Reflecting one of BIAA’s biggest public policy accomplishments this year, a group of Senators issued a letter on August 4, 2008 to Defense Secretary Robert M. Gates urging official TRICARE coverage of cognitive rehabilitation.The group of 10 United States Senators, led by Evan Bayh (D-IN) and Barack Obama (D-IL), sent a letter to Defense Secretary Robert M. Gates calling on him to enact official coverage of cognitive rehabilitation within the military’s TRICARE health insurance program. Several major media outlets covered this story, and the press release announcing this letter included a quote from Democratic Presidential Candidate Barack Obama in which he described cognitive rehabilitation therapy as “one of the most accepted treatments for TBI.”

Throughout the summer, BIAA worked closely with Senator Bayh’s office to support the development of this letter and to urge the support of 10 highly esteemed Senators who signed on in support of this important effort to increase access to timely, state-of-the-art care for returning servicemembers with traumatic brain injury.

A copy of the letter, along with talking points in support of TRICARE coverage of cognitive rehabilitation, and a summary of evidence attesting the efficacy of cognitive rehabilitation, is available on BIAA’s website at http://www.biausa.org/policyissues.htm.

In another promising development, the Congressional Brain Injury Task Force is currently working on a similar effort on the House side.

In addition this week, BIAA submitted an official letter of endorsement for H.R. 2818, The VA Epilepsy Centers of Excellence Act of 2007, which would establish six VA Epilepsy Centers of Excellence (Epilepsy CoEs) across the country to lead the way in epilepsy diagnosis, research, treatment and surgery.

The House Veterans Affairs Subcommittee on Health is scheduled to hold a hearing on the bill next Tuesday, April 15, 2008.

BIAA’s endorsement letter states, “BIAA continues to advocate for the use of all available resources (including civilian sector resources when appropriate), as well as the development of new resources and system capacity within the VA, in order to ensure that all veterans with TBI receive the right care, right now.”

A copy of BIAA’s letter endorsing H.R. 2818 can be obtained by visiting BIAA’s website at the following address: http://www.biausa.org/policyissues.htm.

As can be seen in this latest Bloomberg post, the recent changes in punitive damage settlements cases has had a profound impact on civil and tort litigations around the country. From Ford motor company settlements to the Exxon Valdez, this is a watershed moment in the world of serious injury law and civil litigation. Read more here.

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Jan. 15 (Bloomberg) — A U.S. court crackdown on punitive damages resulted in the second consecutive year of declines and reversals of earlier verdicts, a trend working in favor of companies like Ford Motor Co.

The Dearborn, Michigan-based automaker in the past five years has been hit with more than $392 million in punitive awards. Limits on such damages have given Ford victories in appeals of two decisions totaling more than $100 million and may help it in hundreds of other product-liability suits. Click here for more.

Punitive damages in the 50 biggest verdicts fell to $1.6 billion in 2007 from $1.8 billion in 2006 and $5 billion in 2005, according to data compiled by Bloomberg. A pivotal U.S. Supreme Court decision last year will aid in appeals and help reduce future awards, companies’ lawyers say. The court said defendants can’t be punished for harming anyone not included in a case, such as other customers.

SENATE PASSES TBI ACT REAUTHORIZATION BILL

Earlier today (Tuesday, December 11, 2007), the Senate passed by voice vote S. 793, legislation to reauthorize the TBI Act. The reauthorization includes provisions to continue and hopefully expand TBI Act programs, such as the HRSA State Grant and CDC surveillance programs.

This is a big victory, as the authorization for TBI Act programs officially lapsed in 2005 and advocacy efforts to renew this authority have been vigorous. Stay tuned to BIAA for further information and analysis as developments progress.

APPROPRIATIONS HANG-UP

Unfortunately, as of press time on Tuesday, December 11, 2007, Congressional leadership had still not made a final decision regarding floor consideration of a “split-the-difference” omnibus appropriations bill, and thus, a conference report for this bill has not been filed. Stay tuned to BIAA for the latest updates on this situation.

DEFENSE AUTHORIZATION BILL – INCLUDING TBI CARE PROVISIONS – SET FOR PASSAGE

Congress is expected to pass the National Defense Authorization Act for Fiscal Year 2008 – including key wounded warrior provisions related to TBI care – this week. The House of Representatives is expected to adopt the conference report tomorrow (Wednesday) or Thursday, followed by predicted swift passage in the Senate.

According to CQ Today (Dec. 11, 2007), “Several dozen House members might vote against the bill because of its war authorization, but they are likely to prove only a bump in an otherwise smooth road to adoption. And despite the conferees’ differences with the White House on a wide range of issues including military pay and overseeing contractors, they have sufficiently modified provisions to avert a veto threatened by the administration, members and aides predict.”

BIAA has lobbied actively this year on many of the TBI care provisions contained in the final version of the bill, and grassroots activity on the part of TBI advocates helped ensure that these TBI provisions were included in the conference report.

Below is a summary of the key TBI provisions included in the bill:

Major TBI Provisions in the National Defense Authorization Act for Fiscal Year 2008 (H.R. 1585)

? Overlap of DoD/VA benefits: Allows severely ill or injured service members and veterans to access their health care – including TBI care – based on their medical condition, rather than on their status as active duty or medically retired. For example, if implemented, this overlap of benefits would allow medically retired veterans to access TBI care at private/civilian facilities that are eligible TRICARE providers. Currently, this access is limited to service members who have active duty status. Note: Some civilian TRICARE facilities provide cognitive rehabilitation therapy. This provisions sunsets in 2012. (Sec. 1631)

