Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability: part I – assessment

Journal of Intellectual Disability Research

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© Blackwell Publishing Ltd

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Blackwell Science, LtdOxford, UKJIRJournal of Intellectual Disability Research-Blackwell Publishing Ltd, 118Original ArticleDevelopmental perspective in persons with intellectual disability – part IA. Dosen

Correspondence: Anton Dosen, Torenstraat , AR Helvoirt, the Netherlands (e-mail: [email protected]).

Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability: part I – assessment

A. Dosen

University of Nijmegen, Nijmegen, The Netherlands

Abstract

Background In generic psychiatry there has been increasing interest among scientists for the develop-mental perspective. However, professionals active in the mental health care of people with intellectual disability (ID) have not shown the same degree of interest. The author of this article, who has had a liberal amount of rewarding experiences with the developmental approach in the field of ID, considers the developmental perspective to be innovative and very useful in psychiatric assessment, diagnosis and treatment of this population. The aim of the article is to stimulate a wider application of the developmental perspective as well as to challenge a professional dis-cussion on this issue.Methods Basic assumptions of the developmental perspective are discussed and assessment tools and methods are described.Results In a case vignette, the advantages of devel-opmentally based assessment are emphasized. Emo-tional development and personality development are viewed as the developmental components that play an important role in adaptive and maladaptive behav-iour as well as in the onset and presentation of psy-chopathology. It is clear that interpretative insight

into the totality of the psychosocial aspects of these individuals cannot only be obtained by measuring the level of cognitive development. A wider frame of mind is needed for unambiguous psychiatric diagnos-tics. Therefore, a replacement of the three dimen-sional paradigm (bio–psycho–social) by a four dimensional one (bio–psycho–socio–developmental) for the assessment and diagnosis of persons with ID is proposed.

Keywords assessment, developmental perspective, developmental psychiatry, emotional development, intellectual disability, personality development

Introduction

During the last two decades, scientists within the realm of psychiatry have become increasingly aware of the merits of the developmental perspective (see Rutter ; Cicchetti & Cohen ; Greenspan ; Harris ; Bradley ; Cummings et al. ; Pennington ). Sroufe & Rutter () defined developmental psychopathology as the study of the origins and course of individual patterns of behavioural maladaptation. More recently, Cicchetti & Toth () expanded this, emphasizing that devel-opmental psychopathology enables professionals to extend their diagnostic considerations from descrip-


A. Dosen • Developmental perspective in persons with intellectual disability – part I2

© Blackwell Publishing Ltd, Journal of Intellectual Disability Research , ‒

tive facts to a process-level understanding of normal and abnormal developmental trajectories. Other dis-tinguished authors like Pardes (), Coyle () and Rapoport () have called this approach the ‘new psychiatry’, underscoring the importance of the developmental perspective for the future develop-ment of psychiatry in general.

Despite growing interest in the developmental per-spective, professionals seldom apply this approach within the field of intellectual disability (ID) (Glick ).

In our practice with children and adults with ID we apply the developmental approach in addition to the traditional descriptive phenomenological approach (as represented by the Diagnostic and Sta-tistical Manual of Mental Disorders [DSM] and International Classification of Diseases [ICD] sys-tems), and we call it the Developmental Psychiatric Approach (Dosen , ).

In doing so we have benefited in the understanding of the meaning of a person’s behaviour at a particular developmental level and it has aided us in our under-standing of pathogenesis improving diagnostic proce-dures. Furthermore, it has helped us understand the person’s motivations necessary in designing a more tailored treatment strategy.

In the past two decades we have disseminated the use of this approach in the Dutch-speaking area (the Netherlands and Belgium). The reactions from prac-titioners in the field as well as several publications on the subject are positive and encouraging (Loon van ; Teuchies ; Vonk & Egberts ; Lam-breghts & Andries ; Boutier ). In this article the assessment method and the benefits it has for diagnosis will be discussed.

