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Lesley Cottrell: Flabbed.

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Lesley Cottrell: Alright. I'm going to bring them in.

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Lesley Cottrell: hey? Good afternoon, everyone

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Lesley Cottrell: just letting people in from the waiting room. We appreciate everyone joining us. This is a great group.

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Lesley Cottrell: Thank you so much.

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Lesley Cottrell: We already have our slides ready to go.

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Lesley Cottrell: Gonna have a great discussion. So just to orient everyone. We're in session. 4 of our series, focused on individuals with intellectual and developmental disabilities.

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Lesley Cottrell: And in West Virginia particular focus.

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Lesley Cottrell: within our behavioral health system and processes. So we appreciate you joining us. I'm gonna be putting. My name's Leslie Cottrell. I'm gonna be putting some things in the chat as we go, and, in fact, to get us started. 2 things, if you don't mind to put your name and your affiliation, that would be great that would tell us who was here, and give us a little bit of idea of who's joining us.

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Lesley Cottrell: I see some people with their cameras on. Thank you so much that that leads to friendly conversation, although you don't have to do that. That's quite all right. Totally. Get it? Please make sure. Then on the side, as as our presenters are talking, that your backgrounds muted.

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Lesley Cottrell: But having said that if you have any questions.

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Lesley Cottrell: feel free to raise hand, put it in the chat. We will also include some time to stop, and the whole point of this echo session is to think as a group. What would you do

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Lesley Cottrell: in that situation? What resources do you know about that? We could also share? That's that's the whole nature of the game. So with that I'm gonna turn it over to our first speaker, Dr. Lauren, swaggart

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Lesley Cottrell: and she's gonna be presenting our didactic piece.

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Lesley Cottrell: and then

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Lesley Cottrell: she'll introduce. Sorry I have

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Lesley Cottrell: things going on she'll introduce Alma in more detail, and each of them can give more background. Last thing. Remember, we have close captioning available. Please utilize that. If you run into any issues with any of those services, let me know through the chat, and we'll get it going.

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Lesley Cottrell: Okay with that, Dr. Swagger. I'll turn it over to you. Thank you.

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Lauren Swager: Hi, everybody. Thank you for having me today. Today, we're gonna kind of talk about what the official title is. The difference between behavioral and mental health services. And and I I think you'll learn pretty quickly that I'm actually not a real fan of of those terms. But that is how services are labeled. So we're gonna call it that. But

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Lauren Swager: I think for me. And I'm gonna highlight. This in the discussion today is is especially in looking with individuals with Idd and and other developmental disabilities. It's it's kind of a more appropriate, I guess, way to sort of think about this is what is a developmental need. And what is a mental health or psychiatric ideology of a of a symptom or behavior. And and I think, although we'll be highlighting differences and approach, I think.

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Lauren Swager: and Elma's case will probably highlight. This is the importance of both. In in our populations is is really strong. It's just a different framework or a different way to kind of approach different things. So that we think about it differently in terms of how we think about service needs, but for for most of our

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Lauren Swager: our clients and our patients, it's really a both, and I I think, more than a separation or this or that. So?

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Lauren Swager: We'll dive right in. And then for me, this is a very natural transition cause. My my background is really with children. And the developmental needs of of children extended to developmental needs of adulthood across the spectrum, too. And so this is. This is sort of

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Lauren Swager: an outline of kind of how I've approached those different needs and and assessing people. As always, I love to be interrupted. I think questions are awesome, so please do not hesitate to come off mute and frankly interrupt me or drop something in the chat if I can clarify anything.

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Lauren Swager: So here's some of the objectives that we're gonna talk about today, really looking at behavioral ideology, trying to understand the etiology of a behavior and then using that etiology to really connect to treatments that work and treatments that don't along these differences and symptoms.

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Lauren Swager: And I'm gonna start with just some some definitions, because from some of these definitions,

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Lauren Swager: of either psychiatric or intellectual disability language. We we see where some of the treatment targets come from. And so although most of you on this call are very well informed. The the term intellectual disability has largely replaced and been considered the most appropriate term for quite a a time. And and that is the language that's kind of used in the Dsm diagnoses now, and I'll show you what those say. But

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Lauren Swager: developmental disability which we often use is is actually kind of a broader term with more legal definition. So it it's important to understand that sometimes the terminology.

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Lauren Swager: some some is, is really from legal statutes. Some are from medical statutes, and and sometimes they aren't always the same. But we really, as most of you on this corner. We really want to use person first language. So these are not these are people with intellectual disabilities or people with developmental delays, not not just someone who has

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Lauren Swager: a label. People are not their labels. So we we want to do that. And that's been a big shift in the psychiatric literature as well.

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Lauren Swager: So I wanna, I wanna go into what the definition of an intellectual disability is. Because it is the only

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Lauren Swager: diagnosis in the psychiatric manual that actually requires a test. That is a a test of an elect or an IQ test and there are different variations of that. But it starts with identifying that there is some significant standard deviation, difference or 2 standard deviations below. What is is the normative and

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Lauren Swager: the the language around intellectual disabilities and developmental disabilities, has really tried to get away from numbers and really look at symptoms and functioning. And so typically people labeled that IQ difference as about but below or 70

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Lauren Swager: however, an IQ below 70 alone does not meet the full definition of intellectual disabilities, and it really should is is trying to see that you should get away from

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Lauren Swager: the idea of of numbers altogether, and and again, really look at function. So when we think about what intellectual function is, or cognitive function. And it's it's really the ability for someone to have problem solving skills, reasoning skills, abstract thinking and judgment. It might include a academic learning that they've accumulated through schooling.

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Lauren Swager: We're just life experiences and and trial education. And this is this is developmental. And so for adults and kids, this is a process that that you can gain or lose intellectual and cognitive constructs throughout your lifetime is a variety of exposure, and sometimes people that have had significant psychiatric symptoms or illness on top of intellectual symptoms, can have changes in their cognitive abilities

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Lauren Swager: because of that illness or other medical illnesses as well. So while in theory, we'd like to think of IQ or intellectual functioning as a fixed entity. It really can vary and change over time.

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Lauren Swager: But this, this is this is the cognitive piece.

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Lauren Swager: No, the the actual, more important piece to thinking about treatment and to fully meeting is to not just have evidence of a of a numeric score below standard deviation. But to to really have struggles. That show that you're having problems with adaptive functioning or or how

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Lauren Swager: you're utilizing those skills functionally in your day to day life. And so when people apply for the waiver or for services, there, there actually needs to be some type of adaptive functioning or or

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Lauren Swager: scorrable way about what their their skills are. And sometimes people refer to these as sort of like your Adls, your activities of daily living, adaptive functioning. It has a lot of different names. But this is really looking at a person's interrelatedness in their world and their ability to have

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Lauren Swager: have interactions. And it's broken down into things like communication. How are their communication skills? This could be.

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Lauren Swager: you know, from their words, and but it could also be actions. It could also be pragmatic speech. It could be ability to read social cues. There can be a lot of aspects of that, and it also goes into social skills. That's how you're interacting with others that can entice communication.

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Lauren Swager: But other things like your just ability to take care of yourself. You're dressing your eating, your daily day to day ability to shop or manage money, and just how you're functioning, and a work or school environment all sort of included in that.