? DoD Comprehensive Plan To Address TBI: Requires DoD to submit within 180 days of enactment, in consultation with the VA, a comprehensive plan for programs and activities of the Department of Defense to prevent, diagnose, mitigate, treat, research and otherwise respond to TBI and PTSD. Plans are directed to include provisions for making injured service members aware of options for different treatments. (Sec. 1618)

o This plan is required to include a proposal for the development and deployment of evidence-based means of assessing traumatic brain injury, PTSD, and other mental health conditions in members of the Armed Forces, including a system of pre-deployment and post-deployment screenings of cognitive ability in members for the detection of cognitive impairment. (Sec. 1618)

o This plan is also required to include a proposal on the development and deployment of an education and awareness training initiative designed to reduce the negative stigma associated with TBI and PTSD, and a plan for the provisions of education and outreach to families of members of the Armed Forces with TBI, PTSD, or other mental health conditions. (Sec. 1618)

? VA Individualized TBI Rehabilitation Plans/Use of Civilian Facilities for TBI Care: Requires the VA Secretary to develop an individualized plan for rehabilitation and reintegration into the community for each veteran or service member who receives inpatient or outpatient care at the VA for TBI (Sec. 1702).

o Note: Unfortunately, the final version of this defense authorization bill/conference report does NOT include the provision in the Senate version of the bill which would have required the Secretary of the VA to provide care in non-VA (civilian) facilities if the Secretary determines that the VA is unable to provide care at the frequency or duration prescribed in the individualized plan, for rehabilitation and reintegration, or if the Secretary determines it is optimal for the veteran to receive care in a non-VA facility.

o Similar – but weaker – language, was included, stating that, in implementing and carrying out the individualized plans, the Secretary of the VA “may provide hospital care and medical services through cooperative agreements with appropriate public or private entities that have established long-term neurobehavioral rehabilitation and recovery programs.” (Sec. 1703)

? Procedures for Referrals to VA and Civilian Health Care Services: Requires a comprehensive policy on improvements to care, management, and transition of recovering service members to “provide for uniform policies, procedures, and criteria among the military departments on the referral of recovering service members to the Department of Veterans Affairs and other private and public entities (including universities and rehabilitation hospitals, centers, and clinics) in order to secure the most appropriate care for recovering service members, which policies, procedures, and criteria shall take into account, but not be limited to, the medical needs of recovering service members and the geographic location of available necessary recovery care services.” (Sec. 1611)

? DoD TBI Center of Excellence: Requires the establishment of a Center of Excellence in the Prevention, Diagnosis, Mitigation, Treatment, and Rehabilitation of Traumatic Brain Injury, including mild, moderate, and severe TBI. The Secretary of Defense is directed to enter into partnerships, to the maximum extent practicable, with the VA, institutions of higher education, and other appropriate public and private entities, to further the research efforts of the centers. This DoD TBI Center of Excellence is responsible for implementing the DoD’s comprehensive plan to address TBI – as required by Sec. 1618 – once this plan is developed. (Sec. 1621)

? Collaboration Required in New VA TBI Research Efforts: Requires new VA TBI research efforts to collaborate with facilities that conduct research on rehabilitation for individuals with TBI and receive grants for such research from the National Institute on Disability and Rehabilitation Research of the Department of Education (for example, the TBI Model Systems of Care program). (Sec. 1704)

? National Academy of Sciences DoD/VA TBI Study: Requires DoD, in consultation with the VA, to contract with the National Academy of Sciences to study the physical and mental health – specifically including the neurological, psychiatric, and psychological effects of TBI – of members and former members of the Armed Forces who are deployed in OEF or OIF, and their families as a result of such deployment. Specifically, a comprehensive assessment is required – not later than three years after the date of legislative enactment – of “the full scope of the neurological, psychiatric, and psychological effects of traumatic brain injury on members of the Armed Forces, including the effects of such effects on the family members of such members and former members, and an assessment of the efficacy of current treatment approaches for traumatic brain injury in the United States and the efficacy of screenings and treatment approaches for traumatic brain injury within the Department of Defense and the Department of Veterans Affairs. (Sec. 1661)

? Comprehensive Long-Term TBI Rehabilitation Program in VA: Requires the Secretary of the VA to develop and carry out a comprehensive program of long-term care for post-acute traumatic brain injury rehabilitation that includes residential, community, and home-based components utilizing interdisciplinary treatment teams. This program is to be developed and located in Department of VA polytrauma rehabilitation centers. Eligibility is restricted to veterans diagnosed as suffering from “moderate to severe” traumatic brain injury (excludes mild) who are unable to manage routine activities of daily living without supervision or assistance, as determined by the Secretary. (Sec. 1702)

? Pilot Program on Assisted Living Services for Veterans with TBI: Requires the Secretary of the VA, in collaboration with the Defense and Veterans Brain Injury Center of the Department of Defense, to carry out a five-year pilot program to assess the effectiveness of providing assisted living services to eligible veterans with traumatic brain injury to enhance the rehabilitation, quality of life, and community integration of such veterans (Sec. 1705)

? Report on TBI Classfications: Requires the Secretary of Defense and the Secretary of Veterans Affairs to jointly submit a report – not later than 90 days after the date of legislative enactment – describing the changes undertaken within the Department of Defense and the Department of Veterans Affairs to ensure that traumatic brain injury victims receive a medical designation concomitant with their injury rather than a medical designation that assigns a generic classification (such as “organic psychiatric disorder.”) (Sec. 1664)

TBI Registry in VA: Requires the Secretary of the VA to establish and maintain a registry of names of each individual who: 1) served as a member of the Armed Forces in Operation Enduring Freedom or Operation Iraqi Freedom; 2) exhibits symptoms association with TBI; 3) applies for care and services from the Department of Veterans Affairs or files a claim for compensation for disability associated with such service; and 4) grants permission to the Secretary to include such information in the registry. (Sec. 1704)

Source: http://www.calbia.org/

The House is scheduled to vote on Dec. 11 on a multi-bill “omnibus” Fiscal Year 2008 appropriations bill which splits the difference between the White House and Congressional budget proposals.

The omnibus appropriations package is expected to consist of the 11 remaining spending bills – including the Labor-HHS-Education spending bill, which funds TBI programs – totaling $10.6 billion less than what Congress had originally planned. The new Labor-HHS-Education bill spending allocation in such an omnibus bill is expected to be approximately $3.5 billion less than its current form.

