BILL ANALYSIS Ó
SB 319
Page 1
Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
319 (Beall) - As Amended July 7, 2015
SENATE VOTE: 40-0
SUBJECT: Child welfare services: public health nursing.
SUMMARY: Requires a foster care public health nurse (FCPHN) to
monitor the administration of psychotropic medications to
children in foster care and authorizes the disclosure of health
care information to FCPHN. Specifically, this bill:
1)Authorizes a provider of health care to disclose medical
information to a FCPHN to coordinate health care services and
medical treatment for a minor who has either been taken into
temporary custody, had a petition filed with the court, or
been adjudged a dependent child or ward of the juvenile court,
as specified.
2)Requires the FCPHN and the child's social worker to consult,
collaborate, and share information in a timely manner to
ensure that the child's physical, mental, dental, and
developmental needs are met.
3)Requires that a FCPHN have access to a child's medical,
SB 319
Page 2
dental, and mental health care information in order to allow
that nurse to fulfill his or her duties.
4)Requires a FCPHN, at the request of a nonminor dependent, to
assist him or her in making informed decisions about his or
her health care by, at a minimum, providing educational
materials.
5)Adds to the duties of a FCPHN the monitoring of each child in
foster care who is administered one or more psychotropic
medications and requires that monitoring include, but not be
limited to, all of the following:
a) Reviewing each request for psychotropic medication to
verify that all required information is provided to the
court;
b) Monitoring and recording the appropriate completion of
laboratory tests, other screenings and measurements,
evaluations and assessments in a child's health and
education passport;
c) Reviewing, monitoring, and confirming that the juvenile
court has authorized the psychotropic medication to be
administered to a child;
d) Taking steps to confirm that appropriate periodic
follow-up health visits and procedures are scheduled and
completed;
SB 319
Page 3
e) Completing appropriate documentation concerning
psychotropic medications in a child's health and education
passport; and,
f) Documenting the response of a child to the
administration of psychotropic medication through review of
the child's lab tests and reports, and providing
information to the child's social worker to be included in
court reports if necessary.
EXISTING LAW:
1)Requires the Department of Social Services (DSS) to establish
a program that provides health-related case management
services by a FCPHN to coordinate with child welfare service
workers regarding the provision of health care services to
children in foster care.
2)Requires that, when a child is placed in foster care, the case
plan for each child include a summary of the health and
education information or records of the child maintained in
the form of a health and education passport, or a comparable
format designed by the child protective agency.
SB 319
Page 4
3)Requires FCPHNs to perform health-related case management
duties that include, but are not limited to, documenting that
each child receives initial and follow-up screenings,
collecting health information and other relevant data,
expediting referrals, and facilitating the acquisition of
necessary court authorizations for procedures or medications.
4)Limits the scope of services provided by a FCPHN to services
reimbursable under Title XIX of the federal Social Services
Act, which provides a 75% match for health-related case
management but excludes the direct provision of health care
services.
5)Requires counties to establish a community Child Health and
Disabilities Prevention (CHDP) program for the purpose of
providing early and periodic assessments of the health status
of children in the county or counties. Requires counties to
be reimbursed for the amount required in accordance with the
approved community CHDP plan.
6)Permits only a juvenile court judicial officer to 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.
FISCAL EFFECT: According to the Senate Appropriations
Committee, annual costs of $4.5 million per year to provide
additional services to foster youth who are administered
psychotropic drugs (25% General Fund and 75% federal funds).
SB 319
Page 5
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, nearly one in
four children in foster care and 56% of children in group
homes are receiving psychotropic drugs, often without adequate
oversight. The author states that it is currently unclear if
foster youth are being given these potent drugs as part of a
therapeutic regimen or whether these medications are being
used solely to control a youth's behavior. Without adequate
oversight, these powerful drugs can cause irreversible damage,
and many youth experience long-term side effects, including
diabetes, tics, weight gain, and drowsiness. The author
further states that this bill is grounded in the expertise
developed working with medical experts in the State's Quality
Improvement Project, the federally mandated process for
developing protocols and procedures to govern the use of these
medications on foster children. The author concludes that the
bill utilizes public health nurses, one of the great resources
of our child welfare system, to oversee the medical monitoring
of psychotropic drugs to increase oversight and reduce the
number of children prescribed these powerful drugs.