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Lauren Swager: This is where I I will point out that you know I'm I'm not going to go through the criteria for autism per se. But wanna with with an autism diagnosis you can have an accompany intellectual

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Lauren Swager: decline or or not, it could be normal. But when you see an individual with autism that the difference in the definition of autism and intellectual disabilities from a functional standpoint is that in autism the communication and social skills specifically are much below the other skills with intellectual disabilities. In general disability terms, you may see, decline

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Lauren Swager: equal to what you would expect, sort of with their cognitive abilities. But autism. There's some extra delay. In the social and communication skills even below what's expected.

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gillian mccarty: Can I ask a quick question.

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Lauren Swager: Yeah, yeah, I love questions. Go right?

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gillian mccarty: Yeah, how you

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gillian mccarty: is there

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gillian mccarty: ever

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gillian mccarty: a potentiality for separate tests for that? I am finding that

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gillian mccarty: first of all, autism is through the roof right?

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gillian mccarty: But kids that qualify for this program

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gillian mccarty: free to

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gillian mccarty: 10, give or take

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gillian mccarty: probably past that point shouldn't continue to qualify, yet somehow

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gillian mccarty: do.

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gillian mccarty: because.

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Lauren Swager: You correct.

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gillian mccarty: I I honestly don't know why, because they there are

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gillian mccarty: a lot in my experience that would be perfectly able to be, quote unquote, a productive member of society, but

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gillian mccarty: aren't allotted the the ability because they're on waiver.

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Lauren Swager: Yeah. So I I'm gonna I answer that a couple of different ways. So I I do think, you know.

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Lauren Swager: I I think it's really important to understand sometimes that the IQ tests are just a moment or a snapshot in time. When they're done. There's a lot of

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Lauren Swager: things that can interfere with that. There's a lot of treatment or interventions that can change someone's performance along these things. So when you're talking about kids that are developing. Anyway, there. There should be points in time where the need is reassessed because you will. It's absolutely true. You will see kids

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Lauren Swager: gain 30 IQ points, and it could be a variety of different things from the intervention provided to they. They finally acquired language. And it it wasn't so much intellectual deficit as it was their ability to show their knowledge, and then sometimes on these adaptive scales. And this is one of, I think, the most challenging thing. Is

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Lauren Swager: it you really have to know the person. The person filling them out has to really understand the questions being asked of them, too. Right? I I've seen people report functional scores that are way higher. Just by virtue of not having a standard too. So while I can't answer how the waiver works specifically and reassessment, you are absolutely right, that it's not unusual that you can see.

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gillian mccarty: Same changes.

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Lauren Swager: Declines as well in in things. For a variety of reasons.

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gillian mccarty: Many tests that solely relies on

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gillian mccarty: somebody else who's dependent on that check that comes in. Yeah.

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gillian mccarty: Also makes an impact.

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gillian mccarty: that

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gillian mccarty: I have an autistic son.

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gillian mccarty: and

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gillian mccarty: I know when I needed to get him some services.

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gillian mccarty: What before he could actually communicate.

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gillian mccarty: I made sure he was tired

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gillian mccarty: before we went and did any tests.

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gillian mccarty: because I knew a tired son

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gillian mccarty: is not nearly as productive, and I needed those testers to see.

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gillian mccarty: This is how you get him more often.

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Lauren Swager: Yep.

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gillian mccarty: But if the evaluators don't have the ability to spend the time with the child to truly see what they're capable of or not capable of.

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gillian mccarty: How are we getting true diagnosis and and putting putting

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gillian mccarty: forever diagnosis is on kids that

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gillian mccarty: maybe just need a little bit of help until they're 10.

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Lauren Swager: Yeah, well, I I could not agree with you more. I I think that is a marked limitation of the system.

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Lauren Swager: And some of. It's because we don't have enough providers or or people that have that ability or access to follow people forward, because all of these are also diagnoses that that change right and evolve, and you want to see them evolve and and get better. And and there's there's some fallacy just in a system that has to keep showing illness. Right? I mean that that's a that's a systemic problem. But but you're right, and

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Lauren Swager: you know, you can have a really bad day, and and score terrible. You have a really good day and score better, or the person might just see you at your 10 good minutes. And so these really high quality diagnostics are, are decisions made over time with multiple points of collateral and reassessment.

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Lauren Swager: and and I, I think you also highlight. The point of money, I mean, money is a is an issue. But

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Lauren Swager: you know money money doesn't.

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Lauren Swager: Money drives a lot of things, but doesn't always equate to what people need for success either. And and and when you have limited resources, you know, it's easy to to have

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Lauren Swager: number cutoffs that don't always match

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Lauren Swager: True true health diagnosis, either. So again, that is, that is quite a fallacy. And that's why. Actually, at least, the the Dsm has tried to get away from these hard numbers and really look at things over time, because a lot of services were getting denied, based on hard number cut offs that that really were kind of

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Lauren Swager: going away from that. So when you really read the criteria, they really have tried to get away from using the absolute cutoffs and numbers. Same in the school system. Do they still talk about them? Sure. But but that's just not a full picture of an individual.

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gillian mccarty: Right.

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Lauren Swager: And and it it also is is kind of a challenge, because, you know, cognitive issues as related to intellectual disabilities are really supposed to be things that start early right in childhood or adolescence when when you can develop a developmental problem for a variety of reasons.

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Lauren Swager: But but the technical correct term for those things would be something like a neuro, cognitive disorder instead of a developmental already disability. But things like a traumatic brain injury or stroke, or something that causes a significant loss of cognition that would be acquired later

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Lauren Swager: would be kind of more like an acquired neuro kind of problem, and and there have been hard cut offs used for those as well. But in theory the a true intellectual disability development obviously is one that that starts through from birth, and is not acquired. And and so there is a difference in diagnostic paths of those again. And sometimes it's very hard to get the history to know when you just see someone at X point in time, and you don't have the history of the early development or the trajectory of their needs

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Lauren Swager: sometimes very hard to get the label right.

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Lauren Swager: And so when we talk about this is again where we

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Lauren Swager: we really have tried to get away again back to functional analysis. But you see, in all these examples, they're they're going back to the old language of the numbers. And so when you're really trying to think about the severity

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Lauren Swager: of an illness. It's very of a symptom. You want to link it back to their functional abilities. What what would you expect? They could achieve. And

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Lauren Swager: so they are, these qualifiers of my moderate, severe, profound, intellectual disability that are labeled, and they're supposed to be linked kind of to their functional abilities.

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Lauren Swager: And so you'll you'll see that, you know, in the old language people kind of viewed, mild as 50 to 55 up through 70, with this idea that they they could end up independently. And so this is kind of

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Lauren Swager: a challenge about well, how do you live independently if you don't have the resources of developmental support alongside your IQ. So that you can gain them. And and so this is also where the expectation may be that they cognitively are able to give those skills. But if you don't have the resources to build their independent living skills.

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Lauren Swager: you're gonna fall, fall down in your abilities from from what's expected. And so many of these original definitions implied that they were getting the services to acquire their developmental levels. And and that's not always the case in when you, when we struggle to find resources to support people. So at every moment in time.

