Positive behavioural support in schools for children and adolescents with intellectual disabilities whose behaviour challenges: An exploration of the economic case.

Decision-makers with limited budgets want to know the economic consequences of their decisions. Is there an economic case for positive behavioural support (PBS)? A small before-after study assessing the impact of PBS on challenging behaviours and positive social and communication skills in children and adolescents with intellectual disabilities and behaviours that challenge was followed by an evaluation of costs. Results were compared with the costs of alternative packages of care currently available in England obtained from a Delphi exercise conducted alongside the study. Children and adolescents supported with PBS showed improvement in challenging behaviours and social and communication skills, at a total weekly cost of GBP 1909 (and GBP 1951 including carer-related costs). PBS in schools for children and adolescents with intellectual disabilities and behaviours that challenge may help to support them in the community with potential improvements in outcomes and also cost advantages.

Families of individuals with intellectual and developmental disabilities: policy, funding, services, and experiences.

Families are critical in the provision of lifelong support to individuals with intellectual and developmental disabilities (IDD). Today, more people with IDD receive long-term services and supports while living with their families. Thus, it is important that researchers, practitioners, and policy makers understand how to best support families who provide at-home support to children and adults with IDD. This article summarizes (a) the status of research regarding the support of families who provide support at home to individuals with IDD, (b) present points of concern regarding supports for these families, and (c) associated future research priorities related to supporting families.

Using research evidence to inform public policy decisions.

The application of scientific data in the development and implementation of sound public policy is a well-established practice, but there appears to be less consensus on the nature of the strategies that can and should be used to incorporate research data into policy decisions. This paper describes the promise and the challenges of using research evidence to inform public policy. Most specifically, we demonstrate how the application of a large-scale data set, the National Core Indicators (NCI), can be systematically used to drive state-level policy decisions, and we describe a case example of one state's application of NCI data to make significant changes to its Intellectual and Developmental Disabilities waiver. The need for continued research in this area is highlighted.

Cost of developmental delay from prenatal exposure to airborne polycyclic aromatic hydrocarbons.

Early life exposure to ambient polycyclic aromatic hydrocarbons (PAHs) can result in developmental delay. The negative health effects of PAHs have been well-documented but the cost of developmental delay due to PAH exposure has not been studied. The Columbia Center for Children's Environmental Health previously has reported the significant effect of prenatal exposure to ambient PAHs on delayed mental development at three years, using the Bayley Scales in a cohort of low-income women and children in New York City (NYC). Here we have used the cohort results to estimate the annual costs of preschool special education services for low-income NYC children with developmental delay due to PAH exposure using the Environmentally Attributable Fraction method. The estimated cost of PAH-exposure-related services is over $13.7 million per year for Medicaid births in NYC. This high cost supports policies to reduce level of PAHs in NYC air.

Pushing the employment agenda: case study research of high performing States in integrated employment.

Organizational variables, including policies, practices, collaborations, and funding mechanisms resulting in high performance in integrated employment, were described through case study research in 3 states. Findings address how contextual factors, system-level strategies, and goals of the system are related as well as how they sustain systems change. Strategies such as flexibility in funding and practices; communication of values through data, rewards, and funding incentives; and innovation diffusion through relationships and training were most successful when they were embedded within the context of a solid values base, a network of dedicated stakeholders, and clarity about systemic goals. Implications are presented with respect to state systems, community rehabilitation providers as partners in planning, and future leadership in the field.

Staff recruitment challenges and interventions in agencies supporting people with developmental disabilities.

Recruitment challenges and costs were identified by administrators from 129 randomly selected agencies that provide residential, vocational, and other services to persons with developmental disabilities in Minnesota. Finding qualified applicants was the most difficult staffing problem reported. Common recruitment incentives included providing competitive benefits, allowing time off without pay, and offering paid leave time. Relatively few agencies used innovative strategies (e.g., bonuses for employees who recruit new workers). The average agency had vacancy rates of 6% in direct-support positions and 4% in first-line supervisor positions. On the basis of these findings, one could determine that the cost of advertising and overtime for vacant positions in Minnesota could approach $6.7 million per year.

The quality and costs of residential services for adults with multiple disabilities: a comparative evaluation.

The costs and quality of four different service models for 40 adults with multiple disabilities were compared. The four service models were: specialised institution-based units; a specialised, campus-style, further education service; specialised community-based group homes; and "ordinary" community-based group homes. Some information was also available from five adults with multiple disabilities living in traditional institutions for people with mental retardation. On almost all measures of service outcome the specialised group-home model was the "preferred" service model, although this model was not associated with particularly high service costs. There was, however, considerable variation in quality within, as well as between, service models, with some residents in all service models experiencing levels of support and engagement similar to those found in traditional institutions. The results of the study are discussed in relation to notions of typical practice and normative standards. The implications of the findings are discussed.

Explanatory model to describe school district prevalence rates for mental retardation and learning disabilities.

Data reports from South Carolina's 92 independent school districts were used to calculate prevalence rates of mental retardation and learning disabilities among school-age children. These prevalence rates were 41.66/1,000 children enrolled for mental retardation and 33.21/1,000 children enrolled for learning disabilities. The 1980-1981 school year was selected because this was the last year in which disaggregated reports were submitted for placement in educable mental handicap (EMH), trainable mental handicap (TMH), and profound mental handicap (PMH) programs. Exploratory factor analysis and multiple regression analysis were used to explain school district prevalence rates of categorization of children into programs for mental retardation and learning disabilities. Results show that community SES and tax inputs explain 39% of the variation in prevalence rates and that these factors affect rates indirectly.