2)BACKGROUND.
a) Psychotropic Drugs. Psychotropic medications are any
chemical substance that changes brain function and results
in alterations in perception, mood, or consciousness.
Psychiatric medications are prescribed for the management
of mental and emotional disorders, or to aid in overcoming
challenging behavior. There are six major classes of
psychotropic medications:
SB 319
Page 6
i) Antidepressants, which treat disparate disorders
such as clinical depression, dysthymia, anxiety, eating
disorders, and borderline personality disorder;
ii) Stimulants, which are used to treat disorders such
as attention deficit disorder and narcolepsy and to
suppress the appetite;
iii) Antipsychotics, which are used to treat psychotic
symptoms, such as those associated with schizophrenia or
severe mania;
iv) Mood stabilizers, which are used to treat bipolar
disorder and schizoaffective disorder;
v) Anxiolytics, which are used to treat anxiety
disorders; and,
vi) Depressants, which are used as hypnotics, sedatives,
and anesthetics, depending upon dosage.
While these drugs have been proven effective for many
adults living with mental disorders, the research on their
impacts on youth, particularly children under six, is
minimal. The National Institute on Mental Health states
that while researchers are trying to clarify how early
treatment affects a growing body, families and doctors
should weigh the benefits and risks of each medication.
SB 319
Page 7
b) Media Attention. A recent series of stories published
in the San Jose Mercury News (August, 24, 2014, "Drugging
Our Kids") and most recently in the Los Angeles Times
(April 7, 2015, "Use of Meds by L.A. County Foster,
Delinquent Kids Prompts Reform"), 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. The series detailed significant challenges in
accessing pharmacy benefits claims data held by the
California Department of Health Care Services (DHCS),
eventually overcome through a Public Records Act request
and lengthy negotiations, and demonstrated that prescribing
rates were far higher than had been anticipated by child
welfare system experts. The San Jose Mercury News series,
"Drugging Our Kids," noted that nearly one of every four
adolescents in California's foster system is receiving
psychotropic medications, which is 3 1/2 times the rate for
all adolescents nationwide. Over the last decade, almost
15% of the state's foster youth of all ages were receiving
the medications. Long-term effects, particularly in
children, have received little study, but for some
psychotropics, there is evidence of persistent tics,
increased risk of suicide, and brain shrinkage.
c) CHDP & Health Care Program for Children in Foster Care
(HCPCFC). HCPCFC implements California statute
establishing a program of public health nursing within the
child welfare services system. The program provides public
health nurse expertise to meet the medical, dental, mental
and developmental needs of children and youth in foster
care. Currently, administrative responsibilities for the
program are managed by the local CHDP program. Under the
program, public health nurses provide the following
SB 319
Page 8
services in consultation and collaboration with social
workers and probation officers:
i) Medical and health care case planning;
ii) Assistance foster caregivers in obtaining timely
health assessments and dental examinations for children;
iii) Expediting referrals for medical, dental, mental
health and developmental services;
iv) Coordinating health services for children in
out-of-county and out-of-state placements;
v) Providing medical education through the
interpretation of medical reports and training; and,
vi) Participating in the creation and updating of the
Health and Education Passport
The CHDP program provides complete health assessments for
the early detection and prevention of disease and
disabilities for low-income children and youth. A health
assessment consists of a health history, physical
examination, developmental assessment, nutritional
assessment, dental assessment, vision and hearing tests, a
tuberculin test, laboratory tests, immunizations, health
education/anticipatory guidance, and referral for any
needed diagnosis and treatment."
SB 319
Page 9
d) California guidelines. DHCS and DSS have the shared
responsibility for the oversight of mental health services
provided to children and youth involved with county child
welfare and probation agencies. In early April 2015, the
California Guidelines for the Use of Psychotropic
Medication with Children and Youth in Foster Care were
released specific to those children and youth who are: i)
involved with child welfare services and/or probation
services; and, ii) are placed in foster care. According to
DHCS's Web site, the Guidelines are a statement of best
practice for the treatment of children and youth in
out-of-home care, who may require psychotropic medications.
Depending on the nature, severity, and persistence of
their symptoms, medication may be indicated as part of an
initial treatment plan (as with Attention Deficit
Hyperactivity Disorder, major depression, psychosis and
disabling anxiety); may be considered only after
appropriate psychosocial interventions are employed (as
with moderate anxiety/depression); or, may not be indicated
at all (as with learned defiance and predatory aggression).
