Positive Approaches Journal, Volume 11, Issue 1
Malishchak | 45-54
Volume 11 ► Issue 1 ► May 2022
Enhancements of Identification and Service Delivery to Individuals with Neurodevelopmental Needs within the Pennsylvania Department of Corrections (DOC)
Lucas D. Malishchak,
The Pennsylvania DOC’s Psychology Office recently broadened its system’s process of identifying and treating neurodevelopmental disorders beyond intellectual disabilities, to include those individuals living with autism spectrum disorder (ASD). This improvement is reflective of the Psychology Office’s more comprehensive clinical operational plan of augmenting identification efforts and enhancing service delivery. This article will outline additional components of the DOC’s statewide clinical operational plan, which includes an overview of the ongoing development of a Neurodevelopmental Residential Treatment Unit.
To ensure incarcerated people have adequate access to mental health care, the American Correctional Association indicates that correctional mental health care systems must, at a minimum (i.e., among many other processes and assurances), ensure that each incarcerated person receives appropriate mental health care to assist with the restoration, recovery, and maintenance of each person’s mental wellbeing during their period of incarceration.1 In light of this standard of care, the PA DOC’s Psychology Office annually reviews internal correctional mental health care policies. During a recent annual policy review, which included a field survey of the DOC’s more than 300 front line psychology staff on their knowledge, experience, and skills working with patients diagnosed with neurodevelopmental needs, the Psychology Office leadership team identified the need to enhance systemic identification and treatment efforts of people who may be living with neurodevelopmental needs, beyond intellectual disabilities. Additionally, the team identified that training efforts of clinical staff in these areas were also needed. As a result, the Psychology Office leadership team developed a plan of action to guide these focused enhancements. The following paragraphs will briefly outline several components of this plan and describe the systemic efforts aimed at enhancing access to care for this population.
To best understand the progress made by the DOC over the past few years, it is essential to understand historical clinical processes used to identify and treat neurodevelopmental disorders within the Pennsylvania DOC. In January of 2015, the DOC signed a landmark settlement agreement with Disability Rights Pennsylvania2. The core issue of this settlement agreement included but was not limited to the identification of individuals with serious mental illnesses and other vulnerabilities, including intellectual disabilities, and their diversion from restrictive housing, among numerous other relevant clinical and operational safeguards for this population. The original group of individuals identified to benefit from the new safeguards, while progressive and sizeable, did not specifically include individuals living with other neurodevelopmental disorders like ASD. As a result, two recent revisions that occurred in 2020 included the mandatory training of all DOC psychology staff on the identification and treatment of individuals with neurodevelopmental needs and the inclusion of patients diagnosed with ASD into the known classification of mental health patients that receive the highest clinical and operational safeguards within the DOC.
Mandating annual training on neurodevelopmental disorders and reclassifying individuals with ASD were two straightforward revisions. However, training would need to continue, and the reclassification merely ensured identified patients would be afforded the above referenced safeguards. Unfortunately, at that point in time, the DOC had less than 15 patients (i.e., out of approximately 40,000) diagnosed with ASD or less than .05% of their population. In light of the known prevalence of ASD reaching approximately 1%3, the Psychology Office needed a more comprehensive internal screening and diagnostic process responsive to both the varied intercepts of reception into the DOC and responsive to those patients already living within the system. From early 2020, the Psychology Office continued incorporating additional clinical advancements beyond the original safeguards outlined in DOC policy. Initially, the team identified the need to augment the initial reception screening process (i.e., of all new receptions into the DOC) to include the Autism Quotient-104, a neurodevelopmental screening tool sensitive to identifying signs and symptoms of ASD. By incorporating the Autism Quotient-10 (AQ-10)4 at initial reception, the DOC ensured new and future receptions into the DOC were screened for ASD, thereby enhancing the ability to identify neurodevelopmental needs of the incoming population. However, adding a brief neurodevelopmental screen to the initial reception process could not be introduced without a more thorough and complementary diagnostic process to address those who screened high on the AQ-104. Consequently, as part of their comprehensive approach to improving the identification of ASD, the Psychology Office developed an internal ASD diagnostic protocol, as well. This protocol was developed through the guidance and leadership of the Psychology Office’s four Regional Licensed Psychologist Managers and Administrative Officer, with input and feedback from Licensed Psychologist Managers (LPMs), Psychological Services Specialists (PSSs), and Psychological Services Associates (PSAs) throughout the DOC. The initial screening protocol and differential diagnosis protocol also required integration into the DOC’s electronic health record, as well. Once integrated into the electronic health record’s practice and testing environment, field clinical staff were able to experiment with these tools and provide feedback to developers and clinical leaders for the purpose of enhancing user-friendliness, clinical utility, etc. This information was then used to further improve documentation processes before the new protocols went operationally live.
