Psychotherapy and residential placement as related services

Mental Health Disorders

Psychotherapy and residential placement as

related services

Mental Health Disorders

What do serious diagnosable mental health disorders look

like?

DSM-IV

Diagnostic and Statistical Manual of Mental Disorders

Fourth Edition

Mental Disorders

• Definition considerations:–Mental disorders and physical disorders

are not distinct.–No consistent operational definition

that covers all situations.– Classification of disorders that people

have—not people.– A current manifestation of a behavioral,

psychological, or biological dysfunction.

Mental Disorders

• “…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom”.

Principal DSM-IV Diagnoses

• Pervasive Developmental Disorders (Except Autistic Disorder)

• Attention Deficit Disorder

• Disruptive Behavior Disorders

• Schizophrenia

• Psychotic Disorders• Mood Disorders• Anxiety Disorders• Dissociative Disorders• Impulse Control

Disorder• Adjustment Disorder• Personality Disorders

Excluded DSM-IV Diagnoses

• Mental Retardation• Learning Disorders• Motor Skills

Disorder• Communication

Disorder• Autistic Disorder• Tic Disorder

• Delirium, Dementia• Substance-Related

Disorder• Sleep Disorder• Antisocial

Personality Disorder• Relational problems

Clinical Significance

Clinically significant impairment or distress is the common requirement of

all mental disorder diagnoses


• Common criterion for all mental disorders

– “…causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”.

(DSM-IV, p.7)

Medical Necessity

Medical Necessity

• Definition Considerations:– A term of convenience that describes the

qualification criteria for:• Medi-Cal or insurance funding.

– The term is not used to distinguish between:• Mental disorders and general medical conditions

– Mental disorders can be related to physical or biological factors.

– General medical conditions can be related to behavioral or psychosocial factors or processes.

• Diagnosis of a qualifying condition

Mental Disorder

• Impairment in major area of life functioning, or

• Probability of significant deterioration, or• Probability of developmental delay


• Significantly diminish the impairment, or• Prevent deterioration of a major life

function, or• Allow appropriate developmental

progression

Amenable to Intervention

• Not responsive to physical healthcare treatment

Physical Healthcare Exclusion

CCR 9 1830.205

Educational Necessity

Educational Necessity

• Definition Considerations:– Mental Health disorder must adversely impact

educational performance.• Educational performance is a broader concept than

academic performance

– Mental disorder must have an impact on the ability of the child to function in the school environment by impeding:• Access to education, or• Ability to accomplish IEP goals

– Mental health treatment is available to any child with a disability if it is necessary for the child to benefit from their special education.

• Diagnosis of a condition that meets medical necessity

Mental Disorder

• Impedes access to education, or• Impedes the ability to accomplish IEP goals

(including therapy plan goals)

Educational Significance

• Provide access to education in the LRE• Enable progress in educational

performance

Amenable to Intervention

• Not responsive to physical healthcare treatment alone (medication)

Physical Healthcare Exclusion

Epidemiology

What is the incidence level of mental health disorders

among children?

An estimated 9% to 13% of American children and adolescents between the ages of nine to 17

have serious diagnosable emotional or behavioral health disorders resulting in substantial to

extreme impairment.(Friedman, 2002)

Center for Evidence Based Practice: Young Children with Challenging Behavior www.challengingbehavior.org

Of those children with serious diagnosable emotional or behavioral disorders, less than 4% are identified as ED eligible for special education services.

(Dataquest, CDE, 2009)

Over 15% of all students with disabilities (6-21) are taking psychotropic medications.

About 1/3 of all adolescent students with disabilities have been suspended or expelled.

(USDOE, 2005)


Of children with disabilities with serious emotional or behavioral disorders, only about 1 in 5 received mental health services under AB3632.

(Dataquest, CDE, 2009; LAO, 2010)

• Students with ED reported higher use of:

– alcohol (54%)– illegal drug use

(36%)– marijuana use (33%)– smoking (53%)

than all other disability categories.

(NLTS2, 2008)


• More than 50% of students with ED drop out of grades 9-12, the highest rate among all disability categories.

(U.S. Department of Education, 2002; 2006)


• At 2 years post high school, – 58% of youth with

ED have been arrested at least once, and

– 42% are on probation or parole.

(NLTS2, 2005).


