Tuesday, June 27, 2006

New York State's Medicaid problem in the schools


New York State decided this week to agree on some methods to address fraud as it relates to the $46 billion dollar Medicaid program. Don't for a moment think that the discussion was all high-minded and oriented toward saving the taxpayers money; one of the sticking points that the Dems finally had to let go was letting their trial lawyer buddies get a whack at the money pinata by allowing whistle-blower suits.

So now we have a more fully funded Medicaid Inspector General's office, which has been pinched by the feds to pony up on several billion dollars worth of payments. Of course this means that the state turns around and pinches the counties that administer the Medicaid program, asking for proof of all the services that were provided. Then counties turn around and pinch the municipalities and school service providers for their paperwork. The problem here is that municipalities and school providers probably didn't keep good enough records because they don't know how to integrate the demands of a Medicaid-based reimbursement model with an educational model. What does a widget counter in a school's budget office understand about keeping a medical chart? It is not the same as an 'educational' record at all.

The collective hue and cry that you now hear is from the municipalities that will never be able to meet these auditing paperwork demands. You may also hear the death cries of several million trees as copy machines in municipalities kick into overdrive to start sending their documentation to all of the counties. The other odd sound you may hear is the gleeful rubbing of hands together by bureaucrats in Albany, who now have mountains of paperwork to look at for corrective action audits and who are now guaranteed jobs well into the 27th century.

The sound that you will hear in the coming years is the groan of the taxpayer who will have to pay higher property taxes because the municipality won't be able to meet the burdensome documentation requirements of the Medicaid program - but the children will still require the services.

Undoubtedly we need to combat fraud, and we need to combat it aggressively. The problem is that no one is really interested in combatting fraud - they are really just trying to kill off the Medicaid reimbursement altogether for related therapy services in preschools. No one asked me, but here are some REAL solutions for getting the toothpaste back into the tube:

1. Develop a Medicaid eligibility check for the counties that bill Medicaid. This already exists in the 'private' sector as health providers have to swipe the Medicaid card to determine if the child is even eligible. This will prevent municipalities from billing the state's Medicaid system for children who are not eligible.

2. Move to an integrated Medicaid documentation and billing system. The framework for this system already exists and is being implemented as the "IEP Direct" system. Go to www.iepdirect.com to see how it works. If every provider and every municipality and every county was on this program they could share the data to the state or feds with the click of a button: daily notes, quarterly reports, etc. The only paper that should exist is the original signature sheet that providers would have to have signed each time that they provide a service to a child.

3. Initiate a reasonable debate on entry and exit criteria into the school related services program. Buffalo Schools and the now infamous speech therapy debacle are perfect examples on why we need a reasoned and evidence-based approach to criteria for receiving services.

It is unfortunate that these ideas are all probably just pipe dreams. However, I offer to work for New York State for FREE if they are interested in asking me to spearhead any of the above initiatives.

Now I will go wait for my phone to ring...

Saturday, June 24, 2006

Making sense out of child development

There was a very nice article in Parenting magazine about children's sensory development but as is typical of such articles it could have said so much more. So, in the interest of broadening the dialogue, I submitted the following for them to consider publishing:

Making Sense out of Child Development

When we bring our six month old children to the pediatrician’s office we can usually expect the doctor to ask if they are rolling over or sitting up. When our children are one year old the doctor asks about what words our children are saying and if they started walking. Now with new research that helps doctors better understand child development, you may begin hearing different questions during your well-child visits.

In addition to understanding how children develop typical motor and speech skills, researchers are learning about other aspects of development that make a big difference in children’s lives. Sensory skills are not a totally new area of scientific study, but developmental specialists are increasingly asking parents about this aspect of children’s development.

“It seemed that my child cried non-stop from the time we came home from the hospital up until she was six months old,” explains Julie, the tired parent of a colicky infant who was born four weeks premature. “Our baby didn’t seem ready to handle life outside of my body, and the doctors said that this is common in children who are born prematurely.”

Nature designed our brains to experience a warm, comforting, and protective environment in our mother’s body until the time we are born. When children are born prematurely, the brain is not always ready to interpret and process a bombardment of light, sound, and touch sensations. This bombardment causes parents like Julie to struggle to comfort their children who can’t yet tolerate all of the incoming sensory information.

Occupational therapists are health care professionals who are trained to understand the impact of sensory processing on child development. “The occupational therapist helped us understand that we can help our baby by making simple changes to our home routines,” explains Julie. “We learned to dim the lights and how to use swaddling and gentle touch pressure to calm our baby when she was upset. As parents we knew that taking her for a car ride was the only thing that calmed her; now we understand that it was the containment of the car seat and the gentle movement experience that helped her to calm down.”