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Lauren Swager: I sort of believe we have to understand where someone is cognitively. But we also have to really think where they are developmentally, if they're making the gains that you would expect that they would, are they? Are they not making gains because of some other illness?

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Lauren Swager: But they're not making gains because they're not getting those services to build those skills. That that is, that is a very, very challenging question. When we know how limited resources

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Lauren Swager: we have sometimes

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Lauren Swager: another. This kind of goes back to one of your questions to you. And another kind of category that exists. The Dsm is is actually one for the for children under 5. And I just throw that out there. Because this is this is in those early kids when they.

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Lauren Swager: you know, it's hard to test a kid under 5. There are IQ tests for kids under 5, actually. But they have such rapid needs and rapid development. There's a lot of environmental and nutritional and emotional needs that that are are very key, that there actually is a category of global developmental delay for kids under 5, where they're really struggling to meet their milestones across many levels from physical to cognitive to

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Lauren Swager: other health health delays. And and this is one that is, I think, important to point out that with really intensive early intervention, many of these kids don't go on to meet Idd diagnosis as they would. And and we forget that sometimes.

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Lauren Swager: And this is, I think, the power of services and developmental services and developmental treatments and support. Because you you can, with intensive interventions at helping communication or otpt speech, social skills, engagement, attachment skills, emotional work. You you really can.

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Lauren Swager: show a, as, as I would say, neuroplasticity and growth of those neurons. With a rich environment to to help people grow and gain and skill. And and so people do outgrow their diagnoses there. It is well known that even people with early diagnos of autism or global development lay with that intensive intervention may not meet criteria any longer for those services. Does that mean they don't need anything? Absolutely not

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Lauren Swager: but but that's part of of what we hope to see, and we know we do see with treatment

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Lauren Swager: like, it's also important to kind of. This is where the medical stuff, I think, also really overlaps.

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Lauren Swager: It's also helpful to have a sense of the ideology of the presentation. What

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Lauren Swager: what if if there is a reason, may have contributed to the etiology of these cognitive and developmental symptoms because they may allow us to predict

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Lauren Swager: future needs. Future medical needs. Because many things, especially genetic syndromes, may have expected patterns or things that might develop later. We want to be mindful of and monitor.

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Lauren Swager: you know. Environmental effects can can change presentations as well. So there can be a lot of things from things that happen before birth

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Lauren Swager: during the perinatal period. You know whether it's a toxic exposure, a vitamin, a nutritional deficiency, a birth injury, or some type of insult, or even after birth. If there's a hypoxic injury or or health infections that might be contributing because all of these things. And it's a very overwhelming slide. But all of these medical conditions do impact the health and growth of those brain neurons that help us

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Lauren Swager: gain our cognitive skills. And they have to be treated or or managed, and even stress. Many of you have heard me talk about

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Lauren Swager: sort of the impact of of stress and and and cortisol pathways. Cortisol is destructive to neurons, too. So environmental stress, high emotional intensities or or other sort of even ses needs can that can drive cortisol and and potentially be toxic to these neurons and and inhibit people's path to full acquisition of skills.

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Lauren Swager: But sometimes

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Lauren Swager: it's really important to identify some of the underlying causes because of this predictive ability. And you know, there, there are clear, genetic disorders that that have both high risks and predictable patterns for things like autism, intellectual disabilities, and a clear psychiatric illness. And I give the example of vilocardia facial syndrome, which is a known genetic deletion syndrome of 22 q. 11.

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Lauren Swager: If if that's identified as a cause of delays, it actually is one that really speaks to the fact that they also have a very, very high risk of a psychiatric disorder with almost 25% of people that have this specific deletion, not only having a trajectory of development delays, but 25% have a developmental risk of becoming psychotic and having schizophrenia too.

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Lauren Swager: And it is a major overlap. That occurs. But it's it's not the only one. And so I think it's important.

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Lauren Swager: It's really

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Lauren Swager: to to understand what's a cognitive

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Lauren Swager: part of this picture. And and and what is, is, is the psychiatric piece, too?

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Lauren Swager: As well.

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Lauren Swager: These are other again, sort of developmental differentials, you know, neuro cognitive disorders all involve some degree of of cognitive. And there's many of these also have other patterns.

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Lauren Swager: that may be exhibited, you know, some something like down syndrome, also associated with cognitive decline, that looks like Alzheimer's disease after people acquire to age 40 that that has to be taken into consideration, their care, too. And then autism. We talked about that that it can occur with her without an intellectual change, but really really highlights a much more impairment in the social and communication realms and some of the other self care realms.

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Lauren Swager: One of one of the things I'm I'm a big proponent of. And I'm gonna spend a lot of time talking about is any times we are called to be helpful or get people services because of

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Lauren Swager: behaviors. They're exhibiting a behavior. And sometimes it's a behavior of significant concern. Sometimes it's very hard to to know the details, but it's it's really important that we approach the understanding of these behaviors in a very systematic way

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Lauren Swager: to really understand what the etiology of the behavior is, because behaviors can have a lot of different ideology. It could be from a mental health diagnosis or psychiatric diagnos. It could be an developmental consideration. It could be just an environmental trigger. And so

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Lauren Swager: I I usually am running into people that have had thousands of labels. It feels sometimes I think I

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Lauren Swager: I think I saw one child with 16 diagnoses, including their intellectual disabilities. And I think that's a real disservice. It it looks messy. It looks like people were careless. It looks like people didn't really take the time to really dive in to understand what was truly going on. And so

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Lauren Swager: I I tend to be cautious when I see all these disorders being thrown at at kids to absolutely go back to. Okay. What actually is the behavior that we're seeing? Let's really go back and understand what's causing it, because you will not be able to truly

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Lauren Swager: approach treatment until you really go back through that idea. Do I truly understand where this behavior is coming from? So my treatment plan meets it. And this is where I get very specific on that that terminology. Some behaviors are developmental, and some behaviors truly are medical or psychiatric. And this is really in the details of how you solve the etiology question is to really understand the difference.

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Lauren Swager: So we talk about developmental behaviors. We're really talking about a behavior that occurs because the coping skill or the developmental skill to manage it has not been achieved yet. They haven't learned how developmentally cope with this and so you know, typically developmental triggers are going to kind of wax and wane with environment

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Lauren Swager: may wax and wean with environmental changes or triggers, or that that happen

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Lauren Swager: often. The reason they struggle developmentally is they may misinterpret the environment because of their developmental needs.

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Lauren Swager: Perhaps they don't understand the communication involved. Perhaps they're frustrated at the at the skill or expert because of they don't understand or process it. Sometimes they're overwhelmed by sensory exposures.

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Lauren Swager: But the behavior is occurring, because whatever is prompting the behavior before the behavior is happening in a way that they don't know or have another skill on how to respond more appropriately.

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Lauren Swager: And these developmental behaviors are very, very unlikely to respond to psychotropic medications. And that's that is

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Lauren Swager: something I want to spend a little bit more time on at the end. But we cannot treat developmental behaviors with meds, and and if we do, we will do a disservice to our families and our and our kids.

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gillian mccarty: Well, she's saying.

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gillian mccarty: remembering that not only that, but treating autistic

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gillian mccarty: children who also simultaneously have a psychiatric diagnosis, and the doctors, understanding that psychiatric med on autistic

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gillian mccarty: individuals do not react the same.

