Functional Impairments

ADMHS Clinical Trainings

Elisa A. Gottheil PhD
 Purpose of this Hour

• To familiarize you with the significance of assessing for

functional impairments
• To introduce the WHODAS 2.0 and its relevance in
assessing functional impairment
• To review our working knowledge of
Severe Mental Illness
Serious Pervasive Mental Illness
Severe Emotional Disturbance
Functional Impairment
•
 If your client may be applying for Supplemental Social
Security Insurance (SSI) based on disability…

Social Security Administration wants to know to what extent (if any) the
client’s current mental condition interferes with certain domains of
functioning (and you have to provide supporting data and examples).

What would you focus on to show to SSA that your client in entitled to
receive Supplemental Social Security Income based on disability?
 If your client may be applying for Supplemental Social
Security Insurance (SSI) based on disability…

Form a group
In your group;
Discuss what you believe are the functional impairments that support
Supplemental Social Security Income based on disability?
What areas of functioning should be affected and in what way?
Are there any limitations/exclusions to your suggesting/identifying these
functional impairments?
 If your client may be applying for Supplemental Social Security Insurance (SSI) based on
disability…

Social Security Administration wants to know to what extent (if any) the
client’s current mental condition interferes with each of the following (and
you have to provide supporting data and examples).
Present Daily Activities: Discuss the degree of assistance or direction needed
to properly care for personal affairs, do shopping, cook, use public
transportation, a bills, maintain residence, care for grooming and hygiene,
etc. In what ways, if any, have the patient’s daily activities changed as a result
of the patient’s mental condition?
 If your client may be applying for Supplemental Social Security Insurance (SSI) based on
disability…

Social Functioning: Describe the client’s capacity to interact appropriately

and communicate effectively with family members, neighbors, friends,
landlords, follow employees, etc. In what ways, if any, have these changed as
a result of the patient’s condition?
 If your client may be applying for Supplemental Social Security Insurance (SSI) based on
disability…

Concentration and Task Completion: Describe the client’s ability to sustain

focused attention complete every day household routines, follow and
understand simple written or oral or instructions, etc. In what ways, it any,
have these changed as a result of the patient’s condition?
 If your client may be applying for Supplemental Social Security Insurance (SSI) based on
disability…

Adaptation to Work or Work-like Situations: describe the patient’s ability to

adapt to stresses common to the work environment including decision-
making, attendance, schedules, and interaction with supervisors. In what
way, if any, have these changed as a result of the patient’s condition?
 If your client may be applying for Supplemental Social Security Insurance (SSI) based on
disability…

Severity and nature of mental illness relapses.

 WHODAS 2.0
• http://www.who.int/classifications/icf/
whodasii/en/
 WHODAS 2.0

• Generic assessment instrument for health and disability

• Used across all diseases, including mental, neurological
and addictive disorders
• Short, simple and easy to administer (5 to 20 minutes)
• Applicable in both clinical and general population settings
• Produces standardized disability levels and profiles
• Applicable across cultures, in all adult populations
• Direct conceptual link to the International Classification of
Functioning, Disability and Health (ICF)
 WHODAS 2.0
Covers 6 domains:
Cognition – understanding & communicating
Mobility– moving & getting around
Self-care– hygiene, dressing, eating & staying alone
Getting along– interacting with other people
Life activities– domestic responsibilities, leisure,
work & school
Participation– joining in community activities
 Get together in a small group…
https://www.countyofsb.org/uploadedFiles/admhs_new/staff_and_providers/PP
%2073%20SPMI-SED.pdf

In your group:
Discuss what are the elements of P&P73:
1. Who do we serve?
2. What are the criteria that individuals with a serious
mental illness/SED must meet?
3. As a result of the mental disorder, what must the
individual experience?
4. What would happen without treatment? And…
5. What else do you notice in P&P73?
 Who do we serve… as long as we have funds…
https://www.countyofsb.org/uploadedFiles/admhs_new/staff_and_providers/
PP%2073%20SPMI-SED.pdf