“A baby’s nervous system can be influenced by small changes in experiences, in the environment, and even in interactions with parents,” says Christopher Alterio, an occupational therapist. “By giving parents information on how to provide a safe and nourishing sensory environment for their children, they become empowered to make positive contributions to their children’s development.”

Researchers now understand that all people have different levels of tolerance to sensory information, and the way that they respond to this information can influence their development and learning styles. A. Jean Ayres, an occupational therapist who pioneered the study of “sensory integration,” changed the way that child development is conceptualized and studied.

During development, children acquire different tolerances to sensory stimulation. Children who are born prematurely may develop strong sensory sensitivities, such as aversion to touch or to sound. Children who have chronic ear infections may have difficulty interpreting balance information. Some children develop sensory sensitivities and there doesn’t seem to be any specific cause that can be identified. Because good sensory processing is needed to develop a foundation for motor and speech skills, these children demonstrate how delays or differences in sensory processing may increase the risk of developmental difficulties.

Untreated sensory integration difficulties may cause children to have learning problems in school, to have constricted preferences in their play skills, and may have a negative effect on developing social skills. Treatment generally involves providing children with experiences where they can develop skill in organizing incoming sensory information and then demonstrate mature and skilled behavioral responses. For example, a child who fears movement experiences may not develop the motor skills for jumping and playing on the playground. Occupational therapy would encourage the development of skills by engaging the child in play so that the child is better able to interpret and respond to sensory information associated with balance.

Sensory skills are intricately linked to children’s behavior and development. So, don’t be surprised if you begin hearing developmental specialists ask you new kinds of questions like “What kind of sensory information do you notice is helpful for calming your baby?” or “Does your child have the ability to filter out noise and touch distractions in order to remain seated and complete homework or a meal?” When professionals ask these questions and have an expanded understanding of the factors that influence child development, they will be better able to help you and your child.

Monday, June 19, 2006

On the nature of Truth and getting steamrolled by a CSE

Today I had the opportunity to recall the 1980 presidential election. Perhaps this was the first election where I was politically cognizant. I recall watching debates and listening to candidates speak, but at that time I had no ability to understand how two different people could give two radically different perspectives on the same issue, both citing facts and figures during their explanations. At the time I assumed that certainly one of them had to be right, and the other had to be lying. Certainly one position was the 'Truth.'

I struggled through the entire campaign, not knowing what to think.

I don't have the same problems in trying to understand politics today. I understand now that people 'cherry pick' their facts, and that there are so many facts floating around nowadays that it is not difficult to find those that support your position. So, this picking of facts does not necessarily bring you any closer to Truth - and as soon as you realize this it is much easier to tolerate political debates.

I thought about this today while I was participating in a CSE meeting.

Factually, the child in question was failing many subjects. Factually, the child had difficulty achieving standards on statewide assessments. Factually, many evaluators outside of the district identified the presence of learning difficulties. Factually, the district has refused to identify this student as having a disability, although they did provide speech therapy, occupational therapy, and testing accomodations for many years.

I believe in a logic and evidence-based rhetoric, so I tried pointing out these facts to the committee. The chairperson responded, "We never provided special education services to this child."

"I'm sorry," I replied, but in fact you did provide speech therapy, occupational therapy, and testing accomodations to this child through the fourth grade, until he completed his statewide tests."

The chairperson is a skilled politician, and he responded, "Those were not special education services. They were academic support services. They were never provided under the auspices of the CSE."

Because the philosophical part of my brain reaches toward this concept of 'Truth' I tried to address his argument. Still, on some level he was technically correct. The CSE had historically refused to provide an IEP, but the school did provide some services to the child. By keeping the services off of an IEP there was never any accountability, never any goals, never any annual planning. "Call those services 'chicken soup,' if you prefer - the fact remains that the district identified on some level that this child had difficulties and provided services to address those difficulties."

The rest of the committee was unfortunately comprised of young teachers who didn't understand my perspectives on the transhistorical and intersubjective nature of 'Truth.' So there we were, two existent witnesses to the 'Truth.' The CSE chair continued, "Well we have a consensus opinion on this committee that this child has not ever received special education services and that he does not qualify for them at this time either."

