developmental disabilities

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A Developmental Disability is a severe, chronic disability that: is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in the substantial functional limitations in 3 or more of the following areas of major life activity: self-care receptive and expressive language learning mobility self-direction capacity for independent living economic self-sufficiency reflects the individual’s need for a combination and sequence of special interdisciplinary or generic services, individualized support, and other Definition of Developmental Disabilities Definition of Developmental Disabilities by by The Federal Developmental Disabilities Assistance and The Federal Developmental Disabilities Assistance and Bill or Rights Act Bill or Rights Act of 2000 (Public Law 106-402) of 2000 (Public Law 106-402)

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Page 1: Developmental Disabilities

A Developmental Disability is a severe, chronic disability that: is attributable to a mental or physical impairment or combination of mental

and physical impairments;

is manifested before the person attains age 22;

is likely to continue indefinitely;

results in the substantial functional limitations in 3 or more of the following areas of major life activity:

self-carereceptive and expressive languagelearningmobilityself-directioncapacity for independent livingeconomic self-sufficiency

reflects the individual’s need for a combination and sequence of special interdisciplinary or generic services, individualized support, and other forms of assistance that are lifelong or of extended duration and are individually planned and coordinated.

Definition of Developmental DisabilitiesDefinition of Developmental Disabilitiesbyby

The Federal Developmental Disabilities Assistance and Bill or Rights ActThe Federal Developmental Disabilities Assistance and Bill or Rights Actof 2000 (Public Law 106-402)of 2000 (Public Law 106-402)

Page 2: Developmental Disabilities

Developmental disabilities are a variety of conditions that become apparent during childhood and cause mental or physical limitation.

These conditions include pervasive developmental disorders such as autism, cerebral palsy, epilepsy, mental retardation,

and other neurological impairments”

There are many causes of developmental disabilities that can occur before, during or after birth. Those occurring before birth include genetic problems, poor prenatal care, or exposure of the fetus to toxins including drugs and alcohol. Difficulties during birth, such as restricted oxygen supply to the infant, or accidents after birth can also cause traumatic brain injury resulting in developmental disabilities. Longer-term postnatal causes include malnutrition and social deprivation.

Definition of Developmental DisabilitiesDefinition of Developmental Disabilitiesbyby

New York State Office of Mental Retardation and Developmental Disabilities New York State Office of Mental Retardation and Developmental Disabilities (1999)(1999)

Page 3: Developmental Disabilities

DSM IV: Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence

Mental Retardation (Coded on Axis II)

Learning Disorders

Motor Skills Disorder

Communication Disorders

Pervasive Developmental Disorders

Attention-Deficit and Disruptive Behavior Disorders

Feeding and Eating Disorders of Infancy or Early Childhood

Tic Disorders

Elimination Disorders

Page 4: Developmental Disabilities

DSM IV Diagnostic Criteria for Mental Retardation

(Coded on Axis II)

A. Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of

significantly subaverage intellectual functioning). 

B. Concurrent deficits or impairments in present adaptive functioning (i.e., the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. 

C. The onset is before age 18 years. 

Code based on degree of severity reflecting level of intellectual impairment:

317 Mild Mental Retardation: IQ level 50-55 to approximately 70 

318.0 Moderate Mental Retardation: IQ level 35-40 to 50-55 

318.1 Severe Mental Retardation: IQ level 20-25 to 35-40 

318.2 Profound Mental Retardation: IQ level below 20 or 25 319 Mental Retardation, Severity Unspecified: when there is strong presumption of Mental Retardation but the person's intelligence is untestable by standard tests

Page 5: Developmental Disabilities

DSM IV Diagnostic criteria for Learning Disorder

When individuals demonstrate abilities below the level that would be expected given their age and grade level in school based upon an arbitrary gap, they may be diagnosed with this mental disorder which should be further specified according to the particular academic function affected:

Mathematics Disorder

Reading Disorder

Disorder of Written Expression

Learning Disorder NOS

Page 6: Developmental Disabilities

DSM IV Diagnostic criteria for Learning Disorder

Mathematics Disorder:

A. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education. 

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability. 

C. If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it. 

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

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DSM IV: Motor Skills Disorder

Developmental Coordination Disorder

When a child's motor coordination falls substantially below that which would be expected, and this cannot be accounted for by a known physical illness or injury, this mental disorder may be diagnosed.

A. Performance in daily activities that require motor coordination is substantially below that expected given the person's chronological age and measured intelligence. This may be manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things, "clumsiness," poor performance in sports, or poor handwriting. 

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living. 

C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder. 

D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it. 

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Page 8: Developmental Disabilities

DSM IV Diagnostic Criteria for Communication Disorders

These mental disorders of childhood affect listening, language and speech.