The Labor-HHS-Education bill recently passed by Congress (but vetoed by President Bush) provides $9.455 million for the HRSA Federal TBI program, over the total $8.910 million allocated last year. Likewise, the bill includes $5.960 million in funding for CDC TBI programs, an increase from approximately $5.3 million last year. Also of key importance, the bill includes $900,000 in additional funding for the TBI Model Systems of Care program, which BIAA fought hard for this year, in order to prevent this important research program from being downsized.

If the expected “split-the-difference” omnibus bill is not passed by Congress next week or is vetoed by President Bush, the most likely conclusion to the appropriations standoff would be to send the president an omnibus that matches his budget request before the end of the year. This would result in more drastic spending reductions.

Please click on the “Take Action” link in the upper right hand corner of this email to urge your congressional representatives to pass the omnibus appropriations bill expected to be considered by both chambers the week of December 10, 2007.

Source: http://www.calbia.org/

Local schools are called upon to make major investments in the lives of children with special needs
Name : Ronald Scaglia

Last year, 21 Long Island school districts’ budgets were defeated, and a record number were forced to adopt austerity budgets.

Recent scandals involving the theft and misappropriation of taxpayer funds, an aging Long Island population and ever increasing property taxes all likely played a role in those defeats. And, while school officials in both Nassau and Suffolk County are working hard this year to ensure that their budgets are passed, taxpayers continue to ask why are costs so high?

One answer is the increased cost of providing an ever growing population of special education students with the vital services they need.

“Special education is a great expense,” said Lindenhurst Superintendent Neil Lederer. “Most special education expenses are mandated by New York State or the federal government and the expense is certainly justified. In Lindenhurst, we work to ensure that our special education program is comprehensive, sound and good and we are always looking to improve it.”

“All children deserve a quality education,” said Plainedge’s Director of Special Education, Mona Tobin.

William Bolton, superintendent of schools in Copaigue agreed: “We have children in public schools today that would never have been placed in public school when I began my career in education” he said. “But with the kind of support services we provide now-one-on-one aides, full-time nurse, bus monitors and special transportation to name a few-they have become our responsibility. If it were my child I would want it that way because I would want them to have the enjoyment of a normal educational experience with their peers.”

What school officials wrestle with is not the question of should these services be provided, but how to pay for them without overburdening the local taxpayer. “The brutal reality is that it is very expensive,” said Bolton.

Special education in the United States changed drastically with passage of the Rehabilitation Act of 1973, which was later modified into the Individuals with Disabilities Education Act (IDEA) in 1975. According to that law, all children are entitled to “a free appropriate education in the least restrictive environment.”

Under the law, children with disabilities are required to receive the same educational experience as other children. School districts are required to pro vide specially designed services, instructions or programs to meet the needs of students with disabilities and modifications to the programs or the school environment. These individual educational programs or IEPs help ensure that the students not only get what they need to succeed academically, but that they also are able interact with their peers as much as possible.

IDEA lists 13 categories that qualify a child for special education services: autism, deafness, deaf-blindness, hearing impairment, mental retardation, multiple disabilities, orthopedic impairment, other health impairment, serious emotional disturbance, specific learning disability, speech or language impairment, traumatic brain injury and visual impairment including blindness. When a child is classified as disabled, the local education agency (i.e. the school district where the child resides) is required to provide services, accommodations, equipment, instructors or whatever is deemed necessary to provide the child with a free appropriate education in the least restrictive environment.

According to statistics from the New York State Education Department, more than 7 billion dollars was spent on special education services during the 2002-03 school year by New York State public school districts. This yields an average of $17,818 spent per special education student. By comparison, almost 21 and one half billion dollars was spent on general education students during the same year, which averages out to $7,595 spent per general education student or less than half on the amount spent per special ed student. Statewide, about 12 percent of the student population is classified as needing special education services. Locally, the eleven districts covered by the Massapequa Post, Amityville Record and Babylon Beacon spend about $8,100 per general education student and about $20,000 per special ed student.

“When the special education laws were passed in the 1970s, the federal government promised states a 40 percent reimbursement,” said Massapequa Superintendent Maureen Flaherty. “The reimbursement has only been about eight to ten percent. Therefore, the cost of the laws, fall on the homeowners.”

A common misconception is that these student services deal strictly with helping children who are struggling educationally. In fact, special ed money is spent on a wide variety of services such a speech, physical and occupational therapy, transportation and tuition reimbursements to out-of-district programs such as BOCES, special education teachers, teacher aides, home instruction, psychological services, technological devices such as microphones or audio equipment for children with hearing impairments, nursing and other health-care services. Districts may also have to hire paraprofessionals who can communicate with hearing impaired students using sign language, provide medical assistance as required or other medical or physical needs that have to be met for the child during the regular school day. Sometimes, those costs can be very high. For example, a child with a debilitating disease can cost a district more than $100,00 per school year.

School districts are required to pay for all of these costs, even if the child attends a private school and

they are not reimbursed through individual health insurance programs or plans that would normally assume some of these costs outside of the school environment.

Another major change to special education and general education occurred with the passage of the No Child Left Behind Act in 2001. The law, which resulted from educational proposals made by President George W. Bush during the 2000 campaign, was signed into law by Bush and received bipartisan support in Congress. The law expects all students to graduate high school. To help ensure that goal is achieved in every school district across the country, the law requires additional student testing, improved teacher quality and school choice for parents of children in failing schools. And, while the goals are laudable say many school officials, they have been hoisted on school districts with little or no additional federal funding to pay the costs associated with them. And, they apply to all students, including those with special educational needs.

Nonetheless, school districts scrambled to come up with a plan to meet the new challenges.

“When the No Child Left Behind Act was passed, we reevaluated our program,” said Lindenhurst Superintendent Neil Lederer, a supporter of the measure. “We looked at the needs of the children and felt that the instructional program was not meeting their needs.”

