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Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness


Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness Cath Burns, Ph.D. Barbara Noordsij, APRN, ND, PMHNP-BC * Almost half of 13 to 18 year olds are ... – PowerPoint PPT presentation

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Title: Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness

Issues of Dual Diagnosis Developmental
Disabilities and Mental Illness
  • Cath Burns, Ph.D.
  • Barbara Noordsij, APRN, ND, PMHNP-BC

  • Definitions
  • Incidence and prevalence
  • Etiology of dual diagnosis
  • Issues of Co-morbidity
  • Assessment and differential diagnosis
  • Treatment approaches
  • Examples of common co-morbid conditions
  • Applied activities sprinkled throughout

Mental Retardation
  • Significantly sub-average intellectual
    functioning (an IQ of approximately 70 or below)
  • Commensurate deficits or impairments in adaptive
  • Onset before age 18

Mental Retardation Incidence
  • 1 3 of general population
  • 1.5 time more common in boys than in girls
  • Causes 25 have known biologic causes

Prevalence of Mental Disorder in Adult Population
  • Anxiety disorders
  • ADHD
  • Autism
  • Eating Disorders
  • Mood Disorders
  • Personality Disorders
  • Schizophrenia

Prevalence of Mental Disorder in Adults (NIMH)
Prevalence in Children (NIMH)
Incidence of Psychiatric Disorders in MR
  • 40 70 of individuals have diagnosable
    psychiatric disorders
  • Manifestations of MR may overshadow symptoms
    associated with a mental illness
  • Most types of psychiatric disorders are also
    found in the MR population
  • Increased incidence of Anxiety and Affective
    Disorders across whole MR spectrum
  • More Schizophrenia spectrum disorders in those
    with mild developmental disabilities
  • Existence of behavior disorder is negatively
    correlated with IQ (e.g., repetitive,
    self-stimulating, nonfunctional motor behavior,
    SIB and Pica)

Co-Morbidity the Norm!
  • Our clients more often than not have a two or
    more diagnoses in addition to MR
  • In a clinic sample of ADHD youth
  • 87 had one co-morbid condition
  • 67 had tow or more (Kadesjo Gillberg, 2001)
  • Multiple disorders lead to more frequent mental
    health referrals

Lundby (2009) cohort Study (1947-1997)
  • Dual diagnosis was more prevalent in Mild
    intellectual disability than in moderate
    intellectual disability.
  • No subject with severe ID was diagnosed with a
    mental disorder.

Lundby continued
  • Cummulative incidence for any mental disorder was
  • Mood disorders 11.5
  • Anxiety disorders 11.5
  • Schizophrenia and other psychotic disoders 8
  • Mental NOS due to general medical condition 8
  • Dementia 3.8
  • Alcohol abuse 1.9

Co-morbidity and ASD
  • Emerging area of study
  • Levy, et al. (2010)
  • 2,568 children with ASD
  • 10 had 1 or more co-occurring psychiatric
  • 83 had non-ASD developmental diagnosis
  • Matson Nebel-Schwalm (2005)
  • Mood disorders 2 of ASD ? 30 with Aspergers
  • Fears and phobias
  • Anxiety and Obsessions
  • Anxiety present in children with ASD
  • Debate re whether OCD can be separated from ASD
    Dx stereotypic behavior?
  • Psychosis and ASD (covered later)

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Etiology across population?
  • Cumulative effects of risk
  • Biochemical abnormalities associated with
    specific Disability
  • Prenatal exposure to teratogens increases risk
  • Increased risk with specific conditions
    (epilepsy, developmental language disorders,
    sensory impairments)
  • MOST CASES complex interaction among biological
    (including genetic), environmental and
    psychosocial factors

Etiology in DD Population?
  • Associated with a wide range of neurological,
    social, psychological issues
  • Personality risk factors impaired cognition,
    organic brain damage, communication problems,
    physical disabilities, family psychopathology,
    psychosocial factors
  • Singly or in combination, individuals with DD are
    highly vulnerable
  • Specific chromosomal abnormalities also
    predispose to mental illness

Many causes of mental retardation have associated
Psychiatric Phenotypes associated with the
Some Neurogenic Disorders with a associated
psychiatric phenotype
  • Velocardiofacial sndrome
  • Fragile X
  • Down Syndrome
  • Prader-willi syndrome
  • Turners syndrome
  • Sex chromosone aneuploidy

Velocardiofacial syndrome VCFS also known as
22Q11.2 deletion syndrome
  • Has highly significant behavioral effects in
    childhood and is the single most common known
    genetic risk factor for schizophrenia.
  • Associated with multiple medical and cognitive
  • These patients may present with serious
    psychiatric concerns.

