Differentiating between Mental Retardation/ Developmental Disability and Mental Illness 1
Medicaid RSPMI service codes do not cover services addressing Mental Retardation and Developmental Disabilities. 2
Arkansas Medicaid does recognize it is possible that a person may be Mentally Retarded and also have a Mental Illness. This is called Dual Diagnosis. Dual Diagnosis persons are eligible for RSPMI services that are Medically Necessary. 3
Arkansas Medicaid does recognize it is possible that a person may have Autism Spectrum Disorders (ASDs: Autism, Asperger Syndrome, Pervasive Developmental Disorder-NOS) and also have a Mental Illness. These persons are eligible for RSPMI services that are Medically Necessary. 4
Mild Mental Retardation Approximately 85% of the mentally retarded population is in the mildly retarded category. Their IQ score ranges from 50-75, and they can often acquire academic skills up to the 6th grade level. They can become fairly self-sufficient and in some cases live independently, with community and social support. 5
Moderate Mental Retardation About 10% of the mentally retarded population is considered moderately retarded. Moderately retarded individuals have IQ scores ranging from 35-55. They can carry out work and self-care tasks with moderate supervision. They typically acquire communication skills in childhood and are able to live and function successfully within the community in a supervised environment such as a group home. 6
Severe Mental Retardation About 3-4% of the mentally retarded population is severely retarded. Severely retarded individuals have IQ scores of 20-40. They may master very basic selfcare skills and some communication skills. Many severely retarded individuals are able to live in a group home. 7
Profound Mental Retardation Only 1-2% of the mentally retarded population is classified as profoundly retarded. Profoundly retarded individuals have IQ scores under 20-25. They may be able to develop basic self-care and communication skills with appropriate support and training. Their retardation is often caused by an accompanying neurological disorder. The profoundly retarded need a high level of structure and supervision. 8
Mental Retardation (has manifestations) Commonly caused by an irreversible genetic anomaly, in utero malfunction, or injury Cannot be controlled or ameliorated via drugs Cannot be improved with psychotherapy treatment (Manifestations can sometimes be somewhat ameliorated via educational interventions and techniques.) Using modern medicine and treatment, cannot be cured Mental Illness (has symptoms) May be genetic and/or environmental in origin Can be controlled or ameliorated via drugs Can be improved with psychotherapy treatment Using modern medicine and treatment, can often be rehabilitated 9
Common Mental Retardation Manifestations Misdiagnosed as Symptoms of Mental Illness Short attention span often misdiagnosed as ADD Flat affect often misdiagnosed as Depression Easily frustrated often misdiagnosed as Personality Disorder Does not adapt well to change often misdiagnosed as Obsessive Compulsive Disorder Does not relate well to others often misdiagnosed as Schizophrenia 10
Dual Diagnosis Ability to Benefit from Treatment Level of Mental Retardation Mild Effective Treatment Many of the same forms of treatment for Non- Mentally Retarded Moderate Severe Concrete Structured Behavior modification Medication management Medication management Profound Palliative or comfort therapies 11
Autism Autism is a range of neurological disorders characterized by social impairments, communication difficulties, and restricted, repetitive, stereotyped patterns of behavior. Autism is uncommon (.03%--about 3 out of every 1,000 children includes Autism, Asperger Syndrome, PDD) and occurs more frequently among males than females. Autistic children appear to have a higher than normal risk for certain other neurological co-occurring conditions (Fragile X syndrome [causes mental retardation], tuberous sclerosis [brain tumors], epileptic seizures). 12
Autism (has manifestations) Believed to be caused by an irreversible genetic anomaly Mental Illness (has symptoms) May be genetic and/or environmental in origin Cannot be controlled or ameliorated via drugs Cannot be improved with psychotherapy treatment (Manifestations can sometimes be somewhat ameliorated via educational interventions and techniques.) Can be controlled or ameliorated via drugs Can be improved with psychotherapy treatment Using modern medicine and treatment, cannot be cured Using modern medicine and treatment, can often be rehabilitated 13