It begins early…


Campbell (1995) estimated that approximately 10-15% of all typically developing preschool children have chronic mild to moderate levels of behavior problems.


Children who are poor are much more likely to develop behavior problems with prevalence rates that approach 30% (Qi & Kaiser, 2003).


Children who are identified as hard to manage at ages 3 and 4 have a high probability (50:50) of continuing to have difficulties into adolescence (Campbell & Ewing, 1990; Campbell, 1997; Egeland et al., 1990).


The correlation between preschool-age aggression and aggression at age 10 is higher than that for IQ.

(Kazdin, 1995)


• Early appearing aggressive behaviors are the best predictor of juvenile gang membership and violence.

(Reid, 1993)


• When aggressive and antisocial behavior has persisted to age 9, further intervention has a poor chance of success.

(Dodge, 1993)


Student must be identified as a student

with an emotional disturbance in order to

qualify for mental health services.

MYTH

Mental health treatment is available

to any child with a disability if it is

necessary to benefit from special education.

Mental Health Treatment by Disability

7%5%

21%

21%

32%

12%3%

Column1

AutID/MDEDOHISLDSLIOI/TBI/DHH/VI

Mental Health ServicesAs a Proportion of All Students with Disabilities

Impact of increased availability of school-based MH services: 2003-2011

2003 2004 2005 2006 2007 2008 2009 2010 20110.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

SELPA %

MH 206 176 279 279 454 490 554 600 687

SELPA Count 12,918 13,388 13,875 14,041 13,892 13,478 13,456 13,676 13,679

SELPA % 1.6% 1.3% 2.0% 2.0% 3.3% 3.6% 4.1% 4.4% 5.0%



2003 2004 2005 2006 2007 2008 2009 2010 20110.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

SELPA %

MH 206 176 279 279 454 490 554 600 687

SELPA Count 12,918 13,388 13,875 14,041 13,892 13,478 13,456 13,676 13,679

SELPA % 1.6% 1.3% 2.0% 2.0% 3.3% 3.6% 4.1% 4.4% 5.0%

Etiology

How do mental health disorders develop?

Environmental Factors

• Fear, anxiety and trauma affect the developing brain.

Environmental Factors

• Prenatal Substance Exposure

• Postnatal Exposure to Toxic Stress

Family Factors

• Harsh Parenting• Stressful Family

Life Events• Low Social

Support• Family Instability• Maternal

Depression


Depression Hurts• Children of mothers

who were depressed in their infancy are more likely to be delayed.

• Children of depressed mothers are at increased risk for:– Language delays– Internalizing behavior

problems– Depression, and mood

disorders in adolescence


Early Predictors

•Temperamental Difficulties

•Early Aggression

•Language Difficulties

•Noncompliance


Sobering Facts…


Young Children with Challenging Behavior

• Are rejected by peers

• Receive less positive feedback

• Do worse in school• Are less likely to

be successful in kindergarten


• Preschool children are three times more likely to be “expelled” than children in grades K-12

(Gilliam, 2005)


Faculty in higher education early childhood programs report that their graduates are least likely to be prepared to work with children with persistently challenging behavior (Hemmeter, Santos, & Ostrosky, 2004).


• Of the young children who need mental health services, it has been estimated that fewer than 10% receive services for these difficulties.

(Kataoka, Zhang, & Wells, 2002)


In a Typical Kindergarten Class in

California• 6 children will

manifest significant problem behaviors.

• Only 1 in every 2 classes will receive help.

• 4 children will continue to exhibit aggressive behaviors at age 10 with little chance for successful intervention

There are evidence-based practices that are effective in changing this developmental trajectory…the problem is not what to do, but rests in ensuring access to intervention and support (Kazdin & Whitley, 2006).


Services

What do evidence-based mental health treatment look

like?

Student must be identified as a student

with a disability in order to benefit from

mental health services.MYTH

Schools can choose to provide mental health services to any child

with significant mental health disorders.

Whether schools choose to or not, they

are still providing treatment.

