# Presentation: 493767

## Comprehensive and Coordinated Systems of Care

- The Developmental Neuropsychiatry
- Program
- Louisiana Office of Mental Health
- Cheryll Bowers-Stephens,MD,MBA

## The Developmental Neuropsychiatry Program (DNP)

- System of Care serving  youths who have both a psychiatric illness and a developmental disability
- The program has been in operation for over 10 years
- It was designed for youth that have not responded to traditional mental health and developmental services

## History of Program Development

- Youths with Mental Illness and Developmental Disabilities were falling through the cracks and clogging up isolated service systems ill-equipped to address their needs
- Unacceptable given the prevalence: mental illness occurs in a higher percentage of persons with DD (3-6 times the rate in the general population)
- Rates of physical and sexual abuse are higher

## History of Program Development

- Unique Challenge to service systems both with regard to diagnosis and treatment
- Correctly diagnosing MI in persons with DD is difficult
- Mental Health professionals are ill-equipped to make correct diagnosis
- Repeated misdiagnoses resulting in repeated ineffective treatments and ineffective pharmacotherapy

## System of Care Overview

- Goal is to break the cycle of multiple hospitalizations and institutionalization by promoting community inclusion.
- Outpatient assertive community treatment program serving ages 2 to 22.
- Inpatient adolescent unit serving ages 13 through 18.
- ICF-MR Waiver Demonstration Project
- Long term follow up

## DNP Service Model

- Learning-based, structured teaching approaches
- Encourages healthy, prosocial behaviors promoting social inclusion and reintegration or stabilization in the community
- Therapies adapted to the cognitive abilities and developmental needs of the individual.
- Family and School integrated into treatment

## DNP Service Model

- Treatment promotes social skills development and builds upon the youths’ personal goals and competencies
- Promotes interagency support and coordination

## Evidence Based Practices

- Integration of behavioral and pharmacological interventions
- Functional Analysis and Behavioral Modification(Applied Behavioral Techniques; Cognitive Behavioral Therapy; Classical Behavioral Therapy)
- Continuity of Care
- Modified Linehan Approach (Dialectical Behavioral Therapy)
- Relaxation Training

## Prevalence of Psychotropic Usage by Drug Class (Prior to Admission)

| Drug Class	 | Percentage |
| --- | --- |
| Neuroleptics		
Mood Stabilizer	
Anti-Depressants (non-SSRI)    
SSRI’s	 	
Anti-Depressants (combined)     
Psychostimulant
Anxiolytics
Anti-Convulsants
Anti-Hypertensive | 85.0%
73.5%
54.4%
55.8%
78.2%
46.3%
24.5% 
16.3%
36.1% |

## Prevalence of Psychotropic Usage by Drug Class (Prior to Admission)

| Drug Class	 | Percentage |
| --- | --- |
| Neuroleptics		
Mood Stabilizer	
Anti-Depressants (non-SSRI)    
SSRI’s	 	
Anti-Depressants (combined)     
Psychostimulant
Anxiolytics
Anti-Convulsants
Anti-Hypertensive | 85.0%
73.5%
54.4%
55.8%
78.2%
46.3%
24.5% 
16.3%
36.1% |

## Not Uncommon Errors in Diagnosis

- Psychosis based solely on invalid self-report of auditory hallucinations
- PTSD diagnosed as Psychosis
- PTSD diagnosed as Conduct Disorder
- Bipolar Disorder diagnosed as Conduct Disorder

## Slide 12

## Slide 13

## Slide 14

## AACAP Work Group/1999

- Replacement Behavior Training
- Social Skills Training
- Disability Education
- Individual, Group and Family Therapy
- Behavioral Interventions
- Establish concrete goals
- Treatment delivered by clinicians with experience working with MR
- Concrete emphases (developmentally appropriate)

## AJMR – Consensus Guidelines (May 2000)

- Applied Behavioral Techniques
- Cognitive Behavioral Techniques
- Classical Behavior Therapy

## Behavioral Treatments of Depression

- Increasing Pos. Activities/Stimulation (Lewinsohn)
-  Increase Fun and Success Experiences
- Operant Approaches
- Positive Statements
- Engagement in Activities
- Social Skills Training
- Cognitive Behavior Therapy
- Modifications

## MODIFIED DAILY MOOD LOG

| Sad Thoughts  | Happy Thoughts  |
| --- | --- |
| Nobody likes me.
I don’t have any friends.