Common Manifestations of Autism Misdiagnosed as Symptoms of Mental Illness Shortattentionspan oftenmisdiagnosedasadd Easily frustrated often misdiagnosed as Personality Disorder Does not adapt well to change often misdiagnosed as Obsessive Compulsive Disorder Does not relate well to others often misdiagnosed as Reactive Attachment Disorder Engages in repetitive movements or stereotypical behaviors often misdiagnosed as Obsessive Compulsive Disorder Lack of empathy often misdiagnosed as Sociopathy Impaired social interaction often misdiagnosed as Schizophrenia 14
Aspergers Syndrome and Pervasive Developmental Disorder NOS Asperger Syndrome lacks delays in cognitive development and language. Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS) is diagnosed when the full set of criteria for Autism or Asperger Syndrome is not present. 15
Autism, Asperger Syndrome, PDD Ability to Benefit from Treatment To the extent that any or all of the impairments/ behaviors are due to disorders of neuroligical impairment, psychotherapy treatment is not effective, and may actually cause harm or aggravate the manifestations of the impairment/s. Careful, expert use of psychiatric medications can, in some cases, reduce (via neurochemical interference/blocking) some of the actionistic behaviors associated with the syndrome. 16
Considerations When Requesting RSPMI Services Is the Mental Illness diagnosis accurate, or has there been a misdiagnosis based on the manifestations of the syndrome? Are the symptoms to be addressed treatable symptoms of a Mental Illness or non-treatable manifestations of the syndrome? Is the treatment proposed psychotherapy (requiring the licensure and expert methodology of a licensed Mental Health Professional) or educational (capable of being rendered by a certified school teacher)? 17
The Tragedy of Misdiagnoses There is a growing number of individuals (parents/caretakers)--some misguided and some self-serving--seeking Autistic Spectrum Disorders diagnoses for their children in order to obtain benefits and services. It is the moral and ethical responsibility of physicians, mental health professionals, and educators to accurately differentiate between manifestations of Mental Retardation, Autism Spectrum Disorders, and Mental Illness and to educate parents, teachers, and the public. Psychiatric and/or psychological treatment based on misdiagnosis due to inability to distinguish symptoms of Mental Illness and the manifestations of Mental Retardation and/or Autistic Spectrum Disorders can result in: -- permanent psychological harm to the patient -- dangerous behavior by the patient, and/or -- in some cases, irreversible somatic damage to the patient. 18
DDS Services DDS Waiver and Human Development Centers 19
Intake & Referral DDS Services caseworkers serve as the intake and referral source for the DDS Waiver program and Human Development Center (HDC) applications. The DDS Children s Services assists with applications for children and youth under age 21 who are still in school or have not completed their school program. DDS Services provides applications to the parent/guardian and work with them to obtain a complete application and all additional information required to determine eligibility. Caseworkers sign the application and submit it to the appropriate Unit for processing the application. Caseworkers then assist the parent/guardian in monitoring progress of the application. 20
DDS Categorical Eligibility Categories of eligibility Cerebral Palsy Autism Epilepsy Intellectual Disability Spina Bifida Down Syndrome Other: any other neurological/physical condition that causes a person to function as though they have an Intellectual Disability with the exception of mental illness. (Onset of the developmental disability must have occurred prior to age 22 and caused substantial deficits.) 21
Intermediate Care Facility Level of Care In addition to a Categorically Qualifying Diagnosis, the individual s application is reviewed to determine if they qualify under the ICF LOC. The areas reviewed are: Self Care Understanding & Use of language Learning Mobility Self-Direction Capacity for Independent Living 22
Medical Eligibility So, an individual may have a Categorically Qualifying Diagnosis for DDS, and not be eligible for the DDS Waiver or admission to an HDC if they do not function at the ICF level of care in three of those areas, as measured by adaptive behavior testing. 23
Documentation Reviewed Psychology team reviews psychological testing: IQ and Adaptive Behavior testing done within Birth to 5 y/o: within a year (may be developmental evaluation rather than IQ/adaptive. 5 to 18 y/o (school age): Within 3 years School Forms: The Evaluation/Programming Conference Decision form and The Existing Data Review Adults out of school: Within 5 years 24