• Seriously emotionally disturbed children or adolescents

• Adults and older adults who have a serious mental
disorder.
• Adults and older adults who require or are at risk of
requiring acute psychiatric inpatient care, residential
treatment, or outpatient crisis intervention because of a
mental disorder with symptoms of psychosis, suicidality,
or violence.
• Persons who need brief treatment as a result of a natural
disaster or severe local emergency.
 What are the purposes of a functional
impairment assessment?
So…

How do we get to the relevance of functional

impairments?
 When functional impairment comes into play

Within the frame of establishing medical necessity:

What is the first thing we need to establish?
How do we define serious mental disorder?
 When functional impairment comes into play

Within the frame of establishing medical necessity:

First we established serious mental disorder in adults or severe emotional
disturbance in children.

Serious Mental Disorder is defined as a mental disorder that is

• severe in degree and persistent in duration, and which
• may cause behavioral dysfunction that interferes substantially with primary activities
of daily living, and
• that may result in an inability to maintain stable community adjustment without
treatment, support, and rehabilitation for a long or indefinite period of time.
 Can you fill in the blues?

Serious Mental Disorder is defined as a mental disorder that is

• severe in , and which
• may cause that interferes substantially with
primary activities of daily living, and
• that may result in
without treatment, support, and rehabilitation for a
long or indefinite period of time.
 Medical Necessity Criteria for Outpatient Specialty Mental Health Services
1. Must have an included mental health diagnosis*
2. Impairment Criteria – Must have at least one of A, B, or C below as a result of the included diagnosis:

A. A significant impairment in an important area of life functioning.

B. A probability of significant deterioration in an important area of life functioning.
C. A reasonable probability that a child (under 21) will not progress developmentally as individually
appropriate.

Note: Full-scope Medi-Cal beneficiaries under 21 may qualify under EPSDT regulations if they have a condition as a result of a mental disorder
that Specialty Mental Health Services can correct or ameliorate, even if impairment criteria are not met.

3. Intervention Criteria – A, B and C below must be true:

A. The focus of the proposed intervention is to address the included diagnosis or impairments.
B. The intervention will (at least one of the following must be true):
• Significantly diminish the impairment
• Prevent significant deterioration in functioning
• Allow the child to progress developmentally as appropriate
C. The condition would not be responsive to physical health care based treatment.
 Inclusions and Exclusions…
SECOND, we need to know what is included and what is not
• Excluded Diagnoses
•  Mental Retardation
•  Learning Disorders
•  Motor Skills Disorders
•  Communication Disorders
•  Autistic Disorder
•  Tic Disorders
•  Delirium, Dementia, Amnestic and Other Cognitive Disorders
•  Mental Disorders Due to a General Medical Condition
•  Substance-Related Disorders
•  Sexual Dysfunctions
•  Sleep Disorders
•  Antisocial Personality Disorder
•  Other Conditions that may be a Focus of Clinical Attention, except Medication-Induced
Movement Disorders
•  
• Important TIP: When Medi-Cal beneficiary is found not to meet medical necessity criteria
during a screening appointment a NOA A must be issued and mailed to the client by the
clinician.
•  
• Note: A beneficiary may receive services for an included diagnosis when an excluded
diagnosis is also present.
• Included DSM-IV Diagnoses
•  Pervasive Developmental Disorders, except Autistic Disorder, which is excluded
•  Attention Deficit and Disruptive Behavior Disorders
•  Feeding and Eating Disorders of Infancy or Early Childhood
•  Elimination Disorders
•  Other Disorders of Infancy, Childhood or Adolescence
•  Schizophrenia and Other Psychotic Disorders
•  Mood Disorders, except Substance Induced Mood Disorders, which are excluded
•  Anxiety Disorders
•  Somatoform Disorders
•  Factitious Disorders
•  Dissociative Disorders
•  Paraphilias
•  Gender Identity Disorders
•  Eating Disorders
•  Impulse Control Disorders Not Elsewhere Classified
•  Adjustment Disorders
•  Personality Disorders, except Antisocial Personality Disorder, which is excluded
•  Medication-Induced Movement Disorders
 What are the purposes of a functional
impairment assessment? Cont.

