What happened at the Legislature this session? ASNC Budget Wrap Up Report

Photo credit to Mr. T in DC via Flickr.com

Editor’s Note – The following article was written by Jennifer Mahan, the Autism Society of North Carolina’s Director of Government Relations.

During the General Assembly “short” legislative session that lasted from May 16 to July 3rd, state legislators made small changes to the second year of the two-year state budget they put into place last year. So, what changed?

The legislature:

• Funded Medicaid cost over runs for the current year (2011-2012) and added more funds to Medicaid to cover possible cost increases for 2012-2013.

• Increased funding for education, including teachers’ raises of 1.5% and $27 million for new education reforms, mostly focused on improving early grade reading skills. A loss of Federal funds and larger cuts in state funds in the second year of the budget means more cuts for local schools.

• Continued the $20 million dollar cut to state funded services (IPRS) for developmental disabilities, mental health and addiction, but did not require local management entities to use fund balances to cover the cuts as they did last year. It is likely that this cut will reduce availability of supports like developmental therapies and respite.

• Cut Medicaid personal care services by $6 million and changed the eligibility criteria. Because the changes are new, and the legislative language confusing, no one is sure how many people will lose personal care services.

• Added $1.7 million to Medicaid due to delays in some local management entities (LMEs) converting to the new 1915 b/c managed care waivers, while cutting $8 million from LME administrative budgets. The $8 million reduction is in anticipation of  savings from the conversion from a network of LMEs to MCOs. Legislators did not make changes to the waiver bill they passed last year or to the final timeline for implementation which remains June 30, 2013.

• Created a new “Transitions to Community Living” fund and oversight committee. The fund will help people with mental illness move out of adult care homes and into community housing, while also assisting adult care homes who may lose funding from Medicaid in the process. The new Transitions oversight committee will also look at the issue of housing and community living for people with developmental disabilities.

If you would like to see the entire budget, H 850 (the budget adjustments act), the Committee report for H 850 (i.e. the money report) and S 187 (the budget modifications/corrections bill) go to the General Assembly Website at www.ncleg.net. For a more detailed summary of legislative action that impacts people with on the autism spectrum and other intellectual and developmental disabilities, please read ASNC’s 2012 legislative summary.

Questions? Please use the comment feature or email Jennifer Mahan at jmahan@autismsociety-nc.org.

Tips for Parents Transitioning to the Innovations Waiver

Editor’s Note – The following article was written by Jean Alvarez, Parent Advocate/Trainer for the Autism Society of North Carolina and parent of a young man on the autism spectrum. Jean lives in western NC.

As Local Management Entities (LMEs) move from the old system of service delivery to a network of MCOs and a new waiver – called Innovations, the changes will inevitably cause uncertainty and concern among parents whose children need these services. The Western Highlands Network (including 8 counties in the Asheville area) made the transition in January and the dust has not settled yet. I live and work in the Western Highlands catchment area and based on what I have heard from families and professionals, Innovations is a different playing field and the principal players don’t have all the answers.

My son Jaime has services through the Smoky Mountain LME, soon to be Smoky Mountain Managed Care Organization (MCO) as of July 1. Jaime has a very savvy case manager who walked Jaime’s team through what he called a mock Individual Supports Plan (ISP) meeting on June 12 in preparation for Jaime’s transition to Innovations. Jaime has an August birthday which means his annual plan falls due in the middle of the transition, something which heightened my anxiety. I had been dreading these monumental changes for months and found it very helpful to go through a practice session prior to the transition. The following information is based on what I learned at this meeting and it is intended to help parents be proactive in preventing their child’s needs from becoming someone else’s dropped ball.

Changes in terms:

• Local Management Entity (LME) is now Managed Care Organization (MCO)
• PCP (person centered plan) changes to ISP (Individual Support Plan)
• Person Centered Meeting is now ISP meeting

Other changes:

• Case managers change as well: Under Innovations Care Coordinators work for the MCOs. – Care Coordinators will NOT be the same as case managers and families have to understand this. Care Coordinators are responsible for the plans and meetings. If your child lives outside of the home (Group Home, AFL) or if a person’s parent provides services they need to be seen monthly.
• Coordinators (Qs) with the Providers, such as ASNC, will basically stay the same but will have additional responsibilities
• Community Guide – a new service that can help families navigate the changes as well as help with other areas of need.
• People receiving state funded services may/may not have a Care Coordinator. In some MCOs responsibilities for state funded services have been passed on to the provider coordinators (Qs).

Suggestions for Parents

Case Management is gone now and depending on the MCO, parents may have to advocate for Community Guide service for help navigating the new array of supports. One way to advocate for Community Guide is to emphasize that if any of your child’s services are lost in this process it threatens his/her health and safety. Here is an example:

If an adult was successfully living and working in their community with necessary supports and the new ISP included a reduction in services, this is how it could impact their health and safety. If they only received 3 days per week of supported employment instead of five and did not have a trained job coach with them, what would happen if they became overwhelmed and bolted from the job site? This person would be alone in a city without the judgment and skills to keep themselves safe. In addition to being at risk for exploitation she/he would lose their job. Without a consistent schedule outside of their group home five days a week he/she would also lose their residential placement which would put them at risk for institutionalization.