Medicaid program; prohibitions on FFP for educational and vocational training for institutionalized individuals--HCFA. Final rule.

This final rule revises and clarifies the meaning of the prohibition against the use of Federal financial participation (FFP) for vocational training and educational activities in intermediate care facilities for the mentally retarded (ICFs/MR) and in psychiatric facilities or programs providing psychiatric services to individuals under age 21. It resolves issues that have been raised by the States and courts regarding the method and criteria that have been used by HCFA to determine which services are not eligible for FFP because of the educational and vocational training services exclusion.

An analysis of early intervention expenditures in Massachusetts.

Early intervention expenditure data from Massachusetts were linked to service data on a 157-member sample of Massachusetts early intervention service recipients. The findings revealed an enormous variability in the total expenditure per child estimate. Regression analyses identified specific child, family, and program characteristics that were significant predictors of the hours of service received. These results were then used to estimate expected hours of service and per child expenditures for eight subgroups. Variations in total expenditures by subgroup reflected differences in the distribution of service hours by service type. The implications of these findings for the implementation of Part H of P.L. 99-457 were discussed.

Reimbursement of ICFs/MR program costs based on client resource use.

In this article we have described the impetus, research, and recommendations for a new reimbursement system based on client resource use for ICFs/MR in Minnesota. Research to develop a targeted reimbursement strategy has been completed and a proposal for basing program rates on client resource use developed. Residents (N = 913) in a stratified sample of 65 facilities were assessed and staff resource use determined. Results showed that although predictors in the area of personal interaction, integration, and independence, activities of daily living, special treatment/medical complexity, and behavior accounted for a significant amount of variation in resource use, the unaccounted for variation was sufficiently large to support recommending a system that will base program rates on individual client resource use and the historical costs of individual facilities. Key design issues were also discussed.

Individuals with mental retardation in residential facilities: findings from the 1987 National Medical Expenditure Survey.

Data from the 1987 National Medical Expenditure Survey, a large survey designed to yield national estimates pertaining to the use of medical care, were used to compare residents of state institutions with residents of other types of residential facilities. Findings concur with past studies: Residents of state institutions were more severely retarded and more likely to have other disabilities and functional impairments than were residents of other residential facilities. However, many residents of other facilities had severe impairments. Relatively more persons with severe impairments resided in these facilities in states where small facility beds were relatively plentiful.

Efficiency considerations in delivering special education services to persons with severe mental retardation.

The basic question addressed in this paper is whether formal benefit-cost and effectiveness-cost analyses might allow us to determine whether the outcomes of particular special education services are being offered in their most efficient manner. In attempting to answer this question, we focused upon measuring as many of the cost and outcomes as possible (in both monetary and other terms) from two specialized schools serving youth with severe mental retardation. We examined a number of alternative assumptions for illustrating some of the problematic issues in the use of such evaluation techniques.

Current and future trends in state-operated mental retardation institutions in the United States.

Results of a national study of state-operated institutional care in the United States were presented. The relations among census reduction, staffing level, and resident cost were explored. Resident cost escalated dramatically in recent years, primarily because staffing levels in the states remained relatively stable, whereas the institutional census continued to decline. Econometric projections suggest that by the year 2000, the institutional census will fall below 55,000 persons, cost per resident will rise to more than $113,000 per year, and 28 to 51 institutions will close.

Politics, public policy, and the development of community mental retardation services in the United States.

Data emanating from the community services component of the Third National Study of Public Spending for Mental Retardation and Developmental Disabilities was analyzed. An empirical model of community services spending in the states was tested in a hierarchical regression analysis using cumulative community services fiscal effort in the states across 1977-1988 as the dependent variable. Strength of consumer advocacy organizations in the states coupled with states' historical orientations toward the adoption of policies promoting racial equality were highly significant predictors of state-by-state variance in community spending patterns. The implications of this and other findings emerging from the national study were discussed.

National study of public spending for mental retardation and developmental disabilities.

Results of a nationwide study of public mental retardation/developmental disabilities (MR/DD) spending in the states during Fiscal Years 1977 through 1986 were summarized. Trends identified included: (a) continuing growth in spending for community services, (b) contraction of total spending for institutional operations, and (c) predominance of ICF/MR support in large (16+ beds) congregate care settings. Periodic replication of the study was recommended as was additional research to identify the political and economic determinants of state MR/DD spending.

State government financial effort in mental retardation.

A comparative analysis of the level of financial effort exhibited in the states for financing mental retardation services was presented. States were ranked on a criterion (aggregate personal income) that compensated for differences in each state's financial capacity. During the FYs 1977-1984 period, on a nationwide basis, state governments spent increasingly more of their own funds for community services and increasingly less for institutional operations; however, combined institutional and community services spending was relatively stable. A hierarchical multiple regression analysis on three economic variables was performed: state size, wealth, and degree of federal assistance. All were very poor predictors of community services fiscal effort, implying the presence of more complex determinants of mental retardation spending. Degree of federal assistance was an important, inversely related, predictor of institutional fiscal effort.