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"There's a lot of difference of opinion on the issue of organic versus non-organic," says Jennifer Green, a psychologist who works at the CU Health Sciences Center with children who have been exposed to alcohol prenatally. "The definition of 'organic' typically is that you're dealing with brain damage as a result of a physiological or structural difference in the brain. But there's a lot of crossover with other mental-health problems, and the distinction is not always clear or well-defined."
"The conventional medical wisdom is that you never assume multiple diagnoses unless you can't account for all behaviors with a single diagnosis," responds Dr. Donald Bechtold, medical director for JCMH, who evaluated David in 2002 and was part of the assessment team that denied the Mallamos' request for residential treatment center placement. "The question is, 'What does the bad behavior derive from?' If you have a primary brain insult with secondary behavioral disinhibitions, you have to assume that it's all related. You may have something that kind of, sort of looks like ADHD, but if you treat it repeatedly for ADHD and there's no impact, then you start to link it back to some organic brain pathology."
At the time JCMH denied the Mallamos' request, David's file was full of information indicating he'd experienced some form of prenatal exposure to toxic substances; the social history provided by Pueblo County said that his biological mother was a known drinker who used marijuana and lithium. JCMH therapists and doctors were among those who'd surmised that David's problems had both organic and non-organic components. In March 2002, Bechtold had listed "personality change due to intrauterine toxin" as David's primary diagnosis, with attention deficit hyperactive disorder, a learning disability and developmental coordination disorder listed as related conditions. Yet the issue of dual diagnosis was never raised before David's parents tried to place him into a residential treatment center.
"JCMH knew that this was in his history -- and usually the only place they got that information was from things that Susan and I would tell them, because we did suspect that there were some exposure issues at play. We told them from the get-go that we thought we were probably dealing with a fetal alcohol syndrome kid," Paul says. "But they never made a big deal of the prenatal piece in all the time they were treating him -- over a period of years. This question of organic versus non-organic just never came up.
"Why didn't they deny the benefits then?" he says. "Once we requested the residential treatment center, it was a whole new ballgame. It felt like JCMH was willing to work with us until they really had to get involved and start spending money."
The idea that the presence of some other brain-related disability could limit David's mental-health treatment troubles Tomski, who has known the Mallamo family since 1996. Even if David does have fetal alcohol syndrome, she points out, he's also been repeatedly diagnosed with a host of mental maladies that are included on the Medicaid list: anxiety disorder, explosive personality disorder and attachment disorder, to name a few.
"We know that there can be physiological effects from the psychological trauma experienced by kids like David. The younger the child, the more pervasive the neurological trauma. So them having a dual diagnosis is almost inevitable," Tomski says. "I could walk up to the average person on the street, hand them David's case history and ask them, 'Do you think this kid's mentally ill?' They're going to say yes. In this case, the only one who would dispute that would be JCMH."
Bechtold acknowledges that separating brain from mind is a tricky business. "There's no question that it's difficult," he says. "Part of it is based on family history, but even that can be problematic. Someone will say, well, 'His grandmother was bipolar.' Maybe she was, maybe she wasn't. Unless you've got good clinical records on Grandma, you're just making the best judgments you can.
"One thing that we look at is, if it's mental illness, you expect it to respond over time to treatment," he adds. "But if you've tried everything under the sun, over a period of time going from A to Z, and nothing works, then it ends up being a pretty compelling profile for an organically based condition."
Even if JCMH was in complete agreement with the Mallamos' interpretation of David's pathology, the agency still might not have placed him in a residential treatment center. The agency relies on respite care, day treatments, clubhouse programs and in-home therapy over out-of-home placements, a regimen both less expensive and less restrictive. Although a stay at a residential treatment center costs less than hospitalization at state mental institutions at Fort Logan or in Pueblo, it's more costly than other intensive treatments such as therapeutic foster care or day programs.
"A lot of good treatment is not medically necessary," says Bechtold. "You're trying to spread a limited resource across a wide system. JCMH's posture is that it's better to have a child in the community instead of in an institution. You have to see what alternatives might work better."