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Lauren Swager: Correct.

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gillian mccarty: Is problematic.

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Lauren Swager: Yeah, and that's the whole end of my lecture, Chilean. So I'm gonna so I I wanna show you some of that, too, cause I I suspect you will.

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Lauren Swager: You will understand that as well, and it also, it also is important. And I should say this again. It doesn't mean that you can't have both either. Right? You can have a psychiatric and a medical and a developmental cause. And and that's why treatment often requires many interventions. But a true medical or psychiatric cause is a clear underlying biological component to that

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Lauren Swager: that that really could respond to treatment or has a clear treatment target, and it's much less likely to wax and wane with environment. It may be more likely to be persistent. It could be episodic, but typically episodes occur in weeks or months. And medicines may actually target that. So an example of autism, maybe you can be have autism

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Lauren Swager: and have depression. You can have autism and have Adhd.

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Lauren Swager: Your Adhd symptoms may respond to a medication. But your core autism symptoms and those developmental communication social skills probably will not.

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Lauren Swager: And so it's important. We always think about the both hand

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Lauren Swager: with some of these.

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Lauren Swager: And so many of you have have heard this before, but I live in the world of the ABC's right. We do not change behaviors by understanding behaviors. Yes, I need to know what the behavior is when the behavior occurs. How many times the behavior happens. How severe it is. But I will never, ever fix a behavior if I don't understand the A. And the C.

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Lauren Swager: I must understand the aniseed. Maybe there is no aniseedin, and I need to know that. But I need to understand what is happening before the behavior, but leads up to the behavior. And if there is a queue or trigger, or stressor, or a misperception of the environment that that leads to the behavior.

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gillian mccarty: Aye.

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Lauren Swager: Out!

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gillian mccarty: Annotants also are

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gillian mccarty: very difficult.

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gillian mccarty: and I think maybe more so in a 24 h

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gillian mccarty: setting, and you wouldn't think it would be.

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gillian mccarty: But if if a client has delayed

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gillian mccarty: reaction.

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gillian mccarty: so like, I know people who

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gillian mccarty: let stuff boil up, and so they'll start acting out 3 months after an event.

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gillian mccarty: and having to figure out that that's.

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Mary Wilson: Give me an idea where Todd is

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Mary Wilson: service logist for the week of March seventeenth.

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Lauren Swager: And I would also say that aniseed are even broader than just that, too, that aniseed can be medical. They could see they they can be.

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Lauren Swager: you know, differences in in how you process information like how someone and and some of this may be challenged by communication events that they they? Really, it may not be that there's not an aniseed, and maybe that that client struggles to verbalize the aniseed, or report the aniseed with with other means of communication, and some of it is is going to. Did we do the detective work to try to find it or not?

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Lauren Swager: But also it's important to understand what the consequences. What is the behavior doing? Is the behavior having a purpose. And this is this is really

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Lauren Swager: this is a hard one, because

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Lauren Swager: sometimes caregivers

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Lauren Swager: reinforce behaviors that they don't even realize they're reinforcing right. And so we have to think about our responses to the behavior. And if the behavior, if our responses and the environmental response is making it better or worse.

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Lauren Swager: I I give the example of, you know, my own kid, like having a tantrum in the store over wanting a candy bar, totally embarrassing me as a caregiver, and I hand her the candy bar so she stops. I just really taught her how to throw a good tantrum and get me to give her a candy bar right, and and and may not have realized that she just learned throwing a fit get got the chocolate, even though that was not my intent right? And I again, that's a simple example. But

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Lauren Swager: sometimes we inadvertently reinforce things.

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Lauren Swager: and and sometimes we have to, especially when aggressions are concerned. Sometimes people use aggression to communicate, and sometimes we reinforce things like that, even though we don't mean to, and while we might do it in the short term, we have to step back

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Lauren Swager: and really figure out how to

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Lauren Swager: how to really understand what that looks like in the greater

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Lauren Swager: pattern.

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Lauren Swager: and sometimes it's really hard to figure out right, I mean, and sometimes this is again back to the same thing with the diagnosing.

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Lauren Swager: the best care. The best plan really involve. Someone dedicated at looking this because just because what your pattern is with one behavior may not be what your same pattern is. You always have to be that vigilant detective

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Lauren Swager: at each event.

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Lauren Swager: And and so when when providers change, when caregivers change when there's not

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Lauren Swager: a consistent way of of looking at it. And people change, we, we lose information that can be really helpful. And so this is, this is the hard work, right? This is the digging in the the perseverance to to really

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Lauren Swager: figure it out. And and you can't. You're right. You can't figure it out in a day.

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Lauren Swager: or even a week. This this sometimes I I mean.

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Lauren Swager: I I've had some kids that have had really complicated psychiatric syndrome, and and it took me a while to realize they were psychotic, that that was maybe the trigger for their behavior, and I just couldn't see it. No one could see it. It just took a long time for us to appreciate what it might be into. This is this, is that dedication right to to really look for it over time

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Lauren Swager: and and again. These, these is just a short list, but so many things right, so many things can be a trigger from a sensory misperception, a loud noise, a hearing deficit they made, perceiving the environment differently. Feelings of motor restlessness. We'll talk about medicine side effects can can really be something. People miss as triggers

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Lauren Swager: pain medical problems, illness. How many times have I seen people have an event, and they have a fever 5 days later, and they weren't feeling good. Right? They they can all be things that that could trigger it. Seizure, risk, mood changes

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Lauren Swager: metabolic issues. And then there, there can be other other things. You could be having a trauma response, psychotic symptoms, other mental health things. This, this list is really

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Lauren Swager: yeah. And and again, I think the point, too, is when you think about behavior, you have to think about the whole picture right? So the time of day, you know, if you're noticing it happening at a certain time every day, or when it happens, you know. Is it? Is it really, you know, is there, you know, knowing the time, the date, the location, or all

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Lauren Swager: all things like that. And so we have to think really big with us. And and sometimes again, we may not know the trigger till later. So it's not in that that sense of tracking when we look back at it that we may not see it. And so, even if you don't know what it is, the importance of tracking that behavior over time can really reflect the patterns later. And and I think that's that's something

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Lauren Swager: that's hard when you're in distress, or you want to fix it. Now, to really emphasize, to caregivers sometimes is I really need you to track this so I can figure it out. I know we're not going to figure it out from one event, I think, together. Looking at it. We'll eventually figure it out if we keep an eye on it. So we can start identifying the patterns because you're right. You never see them in one event. So I it's it really is

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Lauren Swager: a a dedicated look. That's hard, and it is frustrating to track things and not immediately know. But it is really, really key to figuring it out, I said I, it's always important. I always I always say we have to be detective, so we can't give up

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Lauren Swager: And then then, when we talk about sort of the more behavioral symptoms, the the non psychiatric ones, we we really want to think about, what's the function of the behavior? Like? If the be, if we know what the trigger is? Well, okay. So this behavior happens. What purpose does the behavior serve.

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Lauren Swager: you know, is the is the behavior that we're seeing, helping someone escape something uncomfortable is the behavior helping us get people's attention or make our needs known.