These include the following specific disorders:

Expressive Language Disorder

Mixed Receptive-Expressive Language Disorder

Phonological Disorder

Stuttering

Communication Disorder NOS

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DSM IV Diagnostic Criteria for Communication Disorders

Expressive Language Disorder:

A. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity. 

B. The difficulties with expressive language interfere with academic or occupational achievement or with social communication. 

C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorders. 

D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems. 

Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Severe impairment pervades broad areas of social and psychological development in children with these mental disorders .

These include the following specific disorders:

Autistic Disorder

Asperger’s Disorder

Childhood Disintegrative Disorder

Rett’s Disorder

Pervasive Developmental Disorder NOS

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Autistic Disorder :

In children with this Pervasive Developmental Disorder there is substantial delay in communication and social interaction associated with development of "restricted, repetitive and stereotyped" behavior, interests, and activities.

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): 

(1) qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (d) lack of social or emotional reciprocity 

Page 12: Developmental Disabilities

DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Autistic Disorder :

(2) qualitative impairments in communication as manifested by at least one of the following: 

(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) 

(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others 

(c) stereotyped and repetitive use of language or idiosyncratic language 

(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level 

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Autistic Disorder :

(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 

(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 

(b) apparently inflexible adherence to specific, nonfunctional routines or rituals 

(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) 

(d) persistent preoccupation with parts of objects 

B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

(1) social interaction,

(2) language as used in social communication, or

(3) symbolic or imaginative play. 

C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder.

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Asperger’s Disorder :

In children with this pervasive developmental disorder language, curiosity, and cognitive development proceed normally while there is substantial delay in social interaction and "development of restricted, repetitive patterns of behavior, interests, and activities."

A. Qualitative impairment in social interaction, as manifested by at least two of the following: 

(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction 

(2) failure to develop peer relationships appropriate to developmental level 

(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) 

(4) lack of social or emotional reciprocity 

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Asperger’s Disorder :

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 

(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 

(2) apparently inflexible adherence to specific, nonfunctional routines or rituals 

(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) 

(4) persistent preoccupation with parts of objects 

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorders

Asperger’s Disorder :

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. 

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years). 

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood. 

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia

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DSM IV Diagnostic Criteria for Attention-Deficit and Disruptive Behavior Disorders

Attention-Deficit/Hyperactivity Disorder

Combined type

Predominantly Inattentive Type

Predominantly Hyperactive-Impulsive Type

Attention-Deficit/Hyperactivity Disorder NOS

Conduct Disorder

Oppositional Defiant Disorder

Disruptive Behavior Disorder

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DSM IV Diagnostic Criteria for Attention-Deficit and Disruptive Behavior Disorders

A. Either (1) or (2): (1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: 

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 

(b) often has difficulty sustaining attention in tasks or play activities 

(c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to

finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) 

(e) often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that

require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys,

school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities 

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DSM IV Diagnostic Criteria for Attention-Deficit and Disruptive Behavior Disorders

(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in

which remaining seated is expected (c) often runs about or climbs excessively in situations in

which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) 

(d) often has difficulty playing or engaging in leisure activities quietly 

(e) is often "on the go" or often acts as if "driven by a motor" 

(f) often talks excessively

Page 20: Developmental Disabilities

DSM IV Diagnostic Criteria for Attention-Deficit and Disruptive Behavior Disorders

Impulsivity(g) often blurts out answers before questions have been

completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into

conversations or games) 

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. 

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). 

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. 

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). 

Page 21: Developmental Disabilities

DSM IV Diagnostic Criteria for Feeding and Eating Disorders of Infancy or Early Childhood

A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month. 

B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux). 

C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food. 

D. The onset is before age 6 years.

Page 22: Developmental Disabilities

DSM IV Diagnostic Criteria for Feeding and Eating Disorders of Infancy or Early Childhood

Pica

Rumination Disorder

Feeding Disorder of Infancy or Early childhood

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DSM IV Diagnostic Criteria Tic Disorders

Tourette’s Disorder

Chronic Motor or Vocal Tic Disorder

Transient Tic Disorder

Tic Disorder NOS

Page 24: Developmental Disabilities

DSM IV Diagnostic Criteria for Tic Disorders

Tourette's Disorder

A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.) 

B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months. 

C. The onset is before age 18 years. 

D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington's disease or postviral encephalitis).

