take psychotropic  
             medication, and specifies that a child cannot be  
             involuntarily administered a psychotropic medication unless  
             otherwise specifically permitted by law.


           2) Establishes various timelines for reports, adoption of  
             rules, updates to appropriate forms, as specified, and other  
             implementation efforts. 


          Background


          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 attention deficit hyperactivity disorder (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 percent of psychotropic medications have been approved by the  
          FDA for use in children or adolescents. Anti-psychotic  
          medications, used to treat more severe mental health conditions,  
          have very limited approval by the FDA for pediatric use.  
          However, the off-label use of anti-psychotics 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"  








                                                                     SB 253  
                                                                     Page 8



          as well as significant weight gain. Compounding the potential  
          for unintended side effects is the use of combinations of  
          psychotropic medications, which foster youth are particularly  
          likely to be prescribed. Protecting the health and well-being of  
          children who are taking one or more psychotropic medications  
          requires ongoing health and metabolic screenings to identify  
          potential adverse effects quickly, however in practice many  
          children fail to receive ongoing screenings and effects may go  
          undetected, causing permanent injury or death.


          Newspaper articles over the past two years have identified  
          concerns that psychotropic medications have been used as a means  
          of controlling, instead of treating, foster youth who suffer  
          from trauma-related behavioral health challenges. A series of  
          articles in the San Jose Mercury News identified prescribing  
          rates, dosages and regimens that concerning to child welfare  
          system experts. A package of bills in 2015 and this year have  
          sought to increase oversight of prescribing to foster youth and  
          ensure the use of other therapies to address behavioral issues.


          Court oversight mechanisms.  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 a description of the child's diagnosis  
          and behavior, the expected results of the medication and a  
          description of any medication side effects. 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. Frequent placement changes of  
          dependent youth may mean that important medical history does not  








                                                                     SB 253  
                                                                     Page 9



          accompany the youth and that some medication regimens, may not  
          be disclosed to a judge, prescribing physician, social worker or  
          caregiver. 


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   Yes


          According to the Assembly Appropriations Committee, this bill  
          will result in a potentially major increase in Medi-Cal program  
          costs up to the low millions of dollars (Federal Funds/General  
          Fund (GF)) annually to the extent the provisions of this bill  
          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.  Additionally, the Committee identified annual costs of  
          about $1 million (Federal Fund/GF) 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 45 days from the date of the request to  
          the court, and attend the additional review hearings. 


          This bill also will result in costs of $1 million to $2 million  
          (GF) annually, for review hearings for approximately 10,000  
          requests for psychotropic medication authorizations each year,  
          and annual costs of around $1 million (GF) for document  
          management related to approximately 10,000 requests for  
          psychotropic medication authorizations per year. This bill also  
          will result in one-time costs of $77,000 (GF) for the Judicial  
          Council to develop or revise forms and rules.


          The Committee also identified potentially significant  
          off-setting decrease in Medi-Cal program costs (Federal  
          Funds/GF) 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  








                                                                     SB 253  
                                                                     Page 10



          in additional offsetting costs. 


          SUPPORT:  (Verified  8/31/16)


          National Center for Youth Law (source)
          Advokids
          AFSCME
          Alameda County Board of Supervisors
          Alameda County Foster Youth Alliance
          California Court Appointed Special Advocates Association 
          California State Department of Justice
          California Youth Connection
          Children's Advocacy Institute
          Children's Partnership
          Consumer Watchdog
          County Welfare Directors Association of California
          Court Appointed Special Advocates of Santa Cruz County
          Dependency Legal Group of San Diego
          Disability Rights California
          East Bay Children's Law Offices
          East Bay Community Law Center
          First Focus Campaign for Children
          Humboldt County Transition Age You Collaboration
          John Burton Foundation for Children Without Homes
          Judicial Council of California 
          Kidsave
          Legal Advocates for Children and Youth
          National Association of Social Workers
          Peers Envisioning and Engaging in Recovery Services
          San Luis Obispo County Department of Social Services
          Sunny Hills Services
          United Advocates for Children and Families
          Youth Law Center
          10 individuals


          OPPOSITION:  (Verified  8/19/16) 


          California Academy of Child & Adolescent Psychiatry








                                                                     SB 253  
                                                                     Page 11



          California Alliance
          California Medical Association
          California Psychiatric Association
          County Behavioral Health Directors Association


          ARGUMENTS IN SUPPORT:     The National Center for Youth Law  
          writes that while courts have been gatekeepers to authorize  
          psychotropic medications for foster children, the courts have  
          not had adequate standards to guide decision making. "When more  
          than 25 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 ? it is  
          clear that the current system is failing our children."


          ARGUMENTS IN OPPOSITION:     A joint letter from the California  
          Medical Association, County Behavioral Health Directors  
          Association, California Psychiatric Association, California  
          Academy of Child and Adolescent Psychiatry and the California  
          Alliance cite a number of concerns. Specifically, they argue the  
          bill does not provide resources for preauthorization reviews and  
          changes or adds to existing processes for courts to review  
          requests, among other concerns. 

           ASSEMBLY FLOOR:  75-0, 8/18/16
           AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,  
            Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos,  
            Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh,  
            Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher,  
            Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez,  
            Gonzalez, Gray, Grove, Hadley, Harper, Holden, Irwin, Jones,  
            Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low,  
            Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin,  
            Nazarian, Obernolte, O'Donnell, Olsen, Quirk, Ridley-Thomas,  
            Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond,  
            Ting, Wagner, Waldron, Weber, Wilk, Wood, Rendon
           NO VOTE RECORDED: Bigelow, Gordon, Roger Hernández, Patterson,  
            Williams











                                                                     SB 253  
                                                                     Page 12




          Prepared by:Mareva Brown / HUMAN S. / (916) 651-1524
          8/31/16 17:09:50


                                    **** END ****