I realize that this example is only relevant to parents of adults and there are many parents with younger children transitioning to the waiver. Keep in mind that Community Guide is a service to help them navigate all these changes and could help them learn how to insure that their child’s needs are still met by Innovations.

The Care Coordinators are brand new people who have huge case loads. It is very likely that they will not have time to read the background information and will not know your child. Parents will have to plan to educate this person on their child and the need for the services they are asking for.

In some cases Care Coordinators have been telling parents what services they can have. Parents have to be sure to ask for the services their child NEEDS. This is not the Care Coordinator’s call, they submit the plan for approval or denial but the team determines what needs to be in the plan.

If a plan is denied there is an appeal process.

Some elements of the plan have stayed the same and some have changed so don’t panic if it looks different. However, the plan should still describe your child’s needs and why the support is necessary.

Don’t sign the signature page until you have read the finalized plan. Care coordinators should not ask parents to sign the signature page before the parent has the opportunity to read through the final plan. There have been cases where the final plan was different from what was discussed and agreed upon by the team. The care coordinator had the signature page signed and did not submit the plan that the team agreed on.

There may be differences from MCO to MCO. Stay informed, ask questions, and advocate for your child.

The Summer Spectrum (arriving in mailboxes and online in early August) will also include information about the transition to Managed Care and Medicaid Services. Meanwhile if you have questions or concerns, visit the ASNC Calendar of Events to see if there is a workshop on this topic near you or contact your ASNC regional Parent Advocate/Trainer.

Responding to Disruptive Behavior in the Classroom

Editor’s Note – The following article was written by Amy F. Hobbs, Training Specialist for the Autism Society of North Carolina.

In teaching students with autism spectrum disorders, it’s helpful to implement a variety of strategies for dealing with disruptions, distractions and inappropriate behavior. First, take the time to get to know your students and establish a positive relationship with each one. Learn what is important and interesting to them and program lessons based upon these interests to increase motivation and engagement. Understand and accept each student’s limitations while using positive praise to acknowledge their accomplishments. Understand how your students communicate and how they best understand information presented to them. Learn the most effective communication style for each student and give them repeated opportunities to communicate appropriately and receive reinforcement for doing so.

Teachers need to be aware of what is going on in the classroom at all times. When there is inappropriate behavior that is interfering with learning in the classroom, it is important for the teacher to respond quickly. Teachers need to have “eyes in the back of their head” to prevent inappropriate behaviors and/or address them before they escalate into bigger concerns.

Because of the unique social challenges of students with autism, some strategies will likely work better than others. For example, eye contact and name dropping may go unnoticed by a student with autism; whereas redirection can be a great tool. If implemented quickly enough redirection can prevent escalation of inappropriate behavior and help a student regain their focus and complete their work. For example, if a student is off task and tapping a pencil loudly on a table, the teacher can redirect them back to their assignment and give them something soft to tap the pencil on or remind them to squeeze a stress ball instead.

Many times teachers mistakenly think that if they put students with autism in the regular education class then they will figure everything else out on their own. In most cases, it doesn’t happen that way. Students with autism need to be taught right from wrong as well as how to interact with other children. They typically don’t learn social skills as easily or in the same way as other students and social understanding does not come naturally for them. Also, these students often don’t connect consequences with their behavior. So, it’s important for teachers to be purposeful, clear and utilize visual supports to ensure understanding.

Inappropriate behaviors can be addressed and minimized by looking at the individual needs of the student. Identify potential distractions in the classroom like noises, lighting, windows or movement of other students. Then think about the design of the classroom and how you can best arrange it to minimize those distractions and meet the needs of the students. Using dividers to section the room, arranging students’ desks to reduce visual distractions, keeping the noise level of the room down, softening harsh or bright lights and modifying other potential distractions are examples of structuring the classroom for success.

Once I was consulting on a student who was not completing his work. The teacher had all the student’s desks in the middle of the room facing the front board. I suggested having an independent work station for this child that was facing a wall. This helped tremendously because it reduced the visual distractions of the room and he was able to focus on his work. Another time a teacher was having problems with a student scratching and pinching her arm while she attempted to teach him. The teacher was seated beside the student and I simply suggested that she work with him from across a table to give a little bit more space. We also developed a visual work system that clearly defined for the student what work they needed to complete and what would happen next. The student gained a better understanding of what he needed to do and could see how much he needed to complete before he was finished. As a result, he began to complete his work with no pinching and scratching.

Another student was disrupting the class by climbing on top of bookshelves, window sills and cabinets and jumping off. We considered the high activity level of this child and his need to jump and climb and created some new options for him. First we brought a trampoline into the classroom for him to use after scheduled instruction times. He can choose the trampoline during his breaks & the teacher sets a timer for 3-5 minutes. When the bell rings the trampoline is put up. We also adjusted the schedule so that at least twice a day and more if needed, the whole class goes for a walk and has time on the playground.