In particular, he said, the district recognized that some special education students were being taught by special education teachers not curriculum-specific teachers such as those teaching the rest of the student population in math or science. As a result, the district expanded inclusion classes at the high school and the middle school giving special ed students the opportunity to be taught by teachers who are experts in the various disciplines.

“This also gives special education teachers the ability to modify the curriculum to the special ed students,” said Lederer. “We’ve had great success with it.”

Similar changes have been made in other districts. In Plainedge, for example, smaller class sizes have helped the district reach its goals.

“We structure smaller classes so that there is a lower ratio of teachers to students, which allows the teachers to spend more time with each student. For students who need smaller class size and more teacher support,” Special Education Director Monica Tobin said.

The district has 15 students a teacher and an aide in those classes. For students with autism the district has provide a teacher and two teacher aides to every six students.

“Our high school programs are geared to students earning a regents diploma and our special ed students do quite well on regents exams,” she said.

To help defray some of the costs of special education as students move through the district, educators have found that providing services early on in a student’s academic career saves money as they move to higher grades. An example of this is Plainedge’s autistic program called CHAMPS.

“It really meets the needs of the autistic students,” said Tobin.

“We spend money in prevention and put efforts into our early childhood program,” said Flaherty. “This helps children and the level of services needed is not as great.”

Massapequa also has an autistic program at its elementary level and teacher training, the Wilson Reading Program, as well as an extended day kindergarten to help students with special needs.

“Some issues are reading issues,” said Flaherty. “By addressing these issues, we’ve seen very strong results in our literacy program. Our extended day kindergarten is also highly successful. We’ve given the children the essentials while holiday down staffing costs.”

Consolidating the services of successful programs such as CHAMPS and offering them to other districts also cuts costs by making them available at a cost that is lower than if each district implemented it while at the same time offsetting the cost of the district providing the services.

“By creating such a good program, we are able to not only save the costs of sending our students out of the district but we receive money from the other districts who send us their students,” pointed out Tobin.

Lederer said that his district also tries to provide its students with services within the district.

“We’re always looking to not only service our children in district as well as take in other students,” he said adding that the district has had success with its 8:2:1 inclusion program, which is eight children to one teacher with two aides. “This may cost us less than $100,000. for all the students for the whole year while sending one child to BOCES costs about $60,000, which would make our costs about a half million dollars.” said Lederer. “Of course, if a student needs out-of-district placement, we will provide it.”

General education teachers can also be very helpful in providing special ed students with the education they need. Often it is a general education teacher that identifies a child who is struggling and determines what the child needs. Districts are relying upon general education teachers to make an early diagnosis, as well as provide the services that special ed students need in an inclusion setting.

“We have excellent general education teachers in Plainedge,” said Tobin. “They give the kids what they need and work very hard to meet all of the standards. All of our personnel work together.”

“We have effective use of our instructional personnel. Often they determine why a child is struggling and what the child needs. They help do a good job in making early determinations,” said Flaherty.

The experts predict that the costs of special education in each district will likely keep increasing. With better diagnostics, newer information, and an increased focus on educational reforms, more demands will be made on districts to help the special education student to achieve and move into adulthood with the educational and social skills they need to become productive members of society, which in the long run is a most cost effective and socially responsible approach. As one administrator said, “Special education kids get a lot of support, but if they could do without the support they wouldn’t be special education students.”

Source: http://www.massapequapost.com/news/2006/0503/Front_page/060.html

By Paul F. Malloy, Ph.D., and Patricia A. Boyle, Ph.D.

Although memory and other cognitive impairments are considered the hallmark features of most dementias, neuropsychiatric abnormalities occur in the majority of such patients (Cohen et al., 1993). Neuropsychiatric symptoms are associated with a rapid course of decline, elevated caregiver distress and overutilization of health care services (Chung and Cummings, 2000; Teri, 1997). Apathy is the most common neuropsychiatric symptom reported among individuals with Alzheimer’s disease (AD), affecting approximately 70% of patients in the mild-to-moderate stages (Landes et al., 2001) and increasing in severity as the illness progresses (Mega et al., 1996). Apathy is common in other dementing illnesses as well (e.g., Parkinson’s disease [PD], vascular dementia) and may even occur in substantial numbers of patients with mild cognitive impairment (Ready et al., 2003). Apathy is associated with functional impairment and caregiver distress at all levels of disease severity (Boyle et al., 2003; Norton et al., 2001; Rymer et al., 2002).

Apathy is characterized by the loss of initiation and motivation to participate in activities, social withdrawal, and emotional indifference (Marin, 1991). Depression shares some overlapping features (e.g., decreased initiation, social withdrawal), but can be distinguished from apathy primarily on the basis of dysphoria (Marin et al., 1994). Symptoms of dysphoria typically are absent in the apathetic patient, who displays a lack of interest and motivation in the context of emotional indifference. Apathy therefore reflects a syndrome of primary motivational loss, whereas depression reflects a primary mood disturbance.

The Neurobiological Basis

Although the neurobiological basis of apathy remains to be fully elucidated, dysfunction in frontal systems is thought to be important. Three subsystems of the frontal lobes are thought to underlie three distinct neuropsychiatric syndromes: 1) The dorsolateral prefrontal circuit is associated with executive cognitive dysfunction; 2) The lateral orbital prefrontal circuit is associated with disinhibition; and 3) The medial (anterior cingulate) circuit is associated with disorders of motivation, including apathy (Cummings, 1993). In the extreme, large bilateral lesions in the anterior cingulate cortex produce akinetic mutism, a state of profound apathy and amotivational immobility. Neuropathological changes in dementia may result in apathy by affecting this medial frontal circuit, as well as parietotemporal brain regions that subserve motivation and emotion. Cummings and Back (1998) have also proposed that medial frontal and limbic cholinergic deficits may underlie apathy. Dopaminergic pathways that influence frontal-subcortical activation may also play a role in apathy.