When psychotropic medication is indicated, it should be
used in conjunction with psychosocial interventions. The
exception is when psychosocial interventions have been
effective and are therefore terminated, but continued use
of medication is necessary to prevent the recurrence of
symptoms.
DHCS notes that the Guidelines represent the first
comprehensive effort at the state level to address the use
of psychotropic medication in children and youth in
out-of-home care being served by the child welfare and/or
probation system. DHCS expects that the Guidelines, which
will be reviewed annually, will evolve over time in
SB 319
Page 10
response to updated research and the evolution of best
practices, and in response to feedback from youth,
families, prescribers, other providers, and additional
community stakeholders.
3)SUPPORT. The sponsors of this bill, National Center for Youth
Law (NCYL) writes that psychotropic medications including
antipsychotics have debilitating effects on children including
crippling sedation, rapid, significant weight gain, diabetes,
metabolic disturbance, heart disease, irreversible tremors,
and other conditions which impact their health even as adults.
NCYL states that since 2004 guidelines issued by the American
Diabetes Association, the American Psychiatric Association,
and the American Academy of Child and Adolescent Psychiatrists
have called for the completion of lab tests and other
screenings before a child is started on antipsychotics. NCYL
argues that these screenings are completed for few foster
children. NCYL concludes that public health nurses' medical
expertise and their existing role in helping to manage health
care services for foster children put them in a unique
position to fill the gap in overseeing the care of children
administered psychotropic medication.
Additional supporters of this bill include the California
Alliance of Child and Family Services, California Nurses
Association, Children Now, the County Welfare Directors
Association of California and others argue that it strengthens
HCPCFC by explicitly giving FCPHNs access to information and
the authority needed to monitor and oversee thousands of
foster youth who are prescribed psychotropic medications.
These supporters also note that this bill gives non-minor
foster youth access to FCPHNs to help them make informed
decisions about beginning or continuing the use of such
medications. Supporters state that psychotropic medications
have debilitating effects on children and cite that of all
foster youth administered the medications 52% are given one or
more antipsychotics-a class of drugs with few Food and Drug
Administration approved indications for children and
SB 319
Page 11
adolescents. Supporters further argue that the benefits and
risks of such medications must be periodically reevaluated,
including follow-up labs and other measures, which this bill
provides.
4)RELATED LEGISLATION.
a) SB 484 (Beall) requires DSS's Director to identify group
homes that inappropriately administer psychotropic
medications to children. SB 484 is pending in the Assembly
Human Services Committee.
b) SB 238 (Mitchell) requires specified certification and
training programs for group home administrators, foster
parents, child welfare social workers, dependency court
judges, and court appointed council to include training on
psychotropic medication, trauma, and behavioral health, for
children receiving child welfare services. SB 238 is
pending in the Assembly Human Services Committee.
c) SB 253 (Monning) requires an order of the juvenile court
authorizing psychotropic medication to require clear and
convincing evidence of specified conditions. SB 253 is
pending in the Assembly Human Services Committee.
5)PREVIOUS LEGISLATION. SB 543 (Bowen), Chapter 552, Statutes
of 1999, mandates 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
SB 319
Page 12
from a physician.
6)DOUBLE REFERRAL. This bill was heard by the Assembly
Committee on Health and Human Services on June 30, 2015
and passed out of the Committee on a 7-0 vote.
REGISTERED SUPPORT / OPPOSITION:
Support
National Center for Youth Law (sponsor)
Kamala Harris, California Attorney General
Abode Services
Accessing Health Services for California's Children in Foster
Care Task Force
Advokids
Alameda County Board of Supervisors
California Academy of Child and Adolescent Psychiatry
SB 319
Page 13
California Alliance of Child and Family Services
California Department of Justice
California Youth Connection
Children's Defense Fund California
Children Now
Children's Partnership
Children's Law Center of California
Consumer Watchdog
County Welfare Directors Association of California
Disability Rights California
First Place for Youth
Humboldt County Transition Age Youth Collaboration
John Burton Foundation for Children without Homes
SB 319
Page 14
Laborer's International Union of North America Local 777 and 792
Mockingbird Society
National Center for Youth Law
Santa Clara County Board of Supervisors
Eight individuals
Opposition
None on file.
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097