I’m fat and ugly.  | I guess when I think deep down inside that there are a lot of people who do like me. (Lists them).

Other people say these things are nice about me.
My hair, eyes, I’m pretty when I smile my eyes my personality |

## Summary/CBT for persons with MR

- Simplify Basic Model of CBT
- Use Simple Explanations
- Use Simple Language
- Teach to Challenge Distorted Thinking
- Teach to Distract Self with Positive Cognitions
- Simplify Task by Refraining from Teaching Categories of Cognitive Distortions

## Behavioral Treatments of Anxiety Disorders

- Phobia Studies
**Peck (1977) and Jackson (1983)**
- Standard Systematic Desensitization
**Establish Fear Hierarchy**
**Teach SUDS Rating**
**Introduce Counterconditioning Element**
**Introduce Exposure**
- Modifications for MR
**Participant Modeling****	**
**Reinforced practice **
**In Vivo Exposure**

## Behavioral Treatments of Anxiety Disorders (cont’) Obsessive Compulsive Disorder

- Case Example
**Gradual Negotiated Change**
**Exposure with Response Prevention**
**Positive R+ (Social/Tangible) of Goal Attainment**
**Generalization to Home Setting**

## Hamilton (1994) – Managing Acute Distress
Relaxation training/Self-calming strategies
Removal from triggers
Cognitive Distraction

Protocol III
Counterconditioning Strategies
Imaginal Flooding
Planning for Possible Triggers
CBT

- Relaxation training/Self-calming strategies
- Removal from triggers
- Cognitive Distraction
- Protocol III
- Counterconditioning Strategies
- Imaginal Flooding
- Planning for Possible Triggers
- CBT

**Behavioral Treatments of Anxiety Disorders (cont’) ****Post-Traumatic Stress Disorder**

## Borderline Personality Disorder

- Linehan – Psychosocial Skills Training for Borderline Personality Disorder
- Emotion Regulation Skills
- Interpersonal Effectiveness Skills
- Distress Tolerance Skills
- Mindfulness Skills

## AACAP Work Group Commentary (1999)

- Some clinicians target symptom suppression without regard for habilitative functioning
- Informed consent often overlooked
- Medication often is not integrated as part of comprehensive treatment plans
- Medications often don’t match diagnosis
- Polypharmacy is overused
- There is often no active monitoring for side effects

## Outcomes

- 207 patients served
- 184 served inpatient
- 60 served outpatient
- 23 outpatient only
- 123 inpatient only
- 37 both inpatient and outpatient

## Outcomes

- 56% male and 44% female
- Mean age at admission is 15
- At admission 50% state custody

## Diagnosis

- 75% have MR
- 25% Autism, PDD, LD, or met federal definition of DD
- 14% had autism or a PDD
- 35% mood disorder
- 25% anxiety disorder with PTSD most common
- 23% ADHD and 4% with thought disorder

## Slide 28

| Level of Care | Initial (177)
 | Current  (131) |
| --- | --- | --- |
| Supported/IND  | 6     (3%) | 27     (21%) |
| Parent/Family | 86   (49%)  | 51      (39%) |
| Foster Family | 25   (14%) | 5         (4%) |
| Group Home | 34   (19%) | 21        (16%) |
| Residential | 6     (3%) | 6          (5%) |
| Hospital | 6     (3%) | 5           (4%) |
| Detention | 3     (2%) | 4           (3%) |
| ICF-MR | 7     (4%) | 11          (8%) |
| Eloped | 4      (2%) | 0 |
| Deceased | 0 | 1            (1%) |

## Outcomes

- 86% in community/non-institutional settings
- 67% no re-hospitalization
- 74% have not served time in a correctional facility
- 88% have not been admitted to an ICF-MR
- 50% have had none of the above

## Juvenile Justice Involvement in DNP Youth

| 147
INPATIENTS | Pre-Treatment | Post-Treatment |
| --- | --- | --- |
| Legal Involvement | 57% | 36% |
| Arrests | 46% | 26% |

## Mental Health Treatment can Reduce Arrest Rates in this Population

- Post treatment 90% of these youth had either no jail time or no jail time less than 30 days.

## Lessons Learned

- These youth are at risk for substance abuse and dependence. Need specialized services.
- These youth are at risk of entering the juvenile justice system and adult corrections.
- These youth are institutionalized as adults.
- Failure to meet the needs of these youth is the most costly mistake that policymakers at both the state and federal level make.