BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 253| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- VETO 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 SENATE FLOOR: 34-5, 8/24/16 AYES: Allen, Beall, Berryhill, Block, Cannella, De León, Galgiani, Glazer, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Pan, Pavley, Roth, Stone, Vidak, Wieckowski, Wolk NOES: Anderson, Bates, Fuller, Gaines, Nielsen ASSEMBLY FLOOR: 75-0, 8/18/16 - See last page for vote SUBJECT: Juveniles: psychotropic medication SB 253 Page 2 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 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). 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. 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 SB 253 Page 3 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 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. SB 253 Page 4 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 her right to object to the authorization and request a hearing. b) The court is provided with the written consent or SB 253 Page 5 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. 5) 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. 6) 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. 7) Prohibits the court from authorizing the administration of psychotropic medications unless it is provided documentation that the appropriate lab tests have been completed, as SB 253 Page 6 specified. 8) 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. 9) 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. 10) Allows a psychotropic medication to be administrated SB 253 Page 7 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 for the child or others; and c) It is impractical to obtain court approval prior to administering the medication. 11) 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. 12) 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 SB 253 Page 8 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 "cardio metabolic and endocrine side-effects" 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 SB 253 Page 9 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 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 SB 253 Page 10 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 in additional offsetting costs. SUPPORT: (Verified 10/11/16) 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 SB 253 Page 11 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: (Verified10/11/16) California Academy of Child and Adolescent Psychiatry 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. SB 253 Page 12 GOVERNOR'S VETO MESSAGE: I am returning Senate Bill 253 without my signature. This bill adds more requirements for juvenile court authorization and oversight of psychotropic medications for children in the child welfare and probation systems. Last year, I signed a bill that required the Judicial Council, working with stakeholders, to amend and adopt rules of court and forms to help judges determine whether to authorize the use of psychotropic medications. These new rules and forms took effect July 1, 2016, and require significantly more information to be submitted to the court. Until we know the impact of these changes, it is premature to legislate additional measures. 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 Prepared by:Mareva Brown / HUMAN S. / (916) 651-1524 10/18/16 12:15:32 **** END **** SB 253 Page 13