"I didn't hear any consensus," I replied. "I just heard you talking." Some small part of me hoped that someone around the table studied Heidegger and the phenomenology of Truth, but I think they all just wanted to keep their jobs. One by one, they individually replied, "I agree with Mr. CSE Chair."

So Truth took a hit today. And a child continues to be neglected by the school. Parents beware: if you are looking for Truth, you won't always find it in your CSE meetings.

Tuesday, June 13, 2006

Eye to eye

Greg was pushed into my office, sitting in a wheelchair, and he didn’t make much eye contact. “Hi Greg,” I said, trying to find a way to elicit some response. He still didn’t look at me, but nodded his head in acknowledgement to my greeting.

Although Greg had limited eye contact he willingly shared the details of his story. Greg had hopes that he could make sense of things. Talking helped him, and he had hopes that things happened for reasons. He told me that he struggled with this on a daily basis. From my vantage point, at the time when we first met, I didn’t have many answers for him.

Greg joined the army when he was 18, hoping to find some structure and discipline in his life. He was a part of the wild crowd in a rural high school. In his opinion, the army was a form of escape - and an opportunity to change things. It was a blank slate, a do-over. Most importantly, he would earn money so that he could continue his education. It was never important to him in high school, superficially, but his heart told him that he needed an education in order to achieve the happiness that he was looking to find.

I am not sure how the army decides what ‘jobs’ or tasks a person will be trained for, but Greg was trained in transportation. There were many different kinds of ratings and rankings of what he could and could not drive, all of which escape me at this time. Greg was responsible for driving some General’s car. I am certain that he spent hours upon hours learning about safe transportation. how to escape safely if under attack and how to ensure personal protection of his occupants in the event of an attack. He performed his job well while in the army, and aside from occasional run-ins with MPs due to “having a little too much fun” as he would put it, his was a successful army career.

Greg knew that the army was not his place: it didn’t ‘speak’ to him, and he knew that all along. However, he was correct in seeing the army as a bridge: an opportunity to grow up, change his behavior, become more responsible, and make some money for college. And, while he was there, he did a good job and served an important function. He mattered. What he did mattered. Now it was time for him to go home.

There is a freedom associated with the removal of old roles. It is an excitement of being able to begin again. It was coming home after the army that was what he really looked forward to. Greg was free. After his wild days through high school that dead-ended his possibilities for college, he set himself up to succeed and had finally arrived at a point of change.

Speeding down the back roads of the rural area where he spent his entire life, rushing into his new future, Greg misjudged the degree of curve in the road. He was a skilled driver, no doubt trained in how to keep a car under control in adverse conditions, but training couldn’t supersede the laws of physics. And he had just broken the rules.

His car left the road at over 70 miles per hour, crashing headlong into the trees. Greg was free that day, also free from his safety belt, and although the car came to a stop his body did not, and he became a human projectile out of the front window.

Fast forward six months, after being in the hospital and treated for a C7 spinal cord injury, and after undergoing extensive rehabilitation. Greg was pushed into my office, ready to continue his outpatient rehabilitation now that he was living at home again. In the medical world, this would have been a real step toward independence, but in very real terms the farther Greg got from that last day of freedom, the more restricted and limited he perceived his own life. The medical people think that going home is progress. Greg saw going home as a cruel reminder of all the things that he would never be able to do again.

Functionally, Greg was restricted to the wheelchair. He only had limited use of his arms, and his hands were not fully coordinated. He did not have any ability to control his trunk, and he was developing strong and painful spasms in both his legs. Whatever future he thought he might have, whatever vistas he imagined his freedoms would bring him, now had to occur at the wheelchair level. Greg was not going to be able to face the world eye to eye, and so he didn’t want to face it at all.

Medical professionals are generally competent and caring individuals, but sometimes ‘professional training’ gets in the way of learning how to work with people. The people who receive services become body parts, each piece neatly divided among professional disciplines based upon traditional mythologies of what constitutes medical science. Of course Greg knew what to expect out of therapy; this was old hat to him. The occupational therapist would strengthen his arms, the physical therapist would stretch his legs, and the social worker would poke at his soul – as if all these parts were somehow really disconnected from each other. This is what he knew ‘rehabilitation’ to be. Patients buy into this model and tend to be quite cooperative with the medical tradition.

Lynn was his physical therapist, and she followed the plan of care that came from the rehab facility. It said that Greg was to work on lower extremity range of motion and wheelchair mobility. So that is what she did. The physical therapist depended upon me working with Greg on upper extremity strengthening, as this would allow him the strength to maneuver the wheelchair with greater skill – to pop wheelies over curbs and so forth. We began to have conflicts, because I wouldn’t follow the treatment plan.