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Lauren Swager: is it? You know we talk about rocking or self injury sometimes that could be just the self stimulation or the movement could be helping with pain or motor, restless feelings, or or just movement consist, you know, or stimulation can help people calm down and and you know, so we really want to think about.

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Lauren Swager: You know what?

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Lauren Swager: Okay? So when this happens, what what purpose does it serve? You know, if I'm being triggered by loud noises, I get somebody's attention. I get removed.

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Lauren Swager: Maybe it's that I was overwhelmed, and it was the removal that actually helped. So how can we find a way to then help with the trigger of the loud sound before the big behavioral concern happens. Like, let's teach ways to remove or find other environments with lower stimuli before we get to the big outburst. And so

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Lauren Swager: one of the challenges that's really key is is helping people communicate many times our clients and patients, especially with more significant. Cognitive difficulties really struggle, and how to communicate. Many are not verbal. We have to think about

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Lauren Swager: how we can continue to help them communicate

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Lauren Swager: and and have alternative ways to to really express those those needs. And I think Leslie shared some.

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Lauren Swager: We'll be sharing some additional resources on that as well.

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Lauren Swager: But the reality is that while we like to again sort of lump and split into intellectual and developmental disabilities and mental health disorders and psychiatric disorders, there actually is a significant overlap where people have both.

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Lauren Swager: That's the that's the reality. And and looking at at true

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Lauren Swager: good diagnosing, you will actually see. And there's some reasons for it that might be beyond this lecture. But there, there really are higher rates of true psychiatric illness and and those with developmental disabilities. And there's actually higher risk of medical diagnoses, too. And some of them that are gonna contribute to these. And so.

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Lauren Swager: you know, there are higher rates of oppositional behavior. I hate that word cause. I think it's often communication, but there are higher rates of oppositional behaviors, adhd symptoms, good disorders, anxiety, disorders, autism, spectrum disorders, stereotypic movement disorders, impulse control disorders. They. They all have higher diagnostic rates than than in pay in populations without an intellectual or developmental delay, so

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Lauren Swager: and many of the times we we have to just appreciate. All of the factors are there, and we have to be detectives. About what part of this is developmental. And what part of this is mental health, or what part of this is medical. So again, you can't escape. These aren't. These are these are messy but it doesn't make it any less solvable. You just have to dig in and really know our clients and understand their behaviors. To solve them.

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Lauren Swager: Here are some rates of of medical conditions associated with these things. So again, these are these are much higher than the normal population, too. So you're gonna you're gonna see them altogether.

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Lauren Swager: It is challenging sometimes for providers to get accurate diagnosis, especially in mental health conditions.

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Lauren Swager: because, you know, if you have a cognitive delay. You can't fill out all the questionnaires, or maybe answer the doctor's questions verbally.

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Lauren Swager: And so there actually is a whole sort of part of psychiatry that's looked at. How do we track psychiatric symptoms in a population with lower cognitive abilities or Idd? And there actually are some specific

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Lauren Swager: checklists that look at certain behaviors differently than in the traditional psychiatric world. And here are just some examples to really look at

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Lauren Swager: the presence of how you look at those symptoms differently, and it kind of is to simplify what it's doing. It's often looking at things that you can assess

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Lauren Swager: outside of reportable stuff. So let me let me kind of give you some examples. I'm an aberrant behavior. Checklist is kind of a good

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Lauren Swager: sort of thing where it's tracking things like aggression or social withdrawal, or if you can look at symptoms of depression by energy changes or withdrawal from activities that people used to enjoy, that don't require the self report. But again, it's harder, because it takes some time, and you have to be looking for it to think it's there.

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Lauren Swager: But there, here are. Here are some examples of specific disordered screenings, kind of designed from a a different population.

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Lauren Swager: So ultimately, when we think about treatment.

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Lauren Swager: we have to treat both. If there truly is an underlying psychiatric condition like someone is psychotic, they will probably need an antipsychotic in traditional psychiatric treatments, but they also probably have needs. Well outside of this, and so

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Lauren Swager: many be, and many behaviors are both as well. Well. They may have mental health components. They may also have this behavioral component. And so I don't need to tell many people on this call. But functional behavioral assessments are really at the heart of some of this behavioral stuff is, we really have to

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Lauren Swager: to understand.

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Lauren Swager: you know, the behavior and the purpose.

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Lauren Swager: And see now

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Lauren Swager: I I will say that not that sometimes again, people get in their lanes with this right. If you're trained in a traditional mental health

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Lauren Swager: realm. As a psychiatrist or not, you might miss the developmental piece, and some people that are really trained, and Fba's might miss the medical piece, because that's not their their. So it's it's really important, I think, in the training of professionals that we expand our mindsets to beyond our traditional training.

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Lauren Swager: I'm gonna be the first person to tell you. I don't think I learned anything about functional behavioral assessments. As a psychiatrist. I didn't learn this until I started working specifically with kids with developmental disabilities. And I was like, this is great.

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Lauren Swager: That was not part of my normal training. And and so, you know, you have to always step back and and sort of think about the lens that that someone's coming from, because again, I'm gonna argue, all of it's important. But but sometimes people don't know what they don't know. And and when we're

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Lauren Swager: when we're all working together, I can tell you now, when I see a really good functional behavior, assessment makes my job so much easier. But I'll also tell you. It's really hard for me to to find people to do it. And so, even though I I know it's something I need. It's it's also challenging to know. And then sometimes it's the reverse. I have people that will do great functional behavioral assessments.

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Lauren Swager: and they'll be like we've done so many Fbas. We've tried all these interventions. And and the behavior is not changing. We actually really think it's psychiatric. We need to find someone willing to to help us with that part. So it really goes back to how critical

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Lauren Swager: collaboration, collaboration and multidisciplinary teams are to approach these problems, because none of us can can help people in a vacuum really, truly takes a village night.

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Lauren Swager: Just saw that pop up to it absolutely. We all come from different different lenses and different skills. And again, more often than not, it's not one answer, right? It's a multi factor sort of thing that's gonna require all those skill sets.

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Lauren Swager: So we move into treatment, and I'm I need to move fast. But I want Elma to get to her case. But treatments kind of encompass all of those things we have to address the medical problems we have to address. The the communication needs, the developmental needs, the social skill needs like language needs. We need to

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Lauren Swager: to understand the perspective of people. How do we teach them skills and empathy? And and we need behavioral intervention plans that can be followed.

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Lauren Swager: And and I'm going to fly through this because I'm just talking so much. We need plans to address behavioral emergencies. And I want to highlight that because lots of times. Behavioral emergencies

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Lauren Swager: are are what get everybody's attention and makes people scared to to participate. But it's often really important to understand that a lot of behavioral emergencies come from the same understanding or missing some of the queues, and we only notice the emergencies. And we've missed all the other work sometimes. But yeah, we still have to protect people and keep them safe.

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Lauren Swager: I I don't. Wanna. I don't wanna spend a lot of time on this. I can. I can do more of this if you would like. But it is no secret that we are over medicating people with intellectual disabilities. I I cannot tell you

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Lauren Swager: how well, I think sometimes pharmacotherapy is really important.

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Lauren Swager: Lots of times people are giving medicines for things that haven't already had the behavioral work done to understand it. And sometimes I see sedation being more of a goal than a true functional correction or target. And so there also is a lot of things to recognize that medicines that are used to treat psychiatric illness have enormous side effects.