Basic assumptions

Development and behaviour are viewed in their bio-logical as well as psychological and social contexts. In this article the focus is on psychosocial develop-ment. In an attempt to make this very complex mate-rial somewhat easier to understand, we have chosen to make use of phases and stage theories of develop-ment. According to these theories (Piaget ; Bowlby ; Stern ; Cicchetti et al. ), the psychosocial development of the average child can be divided into a number of phases or stages, connoting

a progressive sequence of qualitative changes in the structure and function of the central neural system.

In order to develop optimally, the average child must make new psychosocial adaptations during each developmental stage. The capacity for making ade-quate adaptations depends on the bio–psycho–social conditions of the child and on environmental support.

The psychosocial development of persons with ID follows similar sequences and stages like those in average children (Cicchetti & Ganiban ; Hodapp & Zigler ; Greenspan ). When describing these persons, we speak in terms of their develop-mental levels, which roughly correspond to the devel-opmental stages that take place in young persons without ID.

For a better understanding of the processes taking place in these individuals, we have utilized the con-cept of personality development in our practice. Gen-erally speaking, the concept of personality is a rather imprecise one, nevertheless, it is usually meant to describe a person’s distinctive style or pattern of thought, emotions, adaptation and behaviour (Rutter ). Different factors influence the process of per-sonality development, like neurobiological, genetical, temperamental, environmental and others. Some aspects of personality can be described in terms of their cognitive, social and emotional facets (Harris ). In trying to appraise the level of personality development in persons with ID, our approach has been to make use of findings relating to cognitive, social and emotional development. When these three aspects seem to function at the same developmental level, we speak in terms of the level or structure of personality development that has been attained. Each personality level or structure includes coherent and orderly patterns of adaptive behaviour (Zigler & Burack ; Greenspan ). When a person at a particular level of personality development is con-fronted with unfavourable extrinsic and/or intrinsic circumstances, and cannot find an appropriate solu-tion, maladaptive behaviour containing level-specific behavioural features may occur. Progressive maladap-tive behaviour coinciding with accumulative dysfunc-tion of neural mechanisms and conflicts with the surroundings may lead to the onset of psychiatric disorders (recommended literature on this issue: Rut-ter ; Cicchetti & Cohen ; Greenspan ; Burack et al. ; Harris ; Bradley ; Cum-mings et al. ; Praag van ; Pennington ).




Keeping this point of view in mind, for a proper understanding of adaptive and maladaptive behav-iour; for discovering the onset mechanism of psycho-pathology; and for a proper diagnosis of persons with ID, one must, in addition to making use of traditional psychiatric examination and determining the level of cognitive development, also gain an insight into the level of personality development. These elements must all be woven into the assessment procedure.

Developmental psychiatric assessment

In our practice, after the present and developmental histories have been compiled and psychiatric status, genetic, somatic and milieu examinations have taken place, assessment will focus on the psychosocial and developmental aspects of the person. The aim of these inventories is to find the answers to the follow-ing questions:• What is the level of cognitive, social, emotional and personality development?• What are basic emotional needs and motivations?• Is the present behaviour ‘normal’ – ‘abnormal’ (adaptive – maladaptive)?• If abnormal, what is the onset mechanism of the disorder?• How should the symptoms of the disorder be interpreted?• What is the psychiatric diagnosis?

Standardized tests are available for examining the cognitive and social levels. Examining the emotional development, however, presents a problem because appropriate assessment instruments are lacking. In an attempt to gain more insight into emotional develop-ment, we have focused on processes involved in emo-tion activation, emotion expression, experiential components of emotions, emotion–cognitive rela-tions and emotion-related behaviour. With this objec-tive we have integrated different theories of the phase and stage development of the average child: the cog-nitive, psychodynamic, neuropsychological, neurode-velopmental and others (Piaget ; Erikson ; Luria ; Mahler et al. ; Greenspan ; Stern ; Coulter ; Cicchetti et al. ). These were then incorporated into a schema of the phases of emotional development and personality structuring of an average child (see Table ). To con-struct an assessment tool that would fulfil our goal

and that would be applicable to people with ID, we utilized aspects of psychosocial development that had emerged from earlier investigations of children with ID as representing emotion-related functions and behaviour (Dosen ) (Table ). These aspects of psychosocial development were found to be per-manently present throughout life, and, consequently, subject to characteristic changes during the different developmental phases. The assessment tool called the Schema of Appraisal of Emotional Development (SAED) was developed along the lines of the changes taking place in these aspects during the five devel-opmental phases (Dosen , ) (see Table ).