Once developed and tested, the initial screening and follow up diagnostic process still could not begin without first ensuring DOC clinical staff were adequately trained. To accomplish this task, all 277 master’s level Psychology staff members and their Licensed Psychologist clinical supervisors required training on the AQ-104 and the diagnostic interview protocol. Here, the Psychology Office’s four Regional LPMs trained the DOC’s 27 LPMs on the utilization of the AQ-104 and the diagnostic protocol. Once trained, the LPMs trained their 277 front-line PSAs and PSSs. Including these new initial reception products together into existing DOC mental health care processes, advanced the organization’s ability to identify neurodevelopmental needs of the incoming population. However, despite this early work, these new processes merely ensured that all newly arriving receptions were screened for ASD, and that, if clinically indicated, a follow up diagnostic and clinical interview process would occur. Following the promulgation of the enhanced reception product, the Psychology Office brainstormed the most efficient and effective method of screening and identifying individuals currently living in the DOC who may have undiagnosed neurodevelopmental needs.
Screening the entire DOC population for ASD was neither practical nor clinically appropriate. Instead, the Psychology Office clinical team identified smaller groups of people that had diagnoses known to frequently cooccur with ASD (e.g., Intellectual Disability) or known to be mistakenly diagnosed instead of ASD (e.g., Schizophrenia). As frontline psychology staff at the DOC’s 24 State Correctional Institutions (SCI) continue to screen through patients diagnosed with an intellectual disability, the Psychology Office leadership team recognized the need for additional community partnerships and resources beyond the DOC. The purpose of seeking to develop such partnerships was to not only enhance the DOC’s knowledge base with community expert’s insights into the identification and treatment of incarcerated people living with neurodevelopmental disorders, but also in an effort to enhance identification efforts of neurodevelopmental needs among individuals currently involved in the criminal justice system (i.e., a Pennsylvania county jail) who may eventually be transferred to DOC custody. Rather quickly, the Psychology Office established relationships with the Pennsylvania Department of Human Services’(PA DHS) Office of Developmental Programs (ODP) and the Autism Connection of Pennsylvania.
Given the novelty of this work and the identified clinical experience of staff, establishing partnerships with community neurodevelopmental advocates and experts was central to the DOC’s plan of action and subsequent clinical advancements. Under the leadership and insight of former Secretary of Corrections, John Wetzel, a new treatment unit specializing in meeting patient neurodevelopmental needs was proposed within the DOC. The development of this unit represented a unique opportunity for the DOC to lean into their collaboration with community partners even further and to include these external stakeholders into the administrative and clinical brainstorming process guiding the development of the unit. One of the more innovative contributions from the PA DHS’s ODP was to consider integrating a Positive Behavioral Support (PBS) model of care and treatment into this unit5. In response, ODP and the Psychology Office conducted numerous joint planning sessions aimed at introducing PBS to DOC psychology leadership staff, reviewing relevant PBS research, and evaluating the appropriateness of integrating elements of PBS into a correctional milieu for adults. This collaboration culminated with ODP delivering two separate but intuitive and focused PBS trainings to DOC psychology leadership staff and the clinical and administrative leadership teams at SCI-Albion. Additionally, while the development of this unit remains ongoing, the Psychology Office recognizes the importance of attempting to incorporate as many of the essential elements of PBS into the development of this unit as is safely possible, including support team involvement, assessment of contexts and functions, behavior support plan design, data-based decision making, and focus on lifestyle change. An early promising practice that the Psychology Office and ODP are exploring together for integration into this unit is the understanding of the benefits of DOC staff being proactive in identifying patients that are “doing well” and bringing this positive behavior to the attention of the neurodiverse patient, in an effort at influencing future positive behavioral outcomes within the correctional and community settings (i.e., following the person’s reentry to the community).
As the new unit continues to be collaboratively developed, the DOC is optimistic about the future of the individuals that will live in this unit, thankful for the expertise and guidance from ODP and the Autism Connection of Pennsylvania, and forever grateful and proud of the DOC staff at SCI-Albion that are responsible for the overall operations, management, and oversight of this new unit. The SCI-Albion team is the best of the best.