It all started when Greg came into therapy quite excited one day, and told Lynn that he tried to stand up. Apparently, he wheeled the wheelchair up to the washing machine, waited until he had strong extension spasms in his legs, and then pulled himself so that his trunk was lying on top of the machine and his feet were in partial contact with the floor. He was standing. STANDING.

“Well that is the most foolish thing I have ever heard of,” Lynn told him. “You are likely to fall and break your neck all over again. That is NOT standing; that is playing with the extensor tone in your legs. You are lucky you didn’t kill yourself.” Sandy, the aide who worked in the therapy departments, relayed this story to me as she wheeled a dejected Greg into occupational therapy.
We sat alone in the room and I stated, “So I hear that you’ve been trying to stand at home?” I like to hear things from the source and was interested in his motive. Greg replied, “Don’t worry, I was already yelled at about it, so I won’t be trying that again anytime soon.” I thought for a moment, and considered the implications of contradicting a colleague’s instructions to a patient and replied, “You know what Greg? I can’t believe that you were able to do that. And it obviously made you feel good to try. So why don’t you keep on doing it, and if you fall and break your neck at least you will kill yourself on your own terms.” I was half-serious, trying to make a point to him and offer him some opportunity for control. In that life of his that spun madly out of control, I tried to give him a choice. For the first time ever, he raised his head and looked me in the eye, and with a broad smile on his lips he said, “Thank you.”

I had made a commitment to a course of action that could have gotten me into serious trouble, and I spent a lot of time praying that Greg wouldn’t fall at home. So I asked him to only try his standing maneuver when someone else was around. I instructed him quietly in how to wear the transfer belt while he attempted it so someone could easily grab onto him in case he fell. We developed a code for it, as he knew that the PT would never concur with his home activities: we called it the ‘GSHP,’ for ‘Greg’s Secret Home Program.’ He was supposed to be practicing wheelies, but the last thing in the world that Greg wanted was to become proficient at using a wheelchair. He tried a few more times to convince the PT that his goal was to stand, as did I, but it fell on deaf ears. “Greg has a C7 spinal cord injury, and he will never stand again. We are not doing him any favors by allowing him to think that he might.” Talking to that therapist was like talking to a brick wall, although I know that she was doing what she believed was best for him.

That, perhaps, was the crux of the matter. What she believed was best for him. It didn’t matter what Greg thought was best for Greg. But I knew that I could give that to him, easily. “How’s that GSHP?” I would ask as I watched him roll through the hallways. “Better every day” he would tell me.

Diligently, several times a day, Greg pulled himself up against that washing machine and ‘stood.’ And each day it became easier for him. After a week or so he told me, “I notice that when I stand the spasms in my legs seem to go away, and I think I am able to move my left leg a little bit.” The MD noticed that the spasms were decreasing also, and ordered a decrease in the amount of Lioresal he was on. That was it; I knew that I would have to come clean.

I held a conference call with the PT, social worker, and the MD that day, telling them what the ‘GSHP’ was. I went into detail on how I thought Greg might have some residual function underneath all of that muscle tone, and how he derived significant psychological benefit through his efforts. The MD and social worker were guarded; the PT thought I was nuts. Although I was not told to cease and desist, I was certainly told that I was on my own, at least until there was some more concrete evidence that what I was saying was true. They did not want to participate in what was perceived as possible cruelty in unrealistically building his expectations. From their standpoint, professionals always know more than patients. And people who have spinal cord injuries like Greg’s don’t stand.

Now that the proverbial cat was out of the bag, I put Greg into a device called a standing box. It is like strapping someone into a standing position. I would have preferred to use the standing table, which would have been more appropriate at the level he was functioning, but that was a piece of PT equipment, and they wouldn’t let me use it. So Greg got strapped into the standing box, his knees blocked into an extended position. As he lacked the trunk control to maintain himself upright, he simply leaned forward onto the tray in front of the standing box. It was crude, but effective.

“You are eye to eye with me, Greg. You better look at me when we talk!” I would yell at him when he came into therapy. And he did. And each day that he stood in that box, the spasms in his legs decreased and the atrophied muscles of his trunk came back to life. Soon he was able to prop himself up on his forearms, and then his extended arms. And then with only one arm. Greg was tall again.

What did we do while he was in that standing frame? In the beginning we just played cards, as all he could do was support his upper body weight against the tray. But as his trunk strength improved, he started doing other things that he enjoyed: putting together models, and even playing catch. It took months, but he was eventually able to participate in some dynamic standing activities, reaching away from his body while he was catching and throwing.