Page 25: Developmental Disabilities

DSM IV Diagnostic Criteria for Elimination Disorders

Encopresis

With Constipation and Overflow Incontinence

Without Constipation and Overflow Incontinence

Enuresis

Page 26: Developmental Disabilities

DSM IV Diagnostic Criteria for Other Disorders of Infancy, Childhood or Adolescence

•Other Disorders of Infancy, Childhood, or Adolescence:

•Selective Mutism

• Separation Anxiety Disorder

• Reactive Attachment Disorder of Infancy or Early Childhood

• Stereotypic Movement Disorder

• Disorder of Infancy, Childhood, or Adolescence NOS

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A report made by the British Government in 1858 concluded the following:

1. Guggenbuhl was guilty of deceiving people by calling his establishment Kretinen-Heilanstalt (treatment center for cretins), since at most one third of the inmates were cretins. The report went as far as to accuse Guggenbuhl of "smuggling in" normal children to present as cured.

2. Normal children were kept from attending the public schools by housing them at Abendberg.

3. Not a single cretin had ever been cured.

4. There was no medical supervision. The director was away from four to six months each year and made no provisions for a substitute.

5. While at first well-trained instructors had been employed, Abendberg had been without a teacher for several years.

6. Heating facilities, nutrition, water supply, ventilation in dormitories, and clothing were inadequate.

7. The director never kept records of the munificent donations received.

8. No records were kept about the patients' progress.

Early Optimism and Over-promise(1836-1850)

Page 32: Developmental Disabilities

In 1846 Howe convinced the Massachusetts legislature to allocate $2500/year for the teaching and training of ten retarded children.

After a successful experimental period, and institution was incorporated in 1848 under the name “Massachusetts School for Idiotic and Feeble-Minded Youth”. It is now known as the Walter E. Fernald State School.

Howe can be considered the father of institutional care in the US and the one who advocated most explicitly that acting upon the problem of mental retardation was a public responsibility.

Howe’s efforts were followed by the establishment of additional training schools throughout the US through the 1870s

Realistic Optimism of Dr. Samuel Howe(1850-1870)

Page 33: Developmental Disabilities

Difficulties in Coping with Urban Life and the Shift to Custodial Care

(1870-1890)

Quotes from documents Cited by Wolfensberger, W. (1969). The origin and nature of our institutional models. In Robert Kugel & Wolf Wolfensberer (Eds.) Changing patterns in residential services for the mentally retarded. Washington, D.C.: President’s Committee on Mental Retardation.

“Give them an asylum with good and kind treatment; but not a school.”

“A well-fed, well-cared-for idiot, is a happy creature. An idiot awakened to his condition is a miserab le one.”

“They must be kept quietly, safely, away from the world; living like the angels in heaven, neither marrying nor given in marriage.”

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Difficulties in Coping with Urban Life and the Shift to Custodial Care

(1870-1890)

Dangerous Trends in Institutional Development

Isolation: Protection of the deviant from the non-deviantInstitutions were removed from population centers to pastoral surroundings described in idyllic terms, eg. “Garden of Eden”, “happy farm”

Enlargement: Benefits the retardates by congregating large numbers so that the could “be among their own type.”

Economization: Began with noble sentiment about the virtue of work for the retarded, but gave way to the view that they should be working to diminish the economic burden on the public.

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H. H. Goddard's 1912 report of the Kallikak family

Martin Kallikak, a soldier of the Revolution, produced an illegitimate son with a retarded tavern girl. This son turned out to be retarded, too, and went on to produce a line of

prostitutes, alcoholics, epileptics,criminals, pimps, retardates,

and infant casualties. Martin himself went on to marry a respectable woman of a good family and left progeny all of which were representative of the most respectable citizens

Social Darwinism and the eugenic alarm(1890-1914)

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H. H. Goddard's 1912 report of the Edward’s family

Jonathan Edward's family was contrasted to the Jukes and the Kallikaks, since he left 285 college graduates,

of whom 65 became college professors,

13 college presidents,

more than 100 lawyers, and

30 judges

Social Darwinism and the eugenic alarm(1840-1914)

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Three main alternatives for “purging from the blood of the race innately defective strains:

Marriage laws Sterilization Segregation

Social Darwinism and the eugenic alarm(1840-1914)

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Specialized training through public schools

Heavy emphasis on community integration and supervision

Colony plan –prototypes of half-way houses and sheltered workshops

Beginnings of government support for families

Parole plan: retarded people were permitted to live in the community under the supervision of a social worker who took a personal interest in integrating them into the community

Slow development of community alternatives: Post-World-War I to 1950

Page 39: Developmental Disabilities

National Association for Retarded Children: Advocacy group wielded great influence at local and national levels

Medical advances aiding survival of babies with biological defects

Local groups of parents developed community-based alternative services

1961: President Kennedy appointed panel to review conditions for retarded and presented: “A Proposed Program for National Action to Combat Mental Retardation

Landmark legislation: Maternal and Child Health and Mental Retardation Planning Ammendments Act (1963)

Application of behavior analysis to overcome learning and behavior problems experienced by people with developmental disabilities

Renewed Enthusiasm:1950 – Present

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Provisions of the Willowbrook Consent Decree

Designating steps, standards and procedures to protect residents from abuses such a/J seclusion, corporal punishment, degradation, medical experimentation, and routine use of restraints.