Fragile XCGG repeat expansion mutation on the
FMR1 gene
  • By school age boys who have FXS show aberrant
    speech patterns with rapid speech rate, poor
    intelligibility, dyspraxia, perseverative speech
    and impaired pragmatics.
  • The psychiatric and behavioral phenotype is
    hyperactivity , distractibility, irritability,
    repetetive sterotyped movements, pronounced gaze
    aversion and social anxiety.

Downs syndrome
  • Commonly children with DS are cheerful and
    friendly, however 20-40 have behavior problems
    such as aggression, attention problems
  • Adults may present with depression and dementia
    symptoms early onset dementia is more common in
    this population

Klinefelters syndrome the male karyotype has and
abnormal addition of and x chromosone (XXY)
  • Higher rates of psychiatric symptoms
  • Including psychotic disorders
  • Autistic features such as avoidant eye contact,
    restricted affect, rigid patterns of play and
    social deficits
  • MRI studies showed asymmetry in frontal lobes in
    men with KS

  • Talk case load

How are Co-morbid Conditions Diagnosed?
  • Special considerations
  • Mental retardation may make diagnoses of other
    psychiatric disorders more challenging

Signs of Intellectual Disability
  • Infants and children with ID do not reach
    developmental milestones within expected May
    include cognitive delays, problems with short
    term memory
  • Difficulties with social rules
  • Difficulty with problem solving
  • Difficulty with using logic
  • Difficulty with cause and effect relationships

Things to consider in evaluation
  • Talk to the patient, receptive skills may exceed
    expressive skills
  • Pay attention to developmental level of the
  • Avoid leading questions
  • Observe non verbal interactions
  • (example of play)

  • Course of changes in client symptoms need to be
  • Recent changes in life situation
  • Time frame of changes

  • Effects or untoward effects of medications.
  • Medications can cause psychotic symptoms, toxic
    reactions, delerium which can look like a
    comorbid illness

4 Factors Affecting Presentation Sovner (1986)
  • Intellectual Distortion
  • Psychosocial masking
  • Cognitive disintegration
  • Baseline exaggeration

Intellectual distortion
  • Emotional symptoms are difficult to elicit
    because of deficits in abstract thinking and in
    receptive and expressive language skills
  • (Silka Hauser, 1997)

Psychosocial masking
  • Limited social experiences can influence the
    content of psychiatric symptoms
  • example - mania presents as I can drive a car
  • Silka Hauser, 1997)

Cognitive disintegration
  • Decreased ability to tolerate stress, leading to
    anxiety induced decompensation (maybe
    misinterpreted as psychosis) (Silka Hauser,

Baseline exaggeration
  • Increase in severity or frequency of chronic or
    maladaptive behavior after onset of psychiatric
  • (comments on onset)
  • Silka Hauser, 1997)

Elements of Assessment
  • Clinical interview with psychiatric history
  • Developmental history
  • Physical disabilities (e.g.,. Epilepsy)
  • Current social functioning, social circumstances
  • Level of MR and its etiology
  • Family history of mental illness
  • Include information re behavioral changes
  • Sleep disturbance, loss of appetite, weight loss,
    lack of interest, deterioration of social skills,
    bizarre behavior, and any other deviations from
    usual behavior)
  • Information on premorbid functioning and
  • Less subjective complaints or information from
    client increases need to rely upon objective data
  • Direct observations
  • Physical examination