Incorporating opportunities for physical exercise during the school day can help increase students’ ability to concentrate and reduce disruptive behaviors. Planning a recess time or physical activity in the morning as well as in the afternoon with additional opportunities for movement around the classroom is a must for students with short attention spans and excess energy.

For more serious, recurring behaviors, a functional behavior assessment should be completed to determine the purpose or function of the behavior followed by the development of a behavior intervention plan. It’s important to have the support of the whole team when making decisions and monitoring students with these type of behavior plans. Some things to keep in mind are:

• Be sure instructions are clear and given visually as well as verbally.
• Plan lessons using high interest materials and incorporate choices.
• Complete a behavior contract in which the student agrees to work on specific behaviors in your class.
• Spell out the positive behaviors that you want the student to engage in.
• Schedule regular times to check in with the student during the day/ and during the week as needed to give the feedback and a time to talk about things that may be issues.
• Don’t assume that a behavior is intentionally designed to trick you.

If possible, involve the student in finding solutions and writing up a behavioral contract that focuses on what he can do when he becomes upset. Identify those replacement behaviors or calming strategies and make sure that the student has support in utilizing them. For example, if he needs a break or a calm down space away from other students, then the teacher will have a place set up for him and will approve of this when he asks. It’s also important to make sure that he understands what behaviors are not acceptable, such as aggressive acts and what the consequences of those actions will be. Finding ways to keep the student motivated to follow his behavior contract, taking data on his behavior, closely monitoring his progress, and reviewing and revising it with him as needed are also important parts of the process.

Using students with challenging behaviors as peer tutors with younger, disabled students gives them an opportunity to be in a helper role. Being in a role of a peer tutor assists in developing the student’s sense of belonging and generosity. Because of the tendency of students with behavior issues to be seen as trouble makers, this positive role can help change how teachers and other student view them and can also improve their self-esteem.

Implementing a proactive approach in the classroom can prevent many disruptions or behavior problems from occurring in the first place. For higher functioning students, class meetings can be designed to address challenges in the classroom. Focusing on finding solutions with your students as opposed to giving them consequences for behavior will give them a sense of autonomy and also increase their motivation to regulate their behavior. Having regularly scheduled class meeting times will give lots of opportunities for input from the students. The meetings can be the whole class, small groups or individual meetings based on the present needs of the class. Teaching calming strategies and appropriate ways of expressing anger can also be incorporated into the class meetings.

In closing, I think that in order to have a positive impact on behavior, using proactive, preventive techniques are vital. Focusing on the classroom structure, consistency and predictability as well as establishing positive relationships and involving students in finding solutions are all equally important in creating a positive classroom environment.

For additional information and/or consultation please email Amy at ahobbs@autismsociety-nc.org. For a complete list of workshops available through the Autism Society of North Carolina Training Department, click here .

Proposed Changes in DSM-5 Criteria

In recent weeks national and local media outlets have reported about proposed changes to diagnostic criteria for Autism Spectrum Disorders in the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM 5). The proposed changes have not been formalized and that process is expected to be completed by December 2012. – Editor

What will the proposed changes to the diagnostic criteria mean for families and children with ASD? That is certainly a question that many have asked and just as many are researching.

While there are several major changes that include the elimination of diagnostic labels such as Asperger’s Syndrome, Pervasive Developmental Disorder not Otherwise Specified, and Childhood Disintegrative Disorder, the intent of these changes is not to limit the eligibility of individuals, but instead to eliminate an overlap in the criteria that is currently being used. Presently, there are inconsistencies in the distinctions among disorders. The anticipated changes would allow a single diagnostic category, Autism Spectrum Disorder, to represent each individual’s clinical specifiers and associated features.

My hope is that there would be a shift in focus from diagnostic labels to an individual’s characteristics and symptoms, which would lead to more appropriate and specialized treatment. There is great concern by some that reducing diagnostic domains from three to two and requiring both criteria to be completely fulfilled might result in individuals who, by today’s criteria, would receive a diagnosis of Asperger’s Syndrome, not receiving this diagnosis in the future. It is also possible that the broadening of criteria would allow some who have not previously been diagnosed to receive a diagnosis due to the fact that fewer symptoms overall would be required.

The Autism Society of North Carolina (ASNC) is closely monitoring these changes in an effort to ensure that no individual on the autism spectrum is negatively impacted. In addition, ASNC will continue to provide services and supports for all individuals on the autism spectrum and their families. As the debate around proposed changes continues and the new DSM V is completed, we will keep you informed and welcome your feedback.

Leica Anzaldo is Training Manager for the Autism Society of North Carolina and can be reached via email at lanzaldo@autismsociety-nc.org.

Autism Society of North Carolina CEO Tracey Sheriff provided comments to media outlets including WRAL and WNCN-TV. To view those interviews click on the following links:

• WRAL News
• WNCN News