 

Six scheduled hours of program activity each weekday for all residents.

Educational programs for residents including provision for the specialized needs of

the blind, deaf and multi-handicapped.

Well-balanced nutritionally adequate diets.

Dental services for all.

No more than eight residents living or sleeping in a unit.

A minimum of two hours of daily recreational activities-indoors and out-and

availability of toys, books, and other materials

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Provisions of the Willowbrook Consent Decree

Eyeglasses, hearing aids, wheelchairs and other adaptive equipment where needed. ).

Adequate and appropriate clothing.

Physicians on duty 24 hours daily for emergency cases.

A contract with one or more accredited hospitals for acute medical care.

A full-scale immunization program for all residents within three months.

Compensation for voluntary labor in accordance with applicable minimum wage laws.

;..

Correction of health and safety hazards, including covering radiators and team pipes to protect residents from injury, repairing broken windows, and removing cockroaches and other insects and vermin.

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Developmentally Disabled Assistanceand Bill of Rights Act

(1975)

I. Persons with developmental disabilities have a right to appropriate treatment, services and habilitation for such disabilities.

II. The Federal Government and the States both have an obligation to assure that public funds are not provided to any institutional or other residential programs for persons with developmental disabilities that—

A. Does not provide treatment services, and habilitation which is appropriate to the needs to such persons or

B. Does not meet the following minimum standards:1. Provision of a nourishing, well-balanced daily diet to the persons with developmental disabilities served by the program2. Provision to such persons of appropriate and sufficient medical and dental services3. Prohibition of the use of physical restraint on such persons unless absolutely necessary and

prohibition of the use of such restraint a punishment or a s a substitute for a habilitation program

4. Prohibition on the excessive use of chemical restraints on such persons and the use of such restraints as punishment or as a substitute for a habilitation program or in quantities that interfere with services, treatment, or habilitation for such persons.

5.Permission for close relatives of such persons to visit them at reasonable hours without prior notice

6. Compliance with adequate fire and safety standards as may be promulgated by the Secretary of Health, Education, & Welfare.

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Americans with Disabilities Act1990 (Public Law 101-336)

Purposes:

 

I.  to  provide  a  clear  and  comprehensive  national  mandate  for  the  elimination  of  discrimination against individuals with disabilities;

 

II to provide clear, strong, consistent enforceable standards addressing discrimination against individuals with disabilities;

 

III. to ensure that the Federal Government plays a central role in enforcing the standards established in this Act on behalf of individuals with disabilities;

 

IV. to invoke the sweep of congressional authority, including the power to enforce the Fourteenth Amendment and to regulate commerce, in order to address the major areas of discrimination faced day to day by people with disabilities

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Reasons fro the ebb and flow of mental health ideologyCaplan (1969)

Acceptance of ideas has little to do with their intrinsic value.  Community-oriented reforms did not succeed in the past for the following reasons:

 1. A shortage of manpower to implement programs, which in partreflects inadequate training facilities.

2. A shortage of resources associated with the low priority accordedthe mentally ill by the public and their legislators.

3. Theories concerning the etiology and treatment of mental disorder favored exciting new ideas and fads. At the turn of the century, the intellectual and scientific community was buzzing with new ideas in neuropathology and psychoanalysis. Optimistic treatment mo dalities linking patients back to their home communities were considered unrealistic and "old-fashioned.“

4. The naivete and lack of understanding of psychiatrists about prob lems of community dynamics that complicated the implementa tion of their programs. Theories of psychic functioning cannot be formulated in a vacuum. Factors in the social, political, economic, and scientific milieu affect the manner in which theories are developed as well as the success of their implementation.

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Reasons fro the ebb and flow of mental health ideologyCaplan (1969)

Acceptance of ideas has little to do with their intrinsic value.  Community-oriented reforms did not succeed in the past for the following reasons:

5. The tendency of psychiatrists to embrace panaceas and to hail each change as the solution to all difficulties. The system was oversold to the public and to fellow professionals. When shortcomings were revealed, there was a pendulum swing in the opposite direction with the entire system being jettisoned.

6. When public complaints about the failure of optimistic promisesstarted to surface, psychiatrists tended to deal with such outside pressure by evasion rather than by direct confrontation. Psychia trists retreated into their professional guild and lost touch with the realities of community life.

7. Faddish theories were entirely untested. By the time the shortcomings of expensive plans had been realized, so much propaganda and money had been spent that it was difficult to abandon or replace them.