Elements of Assessment (continued)
  • Cognitive and adaptive assessments
  • Diagnostic rating scales specific to MR
  • Psychopathology Inventory for Mentally Retarded
    Adults (PIMRA Senatgore, et al., 1985)
  • Reiss Screen for Maladaptive Behavior (Reiss,
  • Diagnostic Assessment for the Severely
    Handicapped Scale (DASH Matson, 1991)
  • Psychiatric Assessment of Adults with
    Developmental Disability (PAS-ADD
  • Developmental Behavior Checklist (Einfeld
    Tonge, 1995)

Questions to guide diagnostic inquiry
  • How do the symptoms wax and wane?
  • Define the core symptoms of the primary disorder
    (e.g., MR, ASD, etc.) and
  • Use multiple investigators

Differential Diagnosis
  • Distinguishing between diseases of similar
    character by comparing their signs and symptoms
  • Usually involves some sort of decision tree

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Of course
  • Match treatment to presenting symptom.but be
    sure you know the cause of the symptom

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Psychiatric Disorders in Childhood and
Adolescence in MR Population
  • Largely unstudied
  • ADHD significant behavioral and emotional
    problems in early adolescents different
    trajectory compared to non-MR peers (Aman, et al,
  • Depression, Separation anxiety, ODD, RAD, CD and
    disturbances of personality related to early
    emotional development
  • Theory that MR affects early attachments

DD and Behavioral Disturbances
  • Behaviors in and of themselves may not indicate
    an underlying psychiatric disorder
  • Behaviors that are abnormal in a typical-peer may
    be developmentally appropriate to the mental age
    of your client
  • Given this, the ICD 9/10 and the DSM IVR may not
    be the best fit for the DD population!

DD and Behavioral Disturbances SIB
  • Self-Injurious Behavior (SIB) 8 14 of
    institutionalized population
  • More common with IQ lt 50
  • Ages 10 30 years with peak at about 15
  • Related to genetic and organic disturbances
    adverse environmental and developmental
  • Particular psychiatric disorders (e.g.,
    depression) may elicit SIB

Hemmings (2008)
  • Clinical predictors of severe behavioral problems
    in people with intellectual disabilities who were
    referred to a mental health services.
  • Co-morbid schizophrenia and personality disorders
    predicted the presence of severe behavioral
  • Anxiety predicted the absence of severe problems.

Differentiating Autism and Child onset
  • Clinicians experienced with Autism and
    Schizophrenia are helpful to symptom
  • Rapaport et al,2009
  • (strategy- follow along)

COS in PDD vs. Non PDD Samples Rapoport, Chavez,
Greenstein, Addington, Gogtay (2008)
DD and Specific Disorders
  • Given lack of research, much of what will be
    presented comes from adult literature
  • Child psychopathology and DD is an emerging field

Examples DD and Oppositional Defiant and
Conduct Disorders
  • ODD patter of negative, hostile and defiant
    behavior lasting for 6 months
  • CD pattern of behavior in which others rights
    are violated, norms are ignored, or rules are
    broken for at least 12 months
  • Often associated with ADHD and trauma
  • Treatment behavior therapies family support
    and treatment coordination across all
    environments psycho-education and medication
  • In general clients with intellectual disabilities
    may appear to be oppositional
  • Really a cognitive impairment
  • Others around youth assume (incorrectly) behavior
    is oppositional and/ or the child has developed
    these behaviors to escape from activities that
    are overwhelming.

Examples DD and Impulse Control Disorders
  • Intermittent Explosive Disorder
  • Trichotillomania
  • Sexual behaviors, masturbation
  • Treatment medication behavior therapies
    family support and training
  • Shopping Case example 43 year old

Examples DD and Anxiety Disorders
  • Generalized Anxiety Disorders, Panic Disorder,
    Social Phobia, Obsessive Compulsive Disorder,
  • Present with similar presentation to non-DD
  • Adults have fears similar to those of children
    matched for mental age (e.g., separation, natural
    events, injury, animals)
  • Treatment Medication behavior therapies and
    psychotherapy if individual is able to
  • Untreated or symptoms of Anxiety disorders, in
    individuals with developmental disabilities may
    impact functioning.
  • It is important to explore treatment for these
    issues even those these clients may not be as
  • Examples. (community care home)