The definition of serious mental disorder does not exclude

• persons with a diagnosis of substance abuse,
• developmental disability, or
• other physical or mental disorder,
As Long As the serious mental disorder Is Deemed To Be The
Primary Source Of Impairment, that is,
NOT SECONDARY to active substance abuse, or developmental disorder,
or physical disorder.
 Can you fill in what is missing?
This definition does not exclude
• persons with a
• , or
• other,

As Long As the mental disorder Is Deemed To Be

, that is,
NOT to active substance abuse, or developmental
disorder, or physical disorder.
 Can you think of examples of exclusions of
the definition of serious mental disorder?
• Persons with a diagnosis of substance abuse, who are active in
their use and resulting in impairment
• Persons with a developmental disorder which is the etiology,
reason for the impairment
• Persons with a physical disorder which results in impairment
 Summarizing Serious Mental Disorder
From the policy itself… P&P 73
To summarize, individuals with a serious mental disorder must meet all of the
following criteria to be included in the WIC §5600.3 target population:

1. The person has a mental disorder identified in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders, other than a substance
use disorder or developmental disorder or acquired traumatic brain injury.

2. As a result of the mental disorder, the person has substantial functional

impairments or symptoms, or a psychiatric history demonstrating that without
treatment there is an imminent risk of decompensation to having substantial
impairments or symptoms or will not progress developmentally.
 …From the policy itself… P&P 73… cont.
…
For the purposes of WIC §5600.3, "functional impairment" means
being substantially impaired as the result of a mental disorder in
independent living, social relationships, vocational skills, or
physical condition.
3. As a result of a mental functional impairment and circumstances, the
person is likely to become so disabled as to require public assistance,
services, or entitlements.
 Hyper-focusing on Functional Impairments
For the purposes of WIC §5600.3, "functional impairment" means being
substantially impaired as the result of a mental disorder in
independent living,
social relationships,
vocational skills, or
physical condition.

As a result of a mental functional impairment and circumstances, the person is

likely to become so disabled as to require public assistance, services, or
entitlements.
 Serious Mental Disorder and Relation to Functional
Impairment: Putting it all Together

• We establish that there is a mental disorder

• We then establish that as a result of the mental disorder
the person has developed substantial functional
impairments or symptoms,
• OR a psychiatric history demonstrating that without
treatment there is an imminent risk of decompensation to
having substantial impairments or symptoms.
• AND as a result of a mental functional impairment and
circumstances, the person is likely to become so disabled
as to require public assistance, services, or entitlements.
• 
 Moving on to Serious Pervasive Mental Illness

• How is SPMI defined in P&P 73?

• 
 P&P 73 SPMI 18 +
http://www.countyofsb.org/uploadedFiles/admhs_new/staff_and_providers/PP%2073%20SPMI-SED.pdf
What are the various possible functional impairments in the
definition of SPMI?

This mental disorder  results or has resulted in

at least one severe impairment in Category A, and
at least 3 severe impairments in Category B.
 At least one severe impairment in Category A

[  ] Feeling, Mood, and Affect  Severely  erratic dysregulated  emotional intensity and instability is
clearly disruptive, interfering,  and disabling in its effects on most aspects of  all activities of daily
living, including relationships, role performance, socio legal functioning, vocational functioning, and
general risk factor status.

[  ] Thinking Severe impairments and deficits  in  cognition, concentration, persistence, reality
testing/contact, and executive functioning. Frequent or consistent interference with daily life 
activities due to significantly  impaired thought processes. Possible/probable presence of  psychotic
content in the form of  delusions, hallucinations; ideas of reference, flight of ideas.  Thought
processes may be discorded with respect to structure, development, reference, chronology, 
linearity, logic, coherence, pertinence, goal direction, tangentiality, circumstantiality, sequentially, 
and over-inclusivity.