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Lauren Swager: and and and people with intellectual disabilities are actually more likely to get those side effects, and I cannot tell you how many times my career actually have thought the side effects was the antecedent of a behavior because someone was constipated from the medication. Someone was having a condition from the medicine. Someone was fighting sedation from a medication, and so never forget

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Lauren Swager: that, being a zombie, or being zombified or sedated, actually will worsen your behavior 100%, because it's a terrible, awful feeling. And we need to make sure that that's not the goal of medication.

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Lauren Swager: But all too often it is. And then we forget to reassess that the side effect may be part of the problem.

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Lauren Swager: So I I'm I'm gonna let Elma take over. Apologize. Alma did not give you as much time as I promised. But, I think your your case is great, and I'm gonna turn it over to you.

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Elma Fisher: Thank you.

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Elma Fisher: My name's Alma

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Elma Fisher: Our case today is a 33 year old male. He's the middle child. He has an older brother and a younger sister. His parents are still married. He did well in school academically, and he had just sinus and stomach issues otherwise healthy.

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Elma Fisher: His diagnosis was autism, specters, autism, spectrum, disorder, and schizophrenia. When he came to us. I was working in a long term structured residence. And it was 14 individuals in the home.

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Elma Fisher: We had dual diagnoses with mental health and idd and mental health and substance abuse. He was our mental health, Idd.

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Elma Fisher: He was very socially awkward. He had no friends, no job.

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Elma Fisher: He was living with his parents, and a lot of the people at the Rtsr. Thought he could not have autism and schizophrenia. At the same time, however, 30% of children and adolescents with child onset schizophrenia have co morbid autism, spectrum disorder.

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Elma Fisher: So the goals that he wanted for himself was to keep from self harming, live on his own, develop friend friendships.

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Elma Fisher: His barriers were social and communication deficits. In treating the mental health disorder.

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Elma Fisher: So what areas or domains of functioning would you seek assistance? For with this case.

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gillian mccarty: Well, my first question is, are those his goals? Or is that somebody else's goals for him?

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Elma Fisher: Those are his goals.

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gillian mccarty: So he's able to articulate that.

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Elma Fisher: Yes, he's he's almost aspergers.

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gillian mccarty: 5.

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Elma Fisher: He's very high functioning.

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Lesley Cottrell: And those, by the way, those domains of functioning refer back to Dr. Swagger's slides. And they're right in that sub bullet communication, social skills, personal independence at home.

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Lesley Cottrell: school or work functioning were were some of the main ones

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Lesley Cottrell: any of those.

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gillian mccarty: Have to ponder the whole conversation before. I haven't.

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Elma Fisher: His family did very well for him. As he was a child, he had many wraparound services.

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Elma Fisher: he had behavior management.

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Elma Fisher: and I think that's why he

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Elma Fisher: he didn't have

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Elma Fisher: a hard time making the friendships and stuff is because his family was all the time

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Elma Fisher: saturating him with positive supports, and teaching him the ways

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Elma Fisher: that it should go.

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Lesley Cottrell: Yeah, must.

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gillian mccarty: Sorry is the member able to communicate what the schizophrenia does to him.

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Elma Fisher: Yes, he would say that the voices in his head would tell him to hurt himself

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Elma Fisher: so he would cut his self. He would cut his wrist.

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Elma Fisher: 1 one time they told him to kill himself.

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gillian mccarty: Is he compliant with his meds.

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Elma Fisher: He is now.

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Elma Fisher: Yes, he is now.

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gillian mccarty: And does he articulate that the Meds do help him, and that the voices don't talk to him.

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Elma Fisher: He says that they still there, but they're not as bad, and he knows that they're not real now, so he doesn't pay any attention to them.

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gillian mccarty: So is he getting in the community to be able to access different people, to even potentially make those friends that he is, is his goal.

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Elma Fisher: Yes, he actually he's 40 years old now. He actually lives alone. He has. He's holding down his own job, and he does have friends.

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Elma Fisher: so he's doing really well. He's staying on his meds.

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Elma Fisher: so I'm very proud of him.

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gillian mccarty: Her.

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Lesley Cottrell: Elma in terms of the process. So now it seems like he can recognize the voices like you said, How how did people, help him get through that transition

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Lesley Cottrell: until he could recognize that? What like we, we have antecedents, behaviors, consequences. How? What did that look like? Were you around

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Lesley Cottrell: at that time when he was still trying to figure that out.

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Elma Fisher: No, when he came to us he already knew.

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Lesley Cottrell: Okay.

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Elma Fisher: Yeah, he he went through all of that stuff when he was in school. He went up to the teacher the one day and said that

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Elma Fisher: somebody in his head was telling him to cut his self. And he had scissors and was gonna cut his self. And they did functional behavior assessments. They did all kinds of

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Elma Fisher: assessments and things, and they found out that he was actually schizophrenic, and hearing the voices.

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gillian mccarty: Was he?

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Elma Fisher: So long as.

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gillian mccarty: Always in West Virginia.

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Elma Fisher: No, this this case is out of Pennsylvania.

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gillian mccarty: that that sounds like they might have some amazing programs that allotted for 4 time. Because it sounds to me like, even though we had struggles, he had

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gillian mccarty: a good support system, knowledgeable parents that advocated for him.

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gillian mccarty: and we're able to help teach him to articulate those things. So

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gillian mccarty: 4 mile to 6. Son, who is an adult and definitely a borderline kind of guy.

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gillian mccarty: I can see where, if he had had a different set of parents.

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gillian mccarty: his outcome would be very, very different.

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gillian mccarty: And

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gillian mccarty: having those preventatives in the beginning, and somebody who understands

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gillian mccarty: and has the patience to work with them is invaluable, and it is something that the State of West Virginia is hands down, lacking in the resources of.

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Elma Fisher: I agree.

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gillian mccarty: That

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gillian mccarty: that the

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gillian mccarty: mental health crisis is a crisis. But the drug crisis is a real thing.

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gillian mccarty: and it's also a cash cow

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gillian mccarty: and because it's a cash cow. Everybody is coming out of droves for Idd and going to the drug population, and it's leaving us with no resources for these members.

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gillian mccarty: and there were already very least little resources. To begin with.

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Elma Fisher: Right.

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Lesley Cottrell: So we're

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Lesley Cottrell: real quick, Dylan and and to interrupt you. But the

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Lesley Cottrell: so knowing outside of Pennsylvania having better services and than than us, how do we start to implement better services? So I think the last 3 questions are giving us the skills or having us start to think about based on our different roles.

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Lesley Cottrell: What knowledge we we lack? And we may need. I mean, how do we start to

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Lesley Cottrell: think about

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Lesley Cottrell: autism and schizophrenia? What would you do next?

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Lesley Cottrell: What questions come up in people's minds? Let's get a little vulnerable here, and you know, as if we

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Lesley Cottrell: we don't know. And and who would we ask?

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Lesley Cottrell: What are some.

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gillian mccarty: I'm gonna be super honest, because, as somebody who does know

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gillian mccarty: couldn't get any dang on help for my child.

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gillian mccarty: And he went to wvu, and had all the official diagnosis and everything. And and

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gillian mccarty: those same people were like.