Examples DD and Mood Disorders
  • Major Depression
  • Bipolar Disorder
  • Dysthymic Disorder
  • Higher instance of stupor and mutism in
  • Bipolar disorders more common
  • Can be related to specific stressors (e.g., loss
    of caregiver, change of surroundings,
    hospitalization, etc.)
  • Mixed states with features of mania and
    depression, schizoaffective psychoses, psychotic
    responses to cute stress, and rapid-cycling
    bipolar disorder all appear to be more common in
    MR than non-MR
  • Treatment Medication, activities to engage
    individual and exercise, groups for skill
  • Case Study This client had originally presented
    for treatment in elementary school. He was not
    referred until his Senior year in high school.
  • -- Co-morbid diagnoses
  • -- Schizoaffective Disorder
  • -- Mild Mental Retardation
  • -- Obsessive compulsive Disorder

Examples DD and Psychotic Disorders
  • Classical clinical features present (e.g., with
    schizophrenia) that tend to be florid but banal
  • Active psychoses tend to occur at younger age and
    reflect limited social skills and experiences of
    the individual
  • Mixed states more common with MR population than
    with non-MR
  • Treatment Medication behavior therapies
    family support and treatment therapeutic case
  • Case study This client was referred in
    elementary school in about 2nd grade
  • She had many difficulties in school and school
    was largely responsible for her entering the
    system of care.

Approaches to Treatment Therapeutic Case
  • Coordinate services
  • schools, community organizations, extended family
    and supports, other service providers and
    treatment providers
  • Education
  • Regarding diagnosis, long term needs
  • Supports for families, expand if possible

Crowley (2008)
  • This study looked at the benefit of
    psycho-educational groups for people with
    psychosis and mild intellectual disability.
  • Measures of knowledge and self esteem were
    completed pre and post group.
  • Participants were able to understand the concepts
    of psychosis the need for medication and the role
    of stress and early signs of relapse. This
    approach may be helpful.

Approaches to Treatment Behavioral Therapies
  • Goal 1. Stabilize problem behaviors. Identify
    behaviors that cause the most harm and distress
    from the client and familys perspectives.
  • Goal 2 Increase skills and promote prosocial
    and adaptive behaviors that will promote maximum
  • Goal 3 Apply and practice across environments
  • ? Teach at school
  • ? Generalize to home
  • Goal 4 Develop plans based upon principles of
    positive behavior support
  • Goal 5 Plan for crises
  • Pure behavioral models do not attend to internal
    emotional states of the individual.

Approaches to Treatment Caveat
  • There is a lack of randomized controlled trials
    (RCTs) investigating effectiveness of
    psychotherapeutic models (psychodynamic,
    cognitive behavioral, and cognitive approaches)
  • Even less so are available for children
  • In general, all agree that effectiveness
    decreases with decreasing IQ

Approaches to Treatment Psychodynamic Models
  • Focuses upon transference and counter
    transference within the therapeutic relationship
    to investigate the internal world of the client.
  • Predominately case study and/or anecdotal
  • Limited support benefits may have resulted to
    humanistic/person-centered counseling techniques

Approaches to Treatment Cognitive Behavioral
Therapies (CBT) to Address Skill Deficits
  • Dominant modality in treatment today
  • Effective with
  • Panic disorder - Phobias
  • Promoting social behaviors - Depression
  • Anxiety - Parent stress
  • Anger management - Self-management
  • Social problem solving - Self-Instruction
  • Social skills development
  • Generally coupled with relaxation techniques,
    education, planned practice and generalization

Approaches to Treatment CBT to address
Cognitive Distortions
  • Assess for ability to
  • Distinguish between antecedent events and
    associated cognitions and emotions
  • Recognize that cognitions mediate the effects of
    events on emotions
  • Willingness to engage in collaborative
    empiricism to question the accuracy of cognitive
  • Reliability of self-reports
  • Depression, anxiety, anger, and sex offences

Overall Treatment Planning
  • Include community caregivers and staff
  • Develop specific treatment plans that can be
    accomplished in a specific amount of time
    avoiding treatments that cant be implemented in
    the broader community
  • Take into account variables consistency versus
    change in environment, levels of supervision
    available, possible stressors, and behavioral
    management strategies
  • Use therapy and activity groups to bring out the
    persons capacity for learning and participation
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