A final systemic
enhancement worth briefly discussing that appears to have the greatest
potential for the most change into the DOC’s ability to identify and support
individuals with neurodevelopmental needs beyond intellectual disabilities is
Pre-reception Case Identification at the county jail level. Pre-Reception
Case Identification refers to the DOC’s efforts to identify people
currently incarcerated at a Pennsylvania county jail who have known
neurodevelopmental needs and have been sentenced to serve time within the DOC.
Case identification occurs by the above-mentioned community organizations
(i.e., as a result of providing previous service and support to the family and
individual), and with the permission of the families and patients themselves,
are communicated to the attention of the DOC Psychology Office. Once identified
and shared, the Psychology Office opens the lines of communication with County
Jail Administrators and the DOC’s Office of Population Management for the
purpose of expediting transfer to DOC, if clinically indicated, or for
diverting cases away from the traditional DOC initial reception process to a
more protected, safeguarded, and clinically enhanced reception process that
affords a more individualized assessment and initial period of observation and
adjustment for the individual with known neurodevelopmental needs. These
enhancements would not be possible if not for the aforementioned relationships
forged between the DOC Psychology Office and the identified community stakeholders,
families, and organizations. These
relationships afford the DOC a much greater opportunity at retrieving valuable
patient health care records from not only community health care providers but
also from supportive family members. Pre-Reception Case Identification has
ignited the DOC Psychology Office to pursue additional transformational
enhancements aimed at supporting individuals with neurodevelopmental needs who
are preparing for transfer to the DOC. In response, the DOC Psychology Office has
dedicated centralized clinical resources to meet with patients, face to face,
who are currently housed in a Pennsylvania county jail and are awaiting
transfer to the DOC. Pre-Reception Case Identification visits afford lead
Regional LPMs in the DOC the ability to prepare a patient with known
neurodevelopmental needs for initial transfer to the DOC by answering
questions, explaining the transfer, assessment, and classification processes,
and other experiences to expect, which can be an intimidating experience for
anyone let alone an individual living with neurodevelopmental needs. Although
infrequent, this innovative practice has afforded the DOC the ability to
individually support vulnerable patients at an intercept of the criminal
justice system not previously explored for these purposes.
The DOC Psychology Office is greatly appreciative of the relationships established with ODP and the Autism Connection of Pennsylvania, as these bonds have not only facilitated the enhanced and necessary linkages to occur between existing criminal justice organizations and their clinical mental health authorities but have also greatly contributed to the DOC’s efforts of realizing continued improvement of patient access to care.
*Special thanks to
the DOC Central Office Psychology Office staff whose work and contributions are
highlighted in this article, including Dr. Cynthia Wright, Richard Goss, Dr. Brian
Schneider, Dr. Elaine Everding, James Harrington, Angel Jenrette-McDowell, and
1. American Correctional Association, On C, American. Performance-Based Expected Practices for Adult Correctional Institutions. American Correctional Association; 2018.
2. Wetzel Settlement Agreement. Disability Rights Pennsylvania.. https://www.disabilityrightspa.org/wp-content/uploads/2019/12/Web-Copy-Wetzel-Cover-Letter.pdf. Accessed April 7, 2022.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
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Baron-Cohen S. Toward Brief “Red Flags” for Autism Screening: The Short Autism
Spectrum Quotient and the Short Quantitative Checklist in 1,000 Cases and 3,000
Controls. Journal of the American Academy of Child & Adolescent
Psychiatry. 2012;51(2):202-212.e7. doi:10.1016/j.jaac.2011.11.003.
5. Sugai G, Horner RH. Introduction to the Special Series on Positive Behavior Support in Schools. Journal of Emotional and Behavioral Disorders. 2002;10(3):130-135. doi:10.1177/10634266020100030101.
Dr. Lucas D. Malishchak has been the Director of the Psychology Office for the Pennsylvania Department of Corrections since 2017. In this role, Lucas oversees a team of four Regional Licensed Psychologist Managers, who are together responsible for the clinical oversight of the mental health care system of Pennsylvania’s 24 State Correctional Institutions, which includes an infrastructure that supports more than 35,000 incarcerated people and more than 300 mental health care professionals. Lucas’ Doctor of Business Administration degree includes a specialization in Criminal Justice. His dissertation was titled, “Alternatives to Segregation and Seriously Mentally Ill Inmates in Pennsylvania State Prisons: A Case Study of Employee Perceptions.”
Lucas D. Malishchak
Pennsylvania Department of Corrections