These symptoms  appear  to interfere significantly with activities of daily living (hygiene, food,
clothing, shelter); appropriate  interpersonal relationships;  and obtaining/maintaining employment
and adequate income; i.e.;  a prolonged and pronounced functional impairment in his activities of
daily living,  interpersonal relationships, and obtaining housing and employment 
 What are the two categories in A? and how many
is/needed to meet the criteria?

Feeling, Mood, and Affect

Thinking
One
 Must have significant impairments in at least 3 of the
following areas in Category B:
Family & Interpersonal: Inability to establish or maintain appropriate relationships with
family members, teachers, other adults, or peers. Unable to function adequately as a
member of groups and causes or experiences frequent turbulence as a result of a mental
disorder.
Role Performance: Frequent disruption of role performance, and the individual is unable to
meet usual, age-appropriate expectations. Impairment in school functioning, truancy, and
inability to successfully complete daily behavioral expectations due to effects of the mental
disorder.
Socio-legal: Inability to maintain conduct within the limits prescribed by law, rules, and
accepted age-appropriate behaviors. May have disregard for the safety of others, be
destructive to property, have involvement with CWS and/or law enforcement.
Self Care/Basic Needs :Disruption in the ability to provide for his/her own needs in a manner
appropriate to age and/or development. Unable to maintain hygiene in an age-appropriate
manner.
Risk Factors: Significant risk of danger to self or others, as demonstrated by self-harm
gestures, suicidal or homicidal symptoms, actions or behaviors that place the individual at
risk of death or physical injury, frequent hospitalizations.
What are the five categories in B and how many are
needed to meet the criteria?
Family & Interpersonal
Role Performance
Socio-legal
Self Care/Basic Needs
Risk Factors
Three
Severe Emotional Disturbance Criteria Checklist (under 18
years old)
• The child must have a Severe Mental Disorder, and
• The mental disorder must result in at least one severe
impairment in Category A, and
• At least 3 severe impairments in Category B.

(do you notice any differences?

CATEGORY A: MUST HAVE SIGNIFICANT IMPAIRMENTS IN AT
LEAST ONE OF THE FOLLOWING AREAS:
Feeling, Mood, and Affect: Uncontrolled emotion is clearly
disruptive in its effects on a child’s life. Marked changes in mood not
associated with developmental stages. Depression and/or anxiety
incapacitates the person. Emotional responses are inappropriate to
the situation.
Thinking Severe impairment in concentration, persistence and pace.
Frequent or consistent interference with daily life due to impaired
thinking. Presence of delusions and/or hallucinations. Frequent
substitution of fantasy for reality.
CATEGORY B: MUST HAVE SIGNIFICANT IMPAIRMENTS IN AT
LEAST 3 OF THE FOLLOWING AREAS
Family & Interpersonal: Inability to establish or maintain appropriate
relationships with family members, teachers, other adults, or peers.
Unable to function adequately as a member of groups and causes or
experiences frequent turbulence as a result of a mental disorder.
Role Performance: Frequent disruption of role performance, and the
individual is unable to meet usual, age-appropriate expectations.
Impairment in school functioning, truancy, and inability to successfully
complete daily behavioral expectations due to effects of the mental
disorder.
…
CATEGORY B: MUST HAVE SIGNIFICANT IMPAIRMENTS IN AT
LEAST 3 OF THE FOLLOWING AREAS, cont.
…
Socio-legal: Inability to maintain conduct within the limits prescribed by
law, rules, and accepted age-appropriate behaviors. May have disregard
for the safety of others, be destructive to property, have involvement
with CWS and/or law enforcement.
Self Care/Basic Needs: Disruption in the ability to provide for his/her
own needs in a manner appropriate to age and/or development. Unable
to maintain hygiene in an
age-appropriate manner.
Risk Factors Significant risk of danger to self or others, as demonstrated
by self-harm gestures, suicidal or homicidal symptoms, actions or
behaviors that place the individual at risk of death or physical injury,
frequent hospitalizations
Thank you!