Pa and Chapter regulations

[Guest guest]

Some have asked me to send a sample letter. Below is a copy of the letter

that I am sending. Please pass to those who you think might profit from

it. Joe

______________________________________________________________________________

Suzanne Love

Director

Bureau of Policy, Budget, and Planning

Commonwealth of Pennsylvania

Department of Public Welfare

P.O. Box 2675

burg, PA 17105-2675

Ms. Love,

In review of the 1154 draft regulations for Behavioral Health

Rehabilitation Services, I was both struck and quite pleased with the

department's efforts to gain control over a system that is by all accounts

costly and misutilized. In particular, I remain pleased with the overall

tightening of the program and wish that such measures had been in place in

1994, when these services were added to the fee schedule. I still feel

that it is extremely sad, that 12 years post vs. Snider that we have

no clinical outcome data on behavioral health rehabilitation services as a

rehabilitation program.

In particular, I remain pleased that the behavior specialist

position will require certification in behavioral analysis or other

national certification in behavior modification, since I believe that this

is critical to increasing the overall quality of behavior modification

statewide in this program. Also, I remain quite pleased that the

department has tightened the supervision requirements for mobile

therapists and required that some one who had therapy credentials hold the

position. It has been my dismay that in Philadelphia it appears that the

mobile therapists have become glorified case managers. Then again, it

seems that everyone in Philadelphia wants to manage cases and no one wants

to treat children. This said, my below comments should not be taken as a

detraction from my overall agreement with the movement toward greater

accountability and increased treatment integrity but as a serious effort

to help the department to earnestly improve the document and to avoid

unnecessary legal contesting of its contents.

Problems remain in the 1154 draft regulations. The most

troublesome is the failures to include several interventions in section

1154.11 (d) that by themselves constitute evidence-based treatments that

can and should be performed by a TSS worker. This is particularly

troublesome for the department for OBRA89 states that states who wished to

qualify for federal finical participation, must include all medically

necessary treatments whether or not those treatments are included in the

state plan. Well-established treatments would surely run the risk of legal

contest. The obvious missing ones are covered below.

The U.S. Surgeon General (Health and Human Services, 1999) has

listed contingency management as a well-established and efficacious

treatment for ADHD (p. 147), anxiety disorders (p. 162), and disruptive

disorders (p. 166). Given the conclusion of the Surgeon General, it would

appear unwise that a treatment plan containing such an intervention would

not meet the state standards for an acceptable TSS practice. Indeed, a

legal challenge of this type could render the hard work in this document

as to restrictive and harmful to children's treatment.

In addition, the building of social skills, problem solving

skills, and self-control skills are all deemed as probably efficacious in

the U.S. Surgeon General's report for the treatment of depression (see

page 156) and suicide (p. 157). Yet a treatment plan, which a TSS worker

is solely using, these techniques would not be considered acceptable to

the department given section 1154.11 (d). This again, could present a

formidable legal challenge to the document.

Fortunately the above represent the only treatment examples that I

could find so it does not create to much of an effort for the department

to revise the document. However, other problems exist.

A serious problem exists in 1154.12. In particular number 14,

stating that " habilatitive " services are not covered. The definition of

" habilitative " services needs a clearer definition. The vernacular is to

" give the ability. " Habilitation in the common realm of treatment refers

to any skills development program for children who lack that specific

skill with rehabilitation referring to the returning or reacquisition of a

lost skill. Yet, this contradicts 1154.11 number 9, which states that

behavioral interventions for autism are acceptable. Behavior analysis for

children with autism is clearly habilitative in nature and the department

notes this in its statement " promoting more typical development " (p. 10).

Such services as matching to sample, social skills training, problem

solving, verbal behavior/language and communication training, frustration

management, and imitation training are clearly habilatative in nature. In

addition, to not offer these services to children with conduct or

oppositional defiant disorder, who display the same need, would be

discriminatory under the American's with Disabilities Act. I have

personally used behavioral assessment instruments (such as the

-McConnel Scale, The BASC, and the Achenbach TRF) with nationally

recognized norms and standards, which have placed children with

oppositional defiant disorder in the first and second percentile for

emotional management skills, social skills, problem solving ability, and

expressive and receptive language.

From a developmental psychopathology perspective, it is the development

of social, emotional and communicative skills through structured programs

for these children and the motivation to use those skills represents the

heart of treatment. For example, better problem solving skills allows the

depressed person to be less suicidal, because they are lessening there

stress and reducing the overall number of challenges that they can not

manage. At the very least in a multidisciplinary model interventions in

these areas would be beneficial to an overall psychosocial treatment

intervention and should never warrant exclusion. Indeed, it is these

skills for which children face new environmental challenges. In addition,

as stated previously the Surgeon General has found these techniques to be

" probably efficacious " for treating depression, oppositional defiant

disorder, and suicidal behavior. A strict read of the document would

suggest that all of cognitive and behavior therapy, which rely heavily on

the acquisition of new skills such as the skills to challenge ones

thinking, are not reimbursable by the department, which I do not believe

was the department's intent. This action is doubly unfortunate for

children since these therapies current make up most treatment best

practice guidelines (see & Grimes, 1995; , Colvin, & Ramsey,

1995).

Finally it is my belief that the department should require all

agencies to use standardized behavioral assessment instruments in the

evaluation and re-evaluation process. This will allow both documentation

of clinical disorders and offer a measure to show improvement. Formalized

criteria should be used to determine if children are making any change in

the program (such as those outlined in son, Follette an Revenstorf,

1984) and this data should be reported to the department along with

customer satisfaction data.

Hope this is helpful in addressing some of the pressing issues in this

document.

Sincerely,

ph Cautilli, M.Ed., M.Ed., BCBA

CASSP Advisory Board

References

U.S. Department of Health and Human Services (1999). Mental Health: A

report of the surgeon general. Rockville, MD: U.S. Department of Health

and Human Services, Substance Abuse and Mental Health Service

Administration, Center for Mental Health Services, National Institute of

Health, National Institute of Mental Health.

son, N., Follette, W., & Revenstorf, D.(1984). Pychotherapy outcome

research.: Methods for reporting variability and evaluating clinical

significance. Behavior Therapy, 15, 336-352.

, A. & Grimes, J. (1995). Best Practices in School Psychology III.

National Association of School Psychologists.

, H.M., Colvin, G., & Ramsey, E. (1995). Antisocial Behavior in the

Schools: Strategies and Best Practices. s/Cole.