Table 1 Schema of emotional development and personalitystructuring

Phases of emotional development Personality structuring

1. 0–6 months: Adaptation Psycho-physiologicalhomeostasis

Integration of sensorystimuli

Integration of structures oftime, place and persons

2. 6–18 months: Socialization Secure attachmentBondingSecure emotional base

3. 18–36 months: Individuation Self-other differentiationand objective-self

SeparationAutonomy

4. 3–7 years: Identification Ego-forming (impulsiveego)

5. 7–12 years: Reality awareness Ego-differentiation (moralego)

Table 2 Psycho-social aspects

1. How the person deals with his own body2. Interaction with caregiver3. Interaction with peers4. Handling with material objects5. Affect differentiation6. Verbal communication7. Anxiety8. Object permanency9. Experience of self

10. Aggression regulation




The SAED is filled out by experienced profession-als who observe the person in question or interview the caregivers. For the interview, each item in the schema is expressed in terms of three statements (or questions) that are helpful in estimating the level of a particular aspect. Corresponding items are scored on the schema. The assumption is made that the item being scored does indeed represent the actual level of development of the particular psychosocial aspect.

In our experience, the finding that five or more emotional aspects were on or under a particular phase boundary was a good determinant of the mean

level of emotional development of that person. Per-sons with severe and profound ID were regularly found to score under months on all aspects (per-sons at the profound level were usually tabbed in the first and second phases – lower than months, and at the severe level of ID this was spread out over the first three phases – lower than months). The find-ings of persons at the mild and moderate levels of ID were predominantly in the fourth and fifth phases. However, in cases of behavioural and psychiatric problems a discrepancy between emotional develop-ment and cognitive development was often found

Table 3 Schema of appraisal of emotional development

Phases of emotional developmentPhase 1: 0–6 months – adaptationPhase 2: 6–18 months – socializationPhase 3: 18–36 months – individuationPhase 4: 3–7 years – identificationPhase 5: 7–12 years – reality awareness

Development of different emotional aspects at differentphases1. How the person deals with his/her own body

Phase 1: Discovers his own body partsPhase 2: Discovers bodily parts as an instrumentPhase 3: Own body in interaction with othersPhase 4: Own body – centre of the worldPhase 5: Competitive body

2. Interaction with the caregiverPhase 1: Via bodily (proximal) contactPhase 2: Via bodily contact and material (distal senses)Phase 3: Via signs and wordsPhase 4: Verbally and through creativityPhase 5: Through social and cognitive performances

3. Interaction with peersPhase 1: No special interestPhase 2: Via materialPhase 3: Beginning of personal interactionPhase 4: Plays with peersPhase 5: Cooperation, friendship

4. Handling of material objectsPhase 1: No special interestPhase 2: Discovers smell, taste, form and soundPhase 3: Search for inner structure of objects

(destructive)Phase 4: Creative playing with objects (constructive)Phase 5: Productive, making real objects

5. Affect differentiationPhase 1: Excitation, relaxation, anger, apathy, anxiety

pleasure, displeasurePhase 2: Love, anxiety for strangers, anger at loss of love

object, sadness, joyPhase 3: Jealousy, fear of damaging the own body

Phase 4: Happiness, empathy, pride, shame, beginning of guilt and conscience

Phase 5: Responsibility, guilt, penalty, conscience6. Verbal communication

Phase 1: Producing soundsPhase 2: Instrumental use of words, pointingPhase 3: Use of speech and of the word ‘I’Phase 4: Verbalization of fantasyPhase 5: Verbalization of reality