During this time, he was discharged from PT. He had achieved his “maximal functional potential,’ according to the discharge note.

“I’m sick of this box,” he told me one day. “I think I can stand without it.”

“Go for it, Greg, who am I to tell you what you can’t do?”

That day we stole a walker from the PT gym and with help he pulled himself to a standing position, with an erect spine. We practiced transfers from a sitting to standing position and back to sitting. On and off a toilet. In and out of a car. “That’s it,” he told me. “I just have to get a car.”

I went car shopping with Greg later that week, and we found him a car and had it adapted with hand controls. We also had a device installed that stored his wheelchair on top of the car and would bring the chair down to the ground with the touch of a button. “Don’t get all excited about the technology,” he would tell me. “I don’t plan on needing that stupid chair forever.”

Greg came in excited one day and told me, “I’ve been working on a new GSHP. Watch this!” I was amazed, but he stood up with the walker, and ever so slightly raised each leg and marched in place. The right leg was dramatically weaker than the left, but he was doing it. “Time to go to physical therapy again Greg. I shouldn’t be the one to teach you how to walk.” I asked the physiatrist to write an order for a right AFO – ankle foot orthosis – so that Greg could try to walk. She hadn’t seen Greg in a while, and thought it would be a waste of time. So I made one myself, and sent him up to her clinic with my crude example. It was ugly, but it worked. Seeing that it had benefit for him, she ordered the AFO, and re-referred him to PT for gait training.

Greg started PT soon after that, and before I knew it he was walking up and down the hallway in a walker. When it turned to Spring, he would walk from the car to the waiting room. It was arduous, but he could do it.

“I’m going to college,” he announced to me one day. “I have all that army college money sitting there; I might as well use it.” Greg didn’t need me any more. He was doing the things he needed to do. And the things he wanted to do. His body wasn’t the same, but he wasn’t restricted to only being in the wheelchair. All of the occupations that he thought he lost were found again, and he finally was able to see the freedom that he thought he lost forever. And he was able to see it eye to eye.

Thursday, June 08, 2006

Asperger's Syndrome: A primer for occupational therapists

CLASSIFICATION/DIAGNOSIS RESEARCH

Asperger’s Syndrome was first described by Hans Asperger who identified a group of his patients who had difficulties with social skills but intact cognitive ability (Asperger, as cited in Klin & Volkmar, 1997, p.94). Asperger and Leo Kanner were reportedly unaware of each other’s work (p. 95) which respectively focused on similar clinical signs, although those signs were of different degrees of severity. Asperger’s description of autistic psychopathology was focused on higher-functioning, verbal, school-aged children while Kanner’s description was more focused on lower-functioning children (p. 95).

Wing’s (1981) accounting of Asperger’s Syndrome increased familiarity and interest in the diagnosis in the United States; since that time there has been a steady increase in the number of people identified as having the disorder. Actual prevalence is difficult to ascertain because of the constantly evolving nature of the diagnostic criteria. Several authors (Wing & Potter, 2002; Fombonne & Tidmarsh, 2003) indicate that most of the reported rise in prevalence is due to changes in diagnostic criteria and increasing awareness and recognition of autistic spectrum disorders.

Current DSM-IV-TR (2000) diagnostic criteria for Asperger’s Syndrome include qualitative impairment in social interaction and restricted repetitive and stereotyped patterns of behavior, interests, and activities. The disturbance must cause clinically significant impairment in social, occupational, or other important areas of functioning. Additionally, there are no clinically significant language or cognitive delays in the first three years of life (see Appendix for full details).

Several conditions have been identified as having a high level of co-morbidity with Asperger’s Syndrome. Mood disorders have been co-morbidly identified with Asperger’s Syndrome (Klin & Volkmar, 1997, p.105). However, Duggal (2002) warns that traditional methods of medication management may not be appropriate for children who have Asperger’s and that further research is necessary in order to more fully explain what treatments are best and why those treatments work. Schizophrenia has been identified as being linked to Asperger’s in several single-case studies but there are still questions about the validity of this determination (Klin & Volkmar, 1997, pp.104-105). Gillberg & Billstedt (2000) identify that co-morbid conditions are to be expected with autistic spectrum disorders and that weaknesses in the diagnostic and classification manuals may contribute to this confused pattern of co-morbidity. They advocated for stricter diagnostic classifications.

