Developmental Screening April 4, 2009 Baseball, Child Advocacy, and the Role of CCS Paul Russell, MD Children’s Medical Services Department of Public Health

St. Mary’s Industrial School Foster Care Baseball Team 1914

St. Mary’s Industrial School Foster Care, Pitcher, 1914 St. Mary’s Industrial School Foster Care, Pitcher, 1914

World Series, 1918 World Series, 1918

Babe Ruth Hospital Visit Circa 1926

Child Advocacy in America 1927: “Crippled Children’s Services” Program started in California started in California 1930: American Academy of Pediatrics founded to respond to the special developmental respond to the special developmental and health needs of children. and health needs of children. 1935: Title V, Social Security Act passed 1935: Title V, Social Security Act passed to promote and improve maternal and child health nationwide. Seventy-four years later, Title V remains the longest lasting public health legislation in our Nation’s history.

California Children’s Services CCS Medical Treatment Program Medical Therapy Program

CCS Program Eligibility Medical Eligibility: Diagnosis Based - CCS eligible condition as per Title 22, Division 2, Part 2, Subdivision 7, CCS, Chapter 4, Section Residential - Resident of the county - Or enrolled in public schools Financial - M/C, HF, or Annual income under $40K - Medical cost > 20 % of annual income

CCS Referral Process CCS Referral Process * Initial referral by hospital, physician, family. * Medical records are required by CCS; review for support of requested services. * The family completes and submits application. * Nurse, MD and/or therapy manager determine medical eligibility.

Referral Confusion and MTP Eligibility Title 22, Section “ (a) CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS Medical Therapy Program: Referral Confusion and MTP Eligibility Title 22, Section “ (a) CCS applicants with at least one of the following conditions shall be medically eligible for participation in the CCS Medical Therapy Program: (1) Cerebral palsy as specified in Section (a)(2). (1) Cerebral palsy as specified in Section (a)(2). (2) Neuromuscular conditions that produce muscle weakness and atrophy, such as poliomyelitis, weakness and atrophy, such as poliomyelitis, myasthenias, and muscular dystrophies. myasthenias, and muscular dystrophies. (3) Chronic musculoskeletal and connective tissue diseases (3) Chronic musculoskeletal and connective tissue diseases or deformities such as osteogenesis imperfecta, or deformities such as osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputations, and arthrogryposis, rheumatoid arthritis, amputations, and contractures resulting from burns. contractures resulting from burns. (4) Other conditions manifesting the findings listed in (4) Other conditions manifesting the findings listed in section (a) above, such as ataxias, degenerative section (a) above, such as ataxias, degenerative neurological disease, or other intracranial processes. ” neurological disease, or other intracranial processes. ”

“(b) CCS applicants under three years of age shall be eligible when two or more of the following neurological findings are present: (1) Exaggerations of or persistence of primitive reflexes beyond the normal age (corrected for prematurity); reflexes beyond the normal age (corrected for prematurity); (2) Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater; (2) Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater; (3) Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position; (3) Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position; (4) Hypotonicity, with normal or increased DTRs, in infants below one year of age. (Infants above one year must meet criteria described in (a)(1)); or infants below one year of age. (Infants above one year must meet criteria described in (a)(1)); or

Title 22 Sect a.2 “Cerebral palsy, a motor disorder with onset in early childhood resulting from a non- progressive lesion in the brain manifested by the presence of one or more of the following: (A) Rigidity or spasticity (B) Hypotonia, with normal or increased DTR’s, and exaggeration of or persistence of primitive exaggeration of or persistence of primitive reflexes beyond the normal age range reflexes beyond the normal age range (C) Involuntary movements that are described as athetoid, choreoid or dystonic athetoid, choreoid or dystonic (D) Ataxia manifested by incoordination of voluntary movement, dysdiadochokinesia, intention tremor, movement, dysdiadochokinesia, intention tremor, reeling or shaking of trunk and head, staggering reeling or shaking of trunk and head, staggering or stumbling, and broad based gait.” or stumbling, and broad based gait.”

Diagnostic Confusion: The Hypotonic Infant * Hypotonic cerebral palsy * Developmental delay with hypotonia hypotonia * Myopathy

Referral Confusion: The Hypotonic Infant Less than one year: * hypotonia with increased DTRs….refer to * hypotonia with increased DTRs….refer to CCS CCS * hypotonia, developmental delay….refer to * hypotonia, developmental delay….refer to Regional Center/Early Start Regional Center/Early Start * hypotonia with isolated gross motor * hypotonia with isolated gross motor delay…refer to CCS for diagnostic delay…refer to CCS for diagnostic evaluation evaluation Hypotonia with exaggerated primitive reflexes at any age…refer to CCS

Clonus Clonus

Types of CCS Cases CCS only – medical case management only; no MTP services CCS only – medical case management only; no MTP services MTP only – receive PT/OT at MTU, limited medical case management MTP only – receive PT/OT at MTU, limited medical case management CCS and MTP – therapy and medical case management CCS and MTP – therapy and medical case management

Medical Therapy Program MTP Physical Therapy Physical Therapy Occupational Therapy Occupational Therapy Medical Therapy Conference Medical Therapy Conference

Medical Therapy Conference (MTC) Specialty team - It is the function of the MTC to bring together the expertise of combined professional services in order to bring maximum benefit to the child and his/her family Specialty team - It is the function of the MTC to bring together the expertise of combined professional services in order to bring maximum benefit to the child and his/her family Role - Medical Direction versus Role - Medical Direction versus Consultation Consultation

Medical Therapy Conference Pediatric Orthopedist Pediatrician Physical Therapist Occupational Therapist Orthotist Social Worker Nutritionist CCS Case Manager

Misconception Misconception Therapy is good, more is better. Therapy is good, more is better.

Medically Necessary Therapy Once eligible, a therapy assessment is done to determine if there is a need for medically necessary therapy (as opposed to educationally necessary) Once eligible, a therapy assessment is done to determine if there is a need for medically necessary therapy (as opposed to educationally necessary) Services are provided under medical direction (paneled provider) Services are provided under medical direction (paneled provider) –Prescriptions –Medical reports documenting functional gains Therapy is for habilitation and rehabilitation caused by the MTP eligible condition Therapy is for habilitation and rehabilitation caused by the MTP eligible condition

Primary Care Physician Role Perform formal developmental Perform formal developmental screening screening Refer to appropriate agency Refer to appropriate agency Be an active member of the team Be an active member of the team