Evidence-Based Instruction

Universal

Screening

Research-Based

Interventions

Monthly

Progress

Monitoring

Research-Based Interventions

Weekly

Progress

Monitoring

Universal Screening

School-Wide

Positive

Behavior

Strategies

Monthly Progress

Monitoring

Classroom

Strategies

Behavior

Contracts

Weekly Progress

Monitoring

Behavior

Support

Plan

Mental Health Treatment

• Individual• Group• Targeted Case Management• Collateral• Therapeutic Behavioral Services

(TBS)• Rehabilitation• Day Rehab/Day Treatment


• Psychotherapy– Cognitive-Behavioral Therapy (CBT)

• “Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.”

National Association of Cognitive-Behavioral Therapists (http://www.nacbt.org)


• Psychotherapy (Cont.)– Interpersonal Therapy– Exposure Therapy– Behavior Therapy– Parent/Child Interaction Therapy– Theraplay

Choosing the Right Treatment: What Families Need to Know About Evidence-Based Practices (2007) (

http://www.nami.org/Template.cfm?Section=child_and_teen_support&template=/ContentManagement/ContentDisplay.cfm&ContentID=47656

)



Providers

Who can provide these services?

Who Can Provide Mental Health Treatment?

• The answer is related to two factors:–Who is qualified?• Training• Experience

–Who Pays?


• Psychological assessments:– Licensed Psychologist– Credentialed School Psychologist– Licensed Educational Psychologist


• Psychosocial status assessments:– Licensed Clinical Social Worker– Licensed Marriage, Family Therapist– Credentialed School Social Worker– Credentialed School Counselor


• Individual and Group Therapy:– Licensed Physician/Psychiatrist– Licensed Psychologist– Credentialed School Psychologist– Licensed Educational Psychologist– Credentialed School Social Worker– Licensed Clinical Social Worker– Licensed Marriage, Family Therapist

Funding

How do you pay for it?

Prevalence Rates

• LAO stated that about 20,000 students with disabilities received AB3632 services.– 12 in 400 (3%)– 1 in 400 requires residential placement

(.27%)

Prevalence of MH ServicesAs a Proportion of Pupil Count

Pupil Count97%

MH Outpa-tient2.7%

Resi-dential

.3%

Percent

Pupil CountMH OutpatientResidential

Mental Health Funding

2010/112011/12

0

50

100

150

200

250

300

350

400

450

133 218.8

70

105 98.6

69 69

31 31

PreRefIDEACountySSSGF

Millions408 Million 417 Million

Funding Sources


MH ServicesMH Funding

0

1

2

3

4

5

6

Outpatient270

Outpatient2.134

Residential 30

Residential2.905

ResidentialOutpatient

Millions 5.04 Million

100,000 ADA, 10,000 students with disabilities, $5.364 million



2003 2004 2005 2006 2007 2008 2009 2010 20110.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

SELPA %

MH 206 176 279 279 454 490 554 600 687

SELPA Count 12,918 13,388 13,875 14,041 13,892 13,478 13,456 13,676 13,679

SELPA % 1.6% 1.3% 2.0% 2.0% 3.3% 3.6% 4.1% 4.4% 5.0%


MH ServicesMH Funding

0

1

2

3

4

5

6

Outpatient500

Outpatient3.953

Residential 17

Residential2.905

ResidentialOutpatient

Millions 5.60 Million

100,000 ADA, 10,000 students with disabilities, $5.364 million


2010/112011/12

0

100

200

300

400

500

600

700

133 218.8

70

10598.6

6969

3131

288

Medi-CalPreRefIDEACountySSSGF

Millions696 Million 417 Million

EPSDT Medi-Cal Funding

Federal50%

State41%

County9%

Percent

FederalStateCounty

$2.61 @ minute: $156.6 @ hour

LEA Medi-Cal Funding

Federal50%

State41%

County9%

Percent

FederalStateCounty

$44.46 @ hour

Funding Options

• MH Funding Only– Outpatient• $7,900

– Residential R/B• $96,800

• Provider– Schools

Funding Options

• MH Funding plus LEA Medi-Cal– Outpatient• $7,900 Non Medi-Cal• $8790 Medi-Cal


• Provider– Schools

Funding Options

• MH Funding plus EPSDT Medi-Cal– Outpatient

• $7,900 Non Medi-Cal• $11,030 Medi-Cal eligible


• Provider– Schools in partnership with:

• Community-based MH organization• County Department of Mental Health

Why should we do this anyway?

“The good of it is that you climb mountains.”

-John Dewey

Questions?

Documents

Psychotherapy and residential placement as related services