There may be identifiable patterns of neuropsychological profiles in children who have Asperger’s Syndrome that are of particular interest to occupational therapists. In a study of sensory processing abilities, children who have Asperger’s Syndrome scored significantly different than matched controls (Dunn, Myles, & Orr, 2002). Rinehart, Bradshaw, Brereton, & Tonge (2002) have suggested that the time that children develop laterality may be linked to the emergence of some forms of autism. Another study (Weimer, Schatz, Lincoln, Ballantyne, & Trauner, 2001) identified that children who have Asperger’s demonstrate poor performance on tests of practic and balance functions and tend to score better on visual-motor tasks. Several studies indicated that clumsiness is a common finding in children who have Asperger’s (Ghaziuddin, Butler, Tsai, & Ghaziuddin, 1994; Manjiviona, & Prior, 1995; Iwanaga, Kawasaki, & Tsuchida, 2000) although there does not seem to be evidence that clumsiness itself can distinguish between Asperger’s and other forms of autism.

The ICD-10 (1992) specifically states that Asperger’s Syndrome is a “disorder of uncertain nosological validity.” The validity of AS has been and continues to be controversial (Wing, 1991 as cited in Klin & Volkmar, 1997; Klin and Volkmar, 2003). Considerable debate continues regarding the diagnostic validity of Asperger’s Syndrome. Klin and Volkmar (2003) identify co-morbidity as a diagnostic problem for this disorder. Despite these ongoing questions, there is little doubt that people who have the disorder have multiple needs that require multidisciplinary intervention.

ETIOLOGY AND OTHER CONCERNS

Although there are no definitive studies identifying genetic factors as being responsible for Asperger’s, case studies and family studies indicate that there may be an increased incidence of both autistic disorder and Asperger disorder in the relatives of people who have Asperger disorder (Volkmar, Klin, & Pauls, 1998).

A small study was conducted comparing obstetric factors between children identified as having Asperger’s and those having high-functioning autism (Ghaziuddin, Shakal & Tsai, 1995). The children who were diagnosed as having Asperger’s were more likely to have been born outside the optimal age group (twenty to thirty years old) and also tended to have lower APGAR scores at one minute. This study has not been replicated.

Very little has been published regarding the role of the immune system and biochemical interventions for any form of autistic spectrum disorder. Danczak (2000) emphasizes the biochemical approach based on immunology. He states that food allergy is not important and that it is only a symptom of an underlying unstable immune system that needs intervention. He promotes a chemistry-based therapy that is supplemented by a behavioral program. However, this approach has not been published in any peer-reviewed journal despite its wide popularity on the Internet. Croonenberghs, et.al. (2002) identified that there were significant differences of IgG concentration levels in people who have autism that may indicate the presence of an underlying autoimmune disorder and/or enhanced susceptibility to infections. Contrasting this finding is that despite anecdotal reports that impaired autoimmune function can cause autistic spectrum disorders, research indicates that there is strong evidence against the hypothesis that MMR vaccination and associated immunopathology causes autism (Madsen et.al., 2002). The degree to which immunological factors had any impact on the etiology of his condition also remains very unclear.

Because of the combination of factors including questionable nosological classification of Asperger’s Syndrome combined with no clearly identified etiology of the disorder as a whole it is difficult to determine the precise etiology of the condition.


Appendix

Diagnostic Criteria for Asperger's Syndrome in the DSM-IV-TR

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction; failure to develop peer relationships appropriate to developmental level; a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g.,by a lack of showing, bringing, or pointing out objects of interest to other people); lack of social or emotional reciprocity

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus; apparently inflexible adherence to specific, nonfunctional routines or rituals; stereotyped and repetitive motor mannerisms (e.g.,hand or finger flapping or twisting, or complex whole-body movements); persistent preoccupation with parts of objects

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.



References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Revised (DSM-IV-TR). Washington, DC: Author.

Croonenbergs, J. Wauter, A., Devreese, K., Verkerk, R. Scharpe, S., Bosmans, E., et.al. (2002). Increased serum albumin, gamma globulin, immunoglobulin IgG, and IgG2 and IgG4 in autism. Psychological Medicine. 32(8), 1457-63.

Danczak, E.M. (2000). The Biochemical Approach to the Management of Autism Spectrum Disorders. Autism Today. Retrieved June 21, 2003, from http://www.autismtoday.com/biochem.htm

Duggal, H.S. (2002). Bipolar disorder with Asperger's disorder. [comment]. American Journal of Psychiatry. 160(1), 184-185.

