Kevin K. Walsh

Long-term administration of valproic acid in the treatment of affective symptoms in people with mental retardation.

We report the results of an open trial of valproic acid in the treatment of affective symptoms in people with mental retardation. The study population consisted of 209 people with mental retardation who were serially referred to a tertiary-care medical center for the evaluation of behavioral symptoms. Criteria for treatment included the presence of three of the four following symptoms: irritability, sleep disturbance, aggressive or self-injurious behavior, and behavioral cycling. Twenty-one patients met enrollment criteria and were studied prospectively for a 2-year period. Two patients were lost to follow-up. One patient experienced severe drug side effects. Eighteen patients completed the study. Fourteen patients (78%) responded favorably to treatment and were maintained on valproic acid for the 2 years of the study (p < 0.001). Medications prescribed at the time of enrollment were usually discontinued, including neuroleptic medication in 9 of 10 patients and in all patients (N = 3) who were receiving phenobarbital. A history of epilepsy or a suspicion of seizures was strongly associated with a favorable response to valproic acid (p < 0.005). The results of this study suggest that people with mental retardation and concurrent affective disorders can be recognized by a cluster of developmentally appropriate symptoms such as those listed above. In addition, affective symptoms can be successfully treated with valproate with reductions in neuroleptic and barbiturate anticonvulsant medication. Further study of the comparative benefit of valproate and carbamazepine in this population is warranted.

Overview and implications of medicaid managed care for people with devopmental disabilities

The inclusion of people with developmental disabilities in managed care as part of general efforts by states to enroll and Medicaid recipients in such plans was reviewed. Managed care was defined and the processes by which managed care organizations deliver services were explained. Escalating costs and utilization were discussed as the primary reason for the shift to managed care. The use of Medicaid Section 1115 waivers by states to include Medicaid recipients was explored. The relation between acute health care and long-term care, and the utilization patterns in each, were briefly described. Finally, elements of managed care that are particularly important to people with developmental disabilities, such as care coordination, maintenance of quality, and individual and family support, were discussed.

Quality of health care for people with developmental disabilities: The challenge of managed care

Health care quality issues for people with developmental disabilities under managed care were explored. Health-related quality was defined in terms of four domains: structure, process, outcome, and satisfaction. Three general problems in the assessment of health care quality were identified: lack of quality measures, patient response problems, and lack of system elements. Selected current measurement systems were described in relation to their use for people with developmental disabilities. An approach to developing quality measures was outlined using Healthy People 2000, Health Plan Employer Data Information Set, and clinical practice issues. The movement toward quality improvement was examined and recommendations presented for steps in developing and measuring health care quality.

Correlations among the Reiss Screen, the Adaptive Behavior Scale Part II, and the Aberrant Behavior Checklist.

Relations among instruments used in community mental health services for people with developmental disabilities were explored with 284 individuals. Correlation coefficients among the instrument subscales were interpreted in terms of statistical significance and effect size. Of the 157 coefficients, 44% were significant, p < .001, and 35% represented large effects, r > .50. Reiss Screen subscale scores correlated with Irritability, Lethargy, and Hyperactivity on the Aberrant Behavior Checklist (ABC) and with Social Behavior and Disturbing Interpersonal Behavior on the ABS Part II. Stepwise regression analyses predicting Reiss Screen scores from the ABS and ABC resulted in a significant regression, with an overall adjusted R2 of .67. Variance was largely accounted for by two ABS domains and two ABC subscales.

Cost Comparisons of Community and Institutional Residential Settings: Historical Review of Selected Research

A review of the literature on cost comparisons between community settings and institutions for persons with mental retardation and developmental disabilities was conducted. We selected literature for review that was published in peer-reviewed journals and had either been cited in the area of cost comparisons or provided a novel approach to the area. Methodological problems were identified in most studies reviewed, although recent research employing multivariate methods promises to bring clarity to this research area. Findings do not support the unqualified position that community settings are less expensive than are institutions and suggest that staffing issues play a major role in any cost differences that are identified. Implications are discussed in light of the findings.

Technical Elements, Demonstration Projects, and Fiscal Models in Medicaid Managed Care for People with Developmental Disabilities.

We presented a general model of the structure and functioning of managed care and described elements (provider networks, fiscal elements, risk estimation, case-mix, management information systems, practice parameters, and quality improvement) critical to service delivery for people with developmental disabilities. A number of technical elements of managed care systems were delineated and reviewed in relation to the inclusion of people with developmental disabilities. Several managed care demonstration projects were described and, finally, a multi-year hypothetical budget model, including long-term care, was presented as a framework for considering how managed care affects specific service structures. Implications for people with developmental disabilities were discussed.

Medicaid Managed Care Model of Primary Care and Health Care Management for Individuals with Developmental Disabilities.

Lack of sufficient accessible community-based health care services for individuals with developmental disabilities has led to disparities in health outcomes and an overreliance on expensive models of care delivered in hospitals and other safety net or state-subsidized providers. A functioning community-based primary health care model, with an integrated care management component, functioning in the general health care practice marketplace, is described and shown to address recent Surgeon General recommendations as well as evaluative criteria for availability, affordability, acceptability, and appropriateness of care. The model functions in both fee-for-service and managed care environments, including Medicaid managed care for individuals with developmental disabilities. Experience shows this model to be both scalable and replicable, resulting in positive health outcomes and increased patient satisfaction.

The Hissom Closure in Oklahoma: Errors and Interpretation Problems in Conroy et al. (2003)

We reviewed a Mental Retardation article by Conroy et al. (2003) on consumer outcomes following the closure of the Hissom Center in Oklahoma. In this article the authors misconstrued their 254 subjects, implying they are representative of the Hissom Focus Class while failing to account for 128 subjects included in an earlier analysis. We found the research to be seriously compromised by data collection problems and discrepancies between reported findings and those obtained when the analyses were replicated. Problems ranged from those that seriously compromise the findings (such as the sample) to other problems in basic data management, transcription, and analysis that, when taken together, compromise the integrity of the findings, lead to inappropriate interpretations, and give rise to misleading conclusions that do not follow from the data.

Ketamine and the core symptoms of autism

Abstract Autism or autism spectrum disorder (ASD) is a behavioral syndrome characterized by (a) persistent deficits in social communication and social interaction across multiple contexts and (b) restricted, repetitive patterns of behavior, interests or activities. However, the etiology of autism in most cases remains unknown. Ketamine, an N-Methyl-D-aspartate (NMDA) blocker, has been purported by some as a possible treatment for autism. This conclusion is premature. Here, we present a single case study in which a patient with a severe intellectual disability was said to have demonstrated a dramatic, albeit short-lived, remission of the core symptoms of autism following adventitious treatment with ketamine. Although this anecdote is encouraging, we argue that further analysis of ketamine as a treatment for autism is needed.