Apathy Assessment

A number of instruments have been developed for assessing neuropsychiatric symptoms in individuals with dementia (Table).

The Neuropsychiatric Inventory (NPI) is the most widely used instrument for assessing neuropsychiatric functioning in patients with dementia (Cummings et al., 1994). It is a valid and reliable instrument involving a caregiver interview designed to assess the presence and severity of 10 symptoms: apathy, irritability/lability, dysphoria, delusions, hallucinations, anxiety, agitation/aggression, euphoria, disinhibition and aberrant motor activity. Tekin et al. (2001) reported significant correlations between NPI apathy subscale scores and frontal pathology at autopsy in patients with AD, suggesting that the NPI is useful for this purpose. Moreover, the NPI includes apathy and depression items, which can help clinicians distinguish apathy from depression.

The Frontal Systems Behavior Scale (FrSBe) is a newer instrument that was specifically designed to measure behavioral changes related to frontal system dysfunction (Grace and Malloy, 2001). It is a valid, reliable, 46-item questionnaire that assesses the three frontal behavioral syndromes linked to the frontal circuits described earlier: apathy, disinhibition and executive dysfunction. The FrSBe measure of apathy correlates moderately with the NPI apathy rating (Norton et al., 2001) and other ratings of decreased initiation (Ready et al., 2003), but not with the Geriatric Depression Scale (GDS) (Cahn-Weiner et al., 2002). The FrSBe correlates more highly with activities of daily living impairment than the NPI (Boyle et al., 2003; Norton et al., 2001).

The Apathy Evaluation Scale (AES)-Informant version is an 18-item, informant-rated scale that utilizes a four-point Likert-type scale to assess symptoms of apathy (Marin et al., 1991). Although it is widely used, there are very limited guidelines for interpreting AES scores, and Glenn et al. (2002) reported that the AES had poor sensitivity and specificity with respect to the ability to predict the clinician’s designation of a patient as apathetic. The Apathy Inventory (IA) is a new instrument that generates scores for emotional blunting, lack of initiation and lack of interest, in addition to a global apathy score (Robert et al., 2002). Preliminary evidence suggests that the caregiver-rated version of the IA is valid and reliable, and total scores on the IA correlate well with the NPI apathy subscale, suggesting high concurrent validity (Robert et al., 2002). A recent review by Malloy and Grace (2005) provides further information on these and related scales.

Treating Apathy

Cholinesterase inhibitors have some efficacy for reducing the neuropsychiatric symptoms associated with dementia, and apathy is the neuropsychiatric symptom most consistently responsive to treatment (Cummings, 2003; Wynn and Cummings, 2004). Large-scale clinical trials have generally indicated that donepezil (Aricept) improves neuropsychiatric functioning, particularly the symptom of apathy (Birks and Harvey, 2003; Feldman et al., 2001; Gauthier et al., 2002; Trinh et al., 2003). A few studies also indicate that galantamine (Razadyne) and rivastigmine (Exelon) may also have beneficial neuropsychiatric effects (Birks et al., 2000). A placebo-controlled, double-blind study evaluated the effects of galantamine in AD patients with cerebrovascular disease and probable vascular dementia (Erkinjuntti, 2002). Researchers found that galantamine was associated with a significant reduction in apathy and anxiety over six-month follow-up. Dartigues et al. (2002) found that rivastigmine resulted in improvement in apathy, irritability, delusions and anxiety in patients with mild-to-moderate AD over a six-month follow-up.

Preliminary evidence also supports the use of activating pharmacologic agents for treating apathy in patients with dementia (Marin et al., 1995). Psychostimulants such as methylphenidate and dextroamphetamine (Dexedrine, DextroStat) have been shown to reduce symptoms of apathy in case series of patients with AD, PD or cerebrovascular disease (Chatterjee and Fahn, 2002; Galynker et al., 1997; Jansen et al., 2001). Given the phenomenological overlap between apathy and depression, nondepressed dementia patients with apathy may also benefit from the use of antidepressants with stimulant properties. Some evidence suggests that dopaminergic agents may also be useful for reducing apathy, perhaps through enhancement of the functioning of frontostriatal circuits (Corcoran et al., 2004; Muller and von Cramon, 1994; Newburn and Newburn, 2005). Controlled clinical trials are needed to demonstrate convincingly the effectiveness of stimulants, antidepressants and dopaminergic agents in treating apathy in dementia. Additional research is needed to determine the magnitude and duration of positive effect and ensure that reductions in apathy are not accompanied by increases in agitation, psychosis or other side effects. Our research group is currently conducting a double-blind, National Institute on Aging-sponsored study comparing cholinesterase inhibitors alone to cholinesterase inhibitors plus modafinil (Provigil) in the treatment of apathy.

Behavioral Interventions

Combined pharmacological-behavioral approaches have consistently been shown to be more effective than pharmacologic treatments alone in a wide variety of disorders, including depression. In dementia populations, behavior therapy and applied behavioral analysis techniques have been used successfully to improve such diverse problems as incontinence, agitation and aggression (Teri and Gallagher-Thompson, 1991). Although apathy has not been specifically addressed using behavioral interventions to date, evidence suggests that behavioral interventions are effective for treating depression in patients with AD and their caregivers (Teri et al., 1997). Behavioral interventions in dementia have also resulted in improved patient health and lower caregiver burden (Teri et al., 2003). We recently completed a controlled trial of the effectiveness of a novel caregiver-based behavioral training program for reducing apathy in patients with AD and reducing stress among their caregivers. Preliminary findings suggest that behavioral intervention benefited patients with AD and their caregivers (Boyle et al., 2004). Further research examining the benefits of combined, pharmacological-behavioral interventions is needed.

Summary and Conclusions

Apathy is a debilitating and underrecognized syndrome that affects the vast majority of individuals with dementia, results in functional impairment among patients and causes stress among their caregivers. Accurate discrimination of the symptoms of apathy from depression is necessary for optimal treatment. The careful comparison of the symptoms of dysphoria versus symptoms of amotivation is recommended, and a number of instruments have been developed to aid in the discrimination of apathy from depression.