Dunn, W., Myles, B.S., & Orr, S. (2002). Sensory processing issues associated with Asperger Syndrome: A preliminary investigation. American Journal of Occupational Therapy, 56, 97-102.

Fombonne, E., Tidmarsh, L. (2003). Epidemiologic data on Asperger disorder. Child and Adolescent Psychiatric Clinics of North America, 12(1), 15-21.

Gillberg, C., Billstedt, E. (2000). Autism and Asperger syndrome: coexistence with other clinical disorders. Acta Psychiatrica Scandinavica. 102(5), 321-30.

Ghaziuddin, M., Butler, E. Tsai, L. & Ghaziuddin, N. (1994). Is clumsiness a marker of Asperger Syndrome? Journal of Intellectual Disability Research, 38, 519-527.

Ghaziuddin, M., Shakal, J., & Tsai, L. (1995), Obstetric factors in Asperger Syndrome: Comparison with high-functioning autism. Journal of Intellectual Disabilities Research, 39, 538-543.

Iwanaga, R., Kawasaki, C., & Tsuchida, R. (2000). Brief report: Comparison of sensory-motor and cognitive function between autism and Asperger Syndrome in preschool children. Journal of Autism and Developmental Disorders, 30, 169-174.

Klin, A., & Volkmar, F. R. (1997). Asperger’s Syndrome. In D. J. Cohen & F. R. Volkmar (Eds.). Handbook of Autism and Pervasive Developmental Disorders (2nd ed., pp. 94-122). New York: Wiley & Sons.

Klin, A., & Volkmar, F. R. (2003). Asperger syndrome: diagnosis and external validity. Child and Adolescent Psychiatric Clinics of North America, 12(1), 1-13.

Kranowitz, C.S. (1998). The Out-of-sync child. New York: Perigee Books.

Madsen, K.M., Hviid, A., Vestergaard, M., Schendel, D., Wohlfahrt, J., Thorsen, P., et.al. (2002). A population-based study of measles, mumps and rubella vaccination and autism. New England Journal of Medicine, 347(19), 1477-1488

Manjiviona, J & Prior, M. (1995). Comparison of Asperger Syndrome and high-functioning autistic children on a test of motor impairment. Journal of Autism and Developmental Disorders, 25, 23-39

Rinehart, N.J., Bradshaw, J.L., Brereton, A.V., & Tonge, B.J. (2002). Lateralization in individuals with high-functioning autism and Asperger's disorder: a frontostriatal model. Journal of Autism & Developmental Disorders. 32(4), 321-331.

Volkmar, F.R.,Klin, A., & Pauls, D.L. (1998). Nosological and genetic aspects of Asperger syndrome. Journal of Autism and Developmental Disorders, 28, 457-463.

Weimer, A.K., Schatz, A.M., Lincoln, A., Ballantyne, A.O., & Trauner, D.A. (2001). “Motor” impairment in Asperger Syndrome: Evidence for a deficit in proprioception. Journal of Developmental and Behavioral Pediatrics, 22, 92-101.

Wing, L. (1981). Asperger’s Syndrome: A clinical account. Psychological Medicine, 11, 115-129.

Wing, L. & Potter, D. (2002). The epidemiology of autistic spectrum disorders: is the prevalence rising? Mental Retardation & Developmental Disabilities Research Reviews. 8(3), 151-161.

World Health Organization (1992). International Classification of Diseases, 10th edition (ICD-10): classification of mental and behavioral disorders. Geneva, Switzerland: Author.

Tuesday, June 06, 2006

Very random notes from LA

OK, I should have known that it was going to be a very random day. I saw Sigmund, tied to the back of a pickup truck, entering I-10 heading toward LA from Santa Monica. I am not lying.

If you have any idea who Sigmund is, then you truly are my compadre.

Anyway, because of a confluence of events I had the opportunity to do some random occupational therapy surfing, and found a few blog entries that were noteworthy and that I wanted to share.

The first was this story about a family who struggled with the cost of occupational therapy services. It seems like they had a reasonable outcome, but I wince when I hear that insurance has denied coverage. I don't know if I am particularly lucky in my geographic region, but I have virtually no denials for the OT services that we provide. However, we are also keenly aware that insurance companies avoid reimbursement for intervention that they deem 'experimental -' as is their policy with sensory integration. In practice, we don't exclusively use sensory integration techniques - and neither do most therapists - so we avoid using those labels altogether. I hear about this issue frequently, and it just makes me wonder if therapists are labeling their services as 'sensory integration' to the insurance companies when it is not necessary or fully accurate to do so. Also, we would have helped this family interact with the school system, which provides free services if the problems are educationally related. That way they could have had a free evaluation, at a minimum.