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gillian mccarty: he's teetering on this or that. So we're not. Gonna we're not gonna do the 3 h long tests, because

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gillian mccarty: God forbid that would give you some more answers and maybe

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gillian mccarty: open up opportunities

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gillian mccarty: that

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gillian mccarty: because of my background.

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gillian mccarty: And when he became physically aggressive as a teenager.

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gillian mccarty: I saw the value

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gillian mccarty: in

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gillian mccarty: getting him locked up because it was the only way to get resources and and assistance.

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gillian mccarty: but he needed.

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gillian mccarty: and I knew

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gillian mccarty: I gambled

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gillian mccarty: on that, but I knew it was the only way to get him into treatment that might help him.

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Lesley Cottrell: Okay. So

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Lesley Cottrell: so that was your experience. Other and I

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Lesley Cottrell: camera putting her experience was was similar. And this is kind of going in the direction of as they get older and bigger, and and either

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Lesley Cottrell: harm themselves or others, it it becomes less. How do we? How do we move away? So now.

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Lesley Cottrell: Gillian, I'm just. Did I hear any other

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Lesley Cottrell: thoughts about

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Lesley Cottrell: other experiences for what they found, what? What might have worked, maybe different ex experiences or the same. But

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Lesley Cottrell: What about what about others? What other suggestions would we have? Again, we want to turn.

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Lesley Cottrell: turn the curb, turn the direction from these experiences so.

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Brandon Kijewski: One of the I mean 1. One of the the hardest things here is like, now I I've I've worked in waiver for over 10 years now, and before this I some people may know who I am as soon as I say this, but I came from Chicago. That's where I was born and raised, and everything. And I graduated high school in Illinois, and

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Brandon Kijewski: I worked in mental health before I worked in Idd so, and I worked in like state hospitals, residential settings, places that like are a lot rougher than what our Idd folks are. One of the things that I did notice when I first moved. Here was the level of psychiatric care that

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Brandon Kijewski: Idd folks were getting was genuinely not good.

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Brandon Kijewski: and I will not, you know, name names or point fingers or anything to some of them, but I mean there are, I I think some of us maybe, have read the news in the last 5, 10 years, and noticed a name or 2 that

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Brandon Kijewski: lost their medical licenses in West Virginia, who a lot of people at big agencies in the Charleston area. We're seeing

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Brandon Kijewski: you know. Personally, I have been there to see

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Brandon Kijewski: a client walk in and a psychiatrist look at them and write a script and walk out in less than 60 s.

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Brandon Kijewski: there is a lot of

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Brandon Kijewski: they need better psychiatric care from the word go.

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Brandon Kijewski: because ultimately, when we're talking about the behaviors and things so like when I hear this kid, the first thing that keeps ringing in my bell is

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Brandon Kijewski: rule out psychiatric rule out medical before you go to behavioral. And it sounds like the beginning of his issue is a psychiatric issue, because he's responding to command hallucinations. Right? So

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Brandon Kijewski: if that's the case.

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Brandon Kijewski: that has to be the first thing that has to be addressed before we can even start to talk about data collection. And all this other sort of stuff, because all that data collection is not good. If the psychiatric issues are what's prevailing. First and foremost, like he has to be stabilized medically, psychiatrically, before you start addressing maladaptive behaviors in that way. And that's a like in West Virginia. At least, that's a pretty basic tenant of our Bsp of our Bsp teachings.

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Brandon Kijewski: So my my thought, and like my first thing, is.

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Brandon Kijewski: when you find a good psychiatrist.

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Brandon Kijewski: I send anybody and everybody I have that needs a psychiatrist to that person.

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Brandon Kijewski: finding a good one is hard.

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gillian mccarty: Finding one at all that does more than

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gillian mccarty: at least in my area. I don't know what it's like in other places.

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gillian mccarty: but the ones here

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gillian mccarty: see you for maybe 5 min. Change out meds and go about their day, and anybody who

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gillian mccarty: tests higher than mild

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gillian mccarty: mental retardation

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gillian mccarty: medical card doesn't cover therapies for

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gillian mccarty: so so you can't even

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gillian mccarty: pry

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gillian mccarty: to get in as an adult

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gillian mccarty: with a therapist

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gillian mccarty: and have it covered with your medical card.

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Lauren Swager: Well, and I I just wanna articulate from the psychiatrist point of view, too, that you know we have to make sure we get all this good information to the psychiatrist. This is really why communication collaboration is key.

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Lauren Swager: I I like to think of myself as a good psychiatrist that really wants to do well, but also have to tell you how many times I've seen, especially adult patients show up on my schedule.

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Lauren Swager: and no one came with them to tell me what was going on, or provide me with any information, and I just saw someone over medicated having side effects, and I had nothing, and they, if they are able to tell you what's going on, or you don't have that data to look at it. It also is really challenging. And so

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Lauren Swager: I I'm really about the team with with this. I mean, I think you're right. If there's a true psychiatric issue it needs treated.

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Lauren Swager: But how are we. Ca, you know, how are we communicating that if I don't see that behavioral data or I don't get that information, it's really hard to tell in 5 min

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Lauren Swager: that it's psychiatric. And and so I I think sometimes our systems are siloed so that we're not all working together. And I think financially, our our reimbursement. Si system isn't really as structured as it should be to encourage the communication for that type of care. And so

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Lauren Swager: I I go back to sort of the original thing, that that I think the silos of breaking it into psychiatric or behavioral is helpful to degree like academically in our heads. But we all should be sitting in the room together, communicating because I can't do anything within medications, nor can any psychiatrist if they don't get good information. And you're right. We should never medicate things we don't understand, but but that's but what do you do when someone's sitting there?

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Lauren Swager: And and sometimes it the reverse happens right. You'll see people where I'm saying I'm stopping this medicine. I'm not writing that because I just see the side effect, and I don't know why you're on it. And and then people have have problems when medicines are stopped because of poor communication. So

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Lauren Swager: I mean it. It really is.

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Lauren Swager: It really is messy but I I think again, this group is reflecting how important all these different pathways are.

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gillian mccarty: I think we all have just made you realize a great business model that you should open

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gillian mccarty: and have mal multiple diagnosis

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gillian mccarty: and have a teams that

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gillian mccarty: I think part of. I think part of the structural issue

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gillian mccarty: with the system

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gillian mccarty: is that everybody is.

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gillian mccarty: There's such a concern with

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gillian mccarty: keeping our doors open and getting through Olac reviews and all of that stuff, or paying the bills, or getting everybody as many people in as we can.

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gillian mccarty: That

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gillian mccarty: that note.

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gillian mccarty: there's not somebody at the head saying, this is truly what we're going to do, and we're not going to just filter our clients through. But we're truly going to take the time which each of our members

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gillian mccarty: and truly look at at diagnosing these people properly.

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gillian mccarty: and and

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gillian mccarty: every doctor's appointment I've ever been to with any client

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gillian mccarty: has been a 2 min. What are you here for? This is what I can do for you, and out the door they go, and sometimes they don't even look you in the eye as the staff.

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Lesley Cottrell: Mark, you have your hand up. Thank you, Gillian, appreciate that.