Cholinesterase inhibitors have been shown to reduce the neuropsychiatric symptoms of AD and vascular dementia with apathy showing the most consistent gains. The magnitude and persistence of these changes remains a topic for future research. Traditional antidepressants, activating neurologic agents and combined pharmacological-behavioral treatments also hold promise for the treatment of apathy, but controlled large-scale clinical trials are lacking. For more detailed reviews, the reader is referred to Boyle and Malloy (2004) and Wynn and Cummings (2004).

Source: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=174402660

May 07,2006
ROSELEE PAPANDREA
DAILY NEWS STAFF
Greg Acosta was the kid who made everybody laugh.

During his senior year at Jacksonville High School in 2005, he was voted class clown and most unforgettable in the yearbook.

He was a laid back kind of guy who didn’t have a care in the world.

But life has changed for the 20-year-old. It took just a split second, said his mother, Sandy Acosta of Jacksonville.

Greg Acosta attended a St. Patrick’s Day party at a friend’s house in the Northwoods area March 17. He went hoping to have a good time, but he ended up in the middle of a dispute that put him in New Hanover Regional Medical Center in Wilmington with a traumatic head injury.

Joseph Aragona, 19, of Shadowood Drive, was charged by the Jacksonville Police Department with assault inflicting serious bodily injury, which is a felony. Aragona is accused of inflicting frontal and temporal damage as well as contusions and hemorrhaging in Greg Acosta.

At first glance, it’s difficult to tell that the left side of Greg Acosta’s face was fractured — allegedly by Aragona’s fist — or that he has hearing loss and can’t open his jaw very wide.

The scars on the back of his head — where he hit the concrete, bounced and hit the concrete a second time — are now hidden behind wavy brown hair. There’s little sign that the force of the blow caused his brain to bleed and swell.

His memory loss and confusion when information just doesn’t add up aren’t readily apparent. A somber mood has replaced his usual playfulness. He sometimes stares into space and spends a lot of time struggling with headaches that are now commonplace.

“He can breathe, but he can’t smell,” Sandy Acosta said. “He can eat, but he can’t taste.”

He can’t drive. He can’t work. He and his parents have no health insurance, and medical bills are mounting.

Still, the message that Sandy Acosta wants to drive home to other kids is that there are better ways to resolve differences.

“If I could touch one person — one kid — and make them realize that the most effective way to hash out something with a friend is verbally and not physically,” she said.

Aragona and Greg Acosta weren’t enemies. They both played together on Jacksonville High’s football team. The Acostas sat next to Aragona’s family at football games. While Greg Acosta was a year ahead of Aragona, they both hung out with each other at last year’s senior prom.

On the night of March 17, however, Aragona allegedly got into a dispute with a friend of Greg Acosta’s that escalated into punches. Acosta approached in an attempt to find out what was going on. That’s when warrants allege that Aragona hit him. The case has not gone to court.

Julius Acosta III, Greg’s younger brother, rushed him to Onslow Memorial Hospital. When his parents arrived, they heard the news no parent wants to hear.

“We’ve got to get your son out of here,” Sandy Acosta said she was told by doctors. “He has serious head trauma.”

Greg Acosta was vomiting profusely. He was transferred to New Hanover Regional Hospital and then put in a drug-induced coma. While he didn’t stay in the hospital long, it will be six months to a year before doctors will know if Acosta will make a full recovery.

Acosta knows he’s different, but he’s not quite sure how to get back to who he once was.

“I used to be that funny guy,” he said and offered a smile. “Trying to find happiness is harder.”

He’s still trying to come to grips with what happened.

After the incident, many of Acosta’s friends wanted to defend him. But Sandy Acosta asked them to focus their attention on helping her son get better.

“I told them that justice comes through the court,” she said. “I’d rather you pray for Greg and leave Joe and his family alone. The first thing kids think about is what do we do to get even.”

And that was the last thing Sandy Acosta wanted.

Sandy Acosta was grateful her son was alive and overwhelmed by the support she received from family and friends who gathered at the hospital. Aragona’s aunt and grandmother even went to the hospital to check on Greg, she said.

“I don’t want so much animosity,” Sandy Acosta said. “There’s so much animosity in the world. We don’t need more.”

Still, as a mother, Sandy Acosta worries every day. Greg, who experiences piercing pain in his head daily, is prone to seizures. She now understands why some mothers who lose a child to an overdose or to suicide frequently become active in educating others about their situation.

“I can appreciate it now,” she said. “This can happen to you. Your whole life can change.”

Source: http://www.jdnews.com/SiteProcessor.cfm?Template=/GlobalTemplates/Details.cfm&StoryID=41472&Section=News

By Nash N. Boutros, MD, and Kerry Coburn, PhD
Special Report: Neuropsychiatry
April 2006, Vol. XXIII, No. 4

Electroencephalography (EEG) is a noninvasive, widely available, and relatively inexpensive test that can help exclude or identify structural or functional factors contributing to psychiatric syndromes. This article defines the clinical usefulness of EEG in evaluating neuropsychiatric disorders, emphasizing the complementary nature of the visually inspected standard EEG (SEEG) and the computeranalyzed quantified EEG (QEEG).

The recent evolution of neuropsychiatry/behavioral neurology as a subspecialty linking these formerly disparate fields represents a paradigmatic shift regarding the responsibility of psychiatrists in diagnosing and managing behavioral disorders with concomitant and demonstrable brain pathology such as dementia or head injury. In addition, the biologic underpinnings of many mental illnesses, including bipolar disorder and depression, are now described in terms of their anatomy and physiology. QEEG analysis increases the sensitivity of EEG to physiologic or pathologic changes associated with such disorders.