Anyway, story 2 is a chapter in a book about a mom's impression of occupational therapy that she experienced in an inpatient psychiatric setting. She expresses that as she was already dehumanized by the whole hospital experience she did not feel dehumanized by occupational therapy - and that she wanted to "add to this library of lunatic literature by art." It is an interesting depiction of the service from the end-user perspective, and probably understandable to a lot of OTs. It made me feel sad and angry at the same time.

Story 3 was just plain frustrating. The author describes her experience of being evaluated by and occupational therapist after a surgery. The therapist sounds like she is strongly focused on the occupation of evaluating patients -but ironically the patient goes on to discuss the nature of occupation itself! Reflecting on the therapist's strong interest in surgical scars, she writes, "It made me think about how we all have jobs or hobbies as individuals and our training or passions allow us to derive pleasure in things others don't see." The PATIENT then goes on to ask others in her blog "about your job or hobby. What part of it do people outside the field/interest look at as strange or boring but gives you great pleasure?" This made me chuckle, as I would have preferred hearing that the occupational therapist was just as interested in the patient's occupations as she was interested in the scars. This entry wins "Irony of the Day Award."

Anyway, such was my day. How was yours?

Sunday, June 04, 2006

California's Proposition 82 and the slow creation of a caste society

The decision on universal pre-kindergarten is coming to a head in California. Voters will decide on this controversial issue on June 6th.

Proposition 82 establishes a right to voluntary preschool for all four-year old children. The program is funded by a 1.7% tax on individual incomes above $400,000 or $800,000 for couples. More details on the proposal can be found here.

Supporters of the proposition state that Prop 82 gives a free, high quality preschool education to every four-year old in California. They claim that it will provide trained, credentialed teachers in every classroom, more parental involvement, and strict accountability and enforcement to ensure that every dollar is dedicated to preschool.

Opponents of the proposition state that Prop 82 will not appreciably increase preschool participation and that turning over control of preschool to the state will result in a less efficient and more expensive program. They state that the money would be better spent on improving current K-12 programs.

In a previous entry I asked if people could ever believe that the state could administrate and manage an effective program, and would they be willing to pay? If history is any indicator, the government is not capable of running an efficient preschool program. You can read more here about issues I have previously discussed with program overlap between Head Start, Even Start, and IDEA services.

There is no doubt that we need to have high quality preschool and school age programs, but I am just not convinced that we have been able to accomplish this goal. We need to extricate ourselves from the current program disasters and re-invent these programs with more efficient models. Handing over control to a state government just creates another layer of confusion in California and will continue to foster a two-tiered system of services.

While flying to LA this morning I sat next to a mom on the plane who told me that the California school system was a nightmare. "The only kids in public schools are those whose parents think that it served them well enough, or if they don't have the money to escape." She sends her preschooler to an exclusive private school but told me - "You know, I don't mind that we haven't implemented a voucher system yet because if I support the local school through taxes I suppose that it will still support my property value. So I still receive some benefit, even though my child will never attend the public system."

Of course, she lives in an exclusive community and can afford $25,000 a year tuition on her child's private school. Although I don't know her financial situation exactly, I wouldn't be surprised if she will be one of the people taxed under Prop 82.

So there is a population of the most wealthy people who figure they can cough up a few thousand dollars more in taxes, and they don't care. Their children go to private schools anyway.

Obviously, we are just creating a caste society. The wealthy people go to their own schools. They also fund the public schools - administrated by the government, and rife with bureacratic inefficiency. So unless you can break through to the level where you can also afford that private school, I suppose you are stuck with the public system.

Someone help the middle class, because the teacher unions and big government will make sure that a voucher never gets into their hands. In the meantime, those kids pay the biggest price - stuck in an inefficient government-run system that can't get out of its own way to accomplish real education.

Saturday, June 03, 2006

The ABC Therapeutics Road Show

I am on a west coast road trip that will extend to 6/14. Since this trip has virtually nothing to do with my own choices I thought it was fitting to start off with this picture.

Actually I really am starting off here in San Francisco, where I will remain until Sunday - and then I am off to Santa Monica for next week.

I have mastered the art of long distance supervision so I will be able to keep things running through a combination of cell phone interactions and of course relying on the only employee who never complains no matter how much gets heaped on her plate.

I'll try to update here regularly to record my activities...