Other Required Information Areas of Need Form This is the parent/guardian s opportunity to explain how the applicant functions compared to others their own age. Social History Medical diagnosis and additional reports as needed 25
DDS Waiver The formal name is Alternative Community Services Home and Community Based Waiver. Commonly known as the DDS Waiver 26
Enrollment Limitations Enrollment in the Arkansas DDS Waiver is currently limited to 3,988 individuals in waiver slots. The limit is set by the amount of state funding allocated to DDS to fund the state s portion of the waiver. There cannot be an increase in the number of individuals served on the DDS waiver without an increase in state dollars allocated for that purpose. 27
Current Status The DDS Waiver is currently at capacity with a waiting list of over 1,800 individuals. The only method of obtaining a waiver slot is through attrition. This means someone must give up their waiver slot. 28
Priority Categories for Waiver Qualifying individuals that are transitioning out of an ICF/MR facility, ASH, or Nursing Home Qualifying individuals in the custody of the State (DCFS or DHS Adult Protective Services) Qualifying individuals over age 18 who have completed their public school education and have been accepted to live in a group home or independent living apartment. 29
Eligibility for DDS Waiver Category of Medicaid The initial waiver application packet includes forms to determine medical eligibility only. Medicaid eligibility is established at the time a Waiver slot is available for the individual. The Medicaid eligibility is based on the applicant s income and resources only. The parent/guardian s income and resources are not considered. 30
Human Development Centers (HDC) DDS currently operates 5 HDC s Arkadelphia Booneville Conway Jonesboro Warren (Southeast AR) 31
Conway Human Development Center Conway HDC is the only one of the 5 facilities that serves children and youth, because CHDC is the only HDC with education services in place. Long-term plans have been made to transition children and youth out of the Conway HDC into community based settings such as the home or small, private ICF programs. 32
Conway HDC Campus There is a waiting list for admission to Conway HDC. It doesn t operate as a typical waiting list. Conway HDC residents live in cottages that are filled based on gender, age and level of care required. These criteria are followed when a vacancy in a cottage enables someone to come off the waiting list. 33
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Contact Information Program Administrative Staff Children: Nancy Holder, Program Administrator Iris Fehr, Nursing Supervisor Phone: 501-682-2277 Toll Free: 800-482-5850 ext 22277 Adults: Martha Smith, Program Administrator 501 683-5687 35
36 AAIDD: American Association of Intellectual and Developmental Disabilities AAMR: The American Association on Mental Retardation Association for Science in Autism Treatment Autism Speaks interactive Network Autism Help org: Autism, Aspergers, PDD Fact Sheets Baird G., Simonoff E., Pickles A., et al.: "Epidemiology of autistic disorder and other pervasive developmental disorders. Journal of Clinical Psychiatry 66 (Suppl 10): 3 8. (2006). Byrd R. S., Sage AC, Keyzer J et al.: Comorbid psychopathology with Autism Spectrum Disorder in children: an overview. Journal of Residential Developmental Disabilities 28 (4): 341 52. (2005).. Chakrabarti S., Pervasive developmental disorders in preschool children. Journal of the American Medical Association 285 (24): 3093 9. (2010). Fighting Autism.org Fombonne E.: The epidemiology of autism spectrum disorders: is the prevalence rising?. Mental Retardation and Developmental Disabilities.8 (3): 151 61. (2008). GRASP: The Global and Regional Asperger Syndrome Partnership National Autistic Society National Institute of Neurological Disorders Sources and Resources Rutter R.M.: Incidence of autism spectrum disorders: changes over time and their meaning Institute of Psychiatry, Kings College, London, UK. Jan;94(1):2-15. US National Library of Medicine, National Institutes of Health. (2009). Shattuck P. T. The contribution of diagnostic substitution to the growing administrative prevalence of autism in US special education. Pediatrics 117 (4): 1028 37. (2006). Zafeiriou D. I., Ververi A., & Vargiami E. Childhood autism and associated comorbidities. Brain Development. 29 (5): 257 72. (2009).
37 Questions and Answers
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