Standard EEG

SEEG refers to the visual analysis of ongoing voltage recordings from multiple scalp locations. Two types of EEG deviations are usually indicative of significant cerebral pathology. The first is paroxysmal activity, including sharp waves, spikes, and episodic slow waves, indicating episodic abnormal neuronal discharges. These can be focal, suggesting structural pathology, or bilateral and more suggestive of functional pathology. The second type of EEG deviation is sustained slowing of normal brain rhythms. Slowing also can be diffuse, indicating more generalized pathology, or focal, indicating a localized pathology.

The most frequent reason for an EEG referral is to exclude a general medical condition, such as delirium, or a specific neurologic problem, such as epilepsy, as a cause of or a contributing factor to the presenting symptoms. Since the use of routine test batteries to exclude medical conditions is costly, clinicians must rely primarily on 2 red flags to trigger organic workups: unusual presentations and atypical age at onset. The yield is consistently low when using neuroevaluative tests to uncover causes such as tumors or aneurysms for syndromes presenting without manifest neurologic disturbances. It is much more likely that an EEG will uncover a factor that may be contributing to, but does not necessarily fully explain, the syndrome. It may also be helpful in revealing a factor that could help guide treatment, such as temporal lobe spiking in panic disorder.1

Quantified EEG

After the EEG has been recorded and visually interpreted by the electroencephalographer, it may be analyzed further using quantitative means.2 QEEG analysis is always a post hoc procedure done after visual interpretation of the SEEG by a qualified electroencephalographer. It is specifically not recommended for use clinically as a stand-alone procedure. At its most basic level, QEEG provides a method of calling the electroencephalographer’s attention to aspects of the original EEG record that may have been overlooked. QEEG’s quantitative nature makes it exquisitely sensitive to subtle frequency changes and to abnormalities in the coherence of activity within and among brain regions.

Brain activity varies among healthy people, and normal variability must be distinguished from that outside the normal range. An underlying assumption is that the more unusual the patient’s brain activity compared with that of normal persons, the more likely it is that the statistical abnormality represents pathology. The establishment of normal limits is greatly aided by quantitative analysis comparing the patient’s QEEG with those derived from large groups of healthy persons. Brain activity also changes with age, and QEEG tracks the moving window of normal limits across the entire life span.

In addition, QEEG can help the physician arrive at a specific diagnosis. Patients who have known neuropsychiatric disorders often show characteristic QEEG profiles, distinguishing them from patients who have similar disorders. When facing a difficult diagnostic question, the physician can compare the patient’s QEEG with the profiles characteristic of the different diagnostic possibilities, looking for the best fit. An extensive body of research shows that the accuracy of such computerized diagnostic classifications on the basis of QEEG alone typically exceeds 80%, although in an actual clinical setting the physician always makes the diagnosis, informed by other sources of information in addition to QEEG. Well-replicated studies have demonstrated QEEG classification accuracies high enough to be useful in diagnosing learning and attention disorders in children, and mood disorders (including bipolar disorder) and dementia among adults.3

Clinical Indications

The relative usefulness of SEEG and QEEG depends on the clinical indications for testing. Mental status changes, unusual presentations, personality changes, episodic behavior, and attention problems are situations that often prompt testing.

Acute or gradual mental status change

Patients with advanced dementia rarely have normal SEEG results, so a normal EEG is important in diagnosing pseudodementia secondary to depression or psychosis. When dementia and depression coexist, it becomes important to assess the relative contribution of each disorder to the overall clinical presentation; and SEEG has been shown to be helpful in this situation.4 SEEG is insensitive to the early stages of dementia, however, and cannot be relied on in diagnosing frontotemporal dementia (FTD).

One reason for SEEG insensitivity to early dementia is that EEG changes in most dementing disorders are exaggerations of those found in normal aging. QEEG controls for healthy aging, however, and is sensitive even to subtle changes beyond normal limits. QEEG detects significant abnormalities at the earliest stages of dementia, which increase in parallel with increasing dementia severity. Figure 1 shows an example of a QEEG obtained from a demented patient. In addition to the more easily identified dementia types, QEEG may facilitate the difficult diagnosis of FTD. Perhaps of more importance, QEEG has been shown to distinguish accurately between dementia and pseudodementia.

The differential diagnosis of acutely disturbed and disorganized demented or psychotic patients often includes delirium. SEEG may be helpful in revealing whether altered consciousness is the result of a diffuse encephalopathic process, a focal brain lesion, or continued epileptic activity without motor manifestations. Usually, delirious patients have a toxic-metabolic encephalopathy with diffuse slowing of the background rhythms. Figure 2 shows an SEEG obtained from an acutely confused patient. Limited published research, however, suggests that QEEG adds little to standard visual analysis for the detection of delirium.

Unusual presentation

An atypical clinical presentation is the most important factor for initiating an SEEG evaluation.5 However, patients with a nonatypical rapid-cycling bipolar disorder also may exhibit epileptiform EEG discharges.6 This may explain the reported effectiveness of anticonvulsants for rapid-cycling bipolar disorders.

Himmelhoch7 described the clinical characteristics of “subictal mood disorders,” including brief euphorias, mixed bipolar episodes, brief severe depressive dips with impulsive suicide attempts, compulsive symptoms, irritability and hostile outbursts, and marked premenstrual worsening. Patients with these disorders may also have paradoxical reactions to lithium and antidepressants, with better response to anticonvulsants.

QEEG is very sensitive for the detection of depression and for the discrimination between depression and dementia. A limited number of articles in the literature further suggest that QEEG accurately discriminates between unipolar depression and bipolar disorder, but this finding awaits independent replication.