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Marc Wilson: So say, as far as Idd waiver, and people with positive support plans getting good data

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Marc Wilson: from Jack Hairstop has always been an issue, and

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Marc Wilson: getting the data to present to the psychiatrist for Med changes is

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Marc Wilson: is that issue that results from having they. I mean, now.

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Marc Wilson: bad data or not lack of data from the direct care staff. So

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Marc Wilson: you know, cycling in and out of direct care staff and getting good ones to collect good data

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Marc Wilson: for the Bsp. To present to the or to send with the staff to the psychiatric appointment.

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Marc Wilson: you know, leads to not having that data that you're looking forward to

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Marc Wilson: make a good net adjustment. So

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Marc Wilson: it's just

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Marc Wilson: all for the cycle of having lack of direct care staff to

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Marc Wilson: you. Stick around long enough to be your job and

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Marc Wilson: get good training and all that.

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Marc Wilson: And plus, there's just a big lack of

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Marc Wilson: 5. And Bsp. Who are sticking around long enough to get good of their jobs, too. So

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Marc Wilson: it's a stemmach issue.

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Lesley Cottrell: Point

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Lesley Cottrell: thanks. Mark Brittany.

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Brittney Nichol: I want to kind of spin off of what Mark just said, because

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Brittney Nichol: on the flip side we have long term vsps at our agency, and we send reports to every psychiatry appointment and to every therapy appointment. And we still cannot get these guys to make the appropriate adjustments. Take the time with our clients a lot of the time that paperwork gets pushed to the side. They don't even look at it. We try to send it in advance of appointments. I know I've gone personally, even as a at a director level.

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Brittney Nichol: to certain psychiatric appointments, and we still don't see the changes that these guys need we are not. Listen to. We are not, you know, what what we bring to the table is just not taken into account. And you know, a big part of this. You know, this whole

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Brittney Nichol: thing that we're talking about today is that some of this stuff cannot be treated with just basic behavioral interventions, you know, without the stability and without these guys being psychiatrically stable on in on the appropriate medications, getting the right diagnoses and whatnot. Sometimes anything that we do is not gonna help until that is all taken care of and stable first.

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Brittney Nichol: So it's very frustrating on our end. We definitely are lacking good resources. And and these these local psychiatrists here in the the Northern Panhandle, you know, we, we potentially are

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Brittney Nichol: are overloading them with so many people that they just don't have the time to take with our clients.

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Lesley Cottrell: Point.

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Lesley Cottrell: Brandon, I'll I'll come to you to finish this out

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Lesley Cottrell: when you're on mute

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Lesley Cottrell: spray.

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Brandon Kijewski: Sorry about that. I was just gonna share something in in that same vein, you know, in in a personal experience.

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Brandon Kijewski: I I think the only thing that helped me in this story was the fact that I I did work in a psychiatrist office, you know, doing mental health before I came to West Virginia. Had a we had a client who ultimately wound up

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Brandon Kijewski: being treated for something that they weren't actually diagnosed with, and one of the things that for a name. I don't know if anybody ever what will wind up coming across this gentleman. But Dr. Alexander Morrell was his name. Very, very strange but brilliant man, you know those things tend to run hand in hand sometimes. Anyways.

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Brandon Kijewski: He he would. He used to say that sometimes with some of the mental illnesses.

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Brandon Kijewski: sometimes the only way you can figure out what it is is by trying different medications to see what actually works. And I don't know how true that is, or isn't, you know, like I am not a psychiatrist. That's not my job. But he he did point that out particularly when you have things like you know, bipolar, that doesn't have any of the manic episodes with it, and you know, treating that one way as opposed to the major depressive disorders.

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Brandon Kijewski: So anyways, the the point that I was getting at was you know, we had somebody who had been diagnosed with the major depressive disorders, with psychotic features, and I mean aggression does not begin to explain what this was, I mean, we're talking like elopement breaking car windows fighting the police, I mean, I mean, just like.

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Brandon Kijewski: yeah, we're not.

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Brandon Kijewski: Most people are just not equipped to handle this. So on a like a last ditch.

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Brandon Kijewski: just trying to, you know.

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Brandon Kijewski: pull something out of my out of out of thin air. Sorry I almost had something I shouldn't have said there, but trying to pull something out of thin air there.

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Brandon Kijewski: I went back through this client's chart from the charts that we received from Bateman, where he was at some point, and I was just trying to like look and find anything that could help, and I came across one exact page and a whole chart exactly one page

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Brandon Kijewski: that had him diagnosed with bipolar. All the other things had a diagnosis for major depressive disorder.

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Brandon Kijewski: And so I wrote a note, and you know it was just a it was a small thing, you know, and and and like, I believe, Britney said. You know sometimes we will send notes to the psychiatrist appointments and things like that, just to try to help out a little bit, especially if we just. You know, we're throwing our hands in the air, and we don't know what else to do. I just wrote a note, and I was like. Is there any chance, you know, that he might have bipolar, and that maybe we would try something to treat bipolar

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Brandon Kijewski: at that time the psychiatrist? I was told I was not at the appointment. I was told this by the staff who took him. The psychiatrist said, Absolutely not. That's not what this is. The client subsequently flipped over the psychiatrist table in the office and started tearing his office apart. And psychiatrist then said, Well, you know, what what could it hurt to try this like. Let's let's go ahead and try him on lithium.

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Brandon Kijewski: he went on. Lithium he has been stable for the last 7 years.

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Brandon Kijewski: That's just just my my little bit, my little slice of pie. There.

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Brandon Kijewski: Yep.

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Lesley Cottrell: That's a good example.

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Lesley Cottrell: Thanks, Krishna.

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Lauren Swager: Yeah. And and Brandon, I might add to like that. I think that happens a lot right cause. There was clearly a depressive episode. We're carrying that. But there, there really was missing that manic data. I mean one of the most helpful things, too, that when I and I worked in a facility for Idd that that had both. Psychosis is even simple things like tracking appetite and sleep cycles can go a long way to getting the right diagnosis, too. So

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Lauren Swager: you you it's not just tracking the the aggressive behaviors, looking at their energy state or their sleep, can really help pick on pick up. And or if they're head banging, can really pick up on little things like psychotic symptoms or mood changes that that might not meet standards. So even those little things, and and being that detective that you were, can make such a difference. That's that's a beautiful story.

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Lesley Cottrell: Well, we are over. I we really appreciate the great discussion. Dr. Margaret. Elma. Thank you for leading us this session

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Lesley Cottrell: very helpful great discussion. I think everyone everyone's been putting in the chat some comments, suggestions. We're gonna send some resources

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Lesley Cottrell: that Elma and Dr. Swagger provided or referenced in their slides as well as the slides.

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Lesley Cottrell: And so thank you very much. Hope you enjoy your afternoon, and we'll see you for session 5 next month.

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gillian mccarty: Leslie, can I ask one question before we go any success with getting anybody from the Governor's office?

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Lesley Cottrell: I'm not sure if they're on. The invitations. Went out shortly after you suggested that.

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gillian mccarty: Okay.

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Lesley Cottrell: Oh.

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Lesley Cottrell: right!

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gillian mccarty: Awesome.

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gillian mccarty: Thank you.

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Lesley Cottrell: Thank you.

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Lesley Cottrell: Take care! Everyone.

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Elma Fisher: Thanks. Everyone.