Recent personality change

An obvious recent personality change should always be viewed as a danger sign, and a full evaluation should be performed. Chronic postconcussive syndrome deserves special mention. QEEG is more helpful than SEEG in such cases. Even mild concussions in which the patient experiences either no loss of consciousness or less than 20 minutes of unconsciousness can cause reduced attention span, reduced shortterm memory capacity, depression, mood disorders, word-finding problems, and slowness of thought. EEG changes that often accompany mild head injury include reduced beta and/or alpha activity and increased theta activity.8 One commercially available QEEG system is tailored to detect brain damage secondary to closed head injuries and has been demonstrated to do so with greater than 95% accuracy.9

Episodic behavior

Case reports have described patients in whom borderline personality disorder (BPD) was diagnosed but who were subsequently found to have complex partial seizures documented by epileptic discharges over temporal regions.10 The prevalence of abnormal EEGs among clinic populations ranges from 6.6% in patients with rage attacks and episodic violent behavior to 53% in patients with antisocial personality disorder. 11,12 A flowchart for evaluation of patients presenting with episodic aggressive behavior is shown in Figure 3.

Whether an abnormal EEG predicts a favorable therapeutic response to anticonvulsants is currently unknown. Anticonvulsants can block epileptiform discharges and can lead to dramatic clinical improvement in persons exhibiting repeated and frequent aggression.13 The addition of carbamazepine to the treatment regimen of patients with schizophrenia who also exhibit EEG temporal lobe abnormalities but no history of seizure disorder can be beneficial.14 Anticonvulsants also may reduce aggressive tendencies irrespective of EEG abnormalities.15

Finally, panic symptoms resemble symptoms induced by temporolimbic epileptic activity, particularly that originating from the sylvian fissure. Panic disorder is the most common psychiatric disorder that must be differentiated from temporal lobe epilepsy.16

Attention and learning disorders

Frank17 reported that 21 (31%) of a sample of 64 children with attentiondeficit/ hyperactivity disorder had abnormal SEEG. Of these, 84% had spikes or spike-wave discharges. Hughes and associates18 found “definite noncontroversial epileptiform activity” in 53 (30.1%) of 176 children with ADHD. Mainly focal and usually occipital or temporal, the epileptiform activity was less often generalized, with bilaterally synchronous spike and wave complexes seen in 7% of children.

Several large, independently replicated studies have shown that QEEG distinguishes between healthy children and those who have a variety of attention or learning disorders, with accuracies typically exceeding 80%. While autism cannot be diagnosed based on EEG findings, an EEG can help rule out the presence of epileptic activity that is relatively common in this group.

Adequate SEEG evaluation

For an adequate SEEG evaluation, the clinical reason for the referral must be considered. If a slow-wave abnormality is suspected, an awake recording is sufficient. The most important caveat is to make absolutely sure that the patient is alert during the procedure. In patients with borderline results, the inclusion of hyperventilation could enhance the abnormality.

If the purpose of SEEG is to rule out epileptiform discharges, an awake EEG is inadequate, and the inclusion of a sleep tracing is important. The EEG report should clearly indicate the stage of sleep during the recording. Serial recordings enhance the likelihood of finding abnormalities, particularly epileptiform abnormalities.19 In our experience, the yield of more than 2 recordings does not justify the added expense. The second recording may be performed following sleep deprivation.

Adequate QEEG evaluation

As a post hoc analytic procedure, QEEG is supplementary and complementary to SEEG. No special recording procedures are required other than ensuring that filters and sampling rates are set at specified levels. Virtually all modern EEG machines can provide a digitized record suitable for computerized analysis. Because QEEG analysis is easily biased by artifacts, the electroencephalographer begins by selecting artifact-free samples of the alert eyes-closed SEEG, which then are analyzed mathematically using commercial software. Abnormalities detected by QEEG are traced back to the original SEEG and interpreted by the electroencephalographer.

When using QEEG to assist in diagnosis, the physician again plays the central role of narrowing the diagnostic possibilities to a small number (usually 2). The more the physician knows about the patient, the more alternative diagnoses can be excluded, increasing the accuracy of the classification. QEEG is not used as a diagnostic filter, running the patient’s data through all possible classifiers. Such misuse nearly always produces spurious results.

Problems encountered in QEEG generally reflect user error. Incorrectly set filters, unrecognized patient drowsiness or artifacts, and other recording or screening errors can be prevented by thorough training and the maintenance of high laboratory standards. Specific training is required to correctly use QEEG software and to interpret the results. All use of QEEG must be supervised by an electroencephalographer, and its application to psychiatric diagnosis requires additional expertise in the DSM differential diagnostic criteria.

SEEG and QEEG are complementary techniques, and modern digital equipment facilitates and tends to lower the cost of QEEG. Specialized training is necessary to interpret both SEEG and QEEG, and the interpreter must be proficient in psychiatric differential diagnosis.

Dr Boutros is professor of psychiatry and neurology at the Wayne State University School of Medicine in Detroit, as well as director of the neuropsychiatry division and clinical electrophysiology laboratories. He reports that he has no conflicts of interest regarding the subject matter of this article.

Dr Coburn is professor and director of research in the department of psychiatry and behavioral sciences at the Mercer University School of Medicine, Macon, Ga. He reports that he has no conflicts of interest regarding the subject matter of this article.

Source: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=186700416

Name: Carl Butler, Daily Post

A NORTH Wales dad yesterday admitted killing his 14-week-old baby son.

A court heard how David Robert James Price threw the little boy onto the sofa in a fit of “frustration and temper”. The youngster died of severe brain injuries.

Price yesterday admitted the manslaughter of baby Eithan James Williams at Wrexham on February 29, 2004. A High Court judge lifted the 27-year-old’s bail restrictions allowing him to return to Wrexham.

It means he can visit the graves of Eithan and his three-year-old son Kai who tragically died of meningitis in November last year.

The prosecution offered no evidence on a charge of murder against Price and Recorder of Chester Judge Elgan Edwards directed a not guilty verdict.

Electrician Price admitted throwing baby Eithan onto the sofa while caring for the little boy at the Edward Street family home he shared with his former partner.

Michael Chambers QC, prosecuting, said: “It has always been accepted by the crown that the act of the defendant which led to the death of the child was the result of frustration and temper in caring for this child.

Source: http://icnorthwales.icnetwork.co.uk/news/regionalnews/tm_objectid=17051156&method=full&siteid=50142&headline=father-admits-killing-baby-name_page.html