7. Anxiety is caused byPhase 1: Unfamiliar and intensive sensory stimuliPhase 2: Separation from the caretakerPhase 3: Threatening of autonomy, or damaging of one’s

own bodyPhase 4: Anxiety for failurePhase 5: Anxiety of depreciation (social anxiety)

8. Object permanencyPhase 1: NonePhase 2: Looks for hidden objectsPhase 3: Uses transitional objectsPhase 4: Takes a distance from the love objectPhase 5: Feels safe outside of own territory

9. Experience of selfPhase 1: Reacts to sensory and vegetative stimuliPhase 2: Reacts to caretaker (dyadic interaction)Phase 3: Fights for autonomyPhase 4: Accepts the rules of the important other

(super-ego forming)Phase 5: Accepts the rules of the surroundings

10. Aggression regulationPhase 1: With anger and rage, aggression is directed

towards the selfPhase 2: With frustration, aggression is diffuse (tantrums)Phase 3: With frustration, aggression is directed to

particular persons and objects (uncontrolled)Phase 4: Aggression is directed to particular goals

(impulsive)Phase 5: Aggression is directed to particular goals

(controlled)




(emotional development was regularly found at a lower level than the cognitive one). Diffuse levels of development for different psychosocial aspects could also be found in these individuals.

In cases in which the cognitive functioning and the social functioning were at the same level as the emo-tional development the personality development was considered to be at the same level as well. At each level of personality development we could identify characteristic adaptive behaviour and in cases in which unfavourable circumstances and coping diffi-culties were present we could distinguish maladaptive traits (Dosen , ) (see Table ).

When a discrepancy was found between the cogni-tive and emotional levels, and in cases in which dif-ferent emotional aspects were in differing phases, no conclusion could be made regarding the level of per-sonality development. In these cases the evaluation read: labile personality structure with heightened vul-nerability to maladaptive behaviour and psychiatric disorders.

This assessment tool is used ‘unofficially’ by many professionals in the Netherlands and Belgium, but, unfortunately, has not been validated yet. For practi-cal purposes, we use it regularly, in addition to the Vineland Adaptive Behavior Scale (VABS) (Sparrow et al. ). Comparing the findings of the SEAD and VABS Socialisation Domain, we usually find that the results correspond with each other. The differ-ence between our schema and VABS Socialisation Domain is that more information relating to the per-sonality characteristics of the person and his basic emotional needs and motivations is accumulated via SEAD than with the VABS.

Emotional needs (Table ) play an important role in the formation of a person’s motivations, and these are responsible for goal-directed activities and inter-actions with the surroundings (see Reiss & Haver-camp ; Lecavalier & Tasse ). Understanding these aspects in their relationship to the environmen-tal circumstances can aid in distinguishing between normal and abnormal (adaptive and maladaptive) behaviour.

When an abnormal condition is established, the assessor makes a reconstruction of the onset mecha-nism of the disorder on the basis of the insights into the various bio–psycho–social factors, developmental processes and environmental circumstances. Deter-mining the precipitating mechanism can be very

important in establishing the correct diagnosis and in finding the best treatment strategy.

Realizing that the symptoms of psychiatric disor-ders in this population (in particular at the lower developmental levels) can be very atypical, it is abso-lutely necessary that the symptoms be interpreted within the holistic context of all of the findings referred to above.

The final result of all these findings is an integrative diagnosis (see Part II – diagnosis [pp. – in this issue]).

Table 4 Maladaptive traits at different levels of personalitydevelopment

Personality level Traits

0–6 months:Homeostasis

Irritability to intensive sensory stimuliPassivityStereotypyWithdrawalTantrums because of changes in the

environmentSelf-stimulationSelf-injurious behaviourProblems with physiological functions

like sleeping and eating6–18 months:

AttachmentAnxiety in the presence of strange

peopleAggressive outbursts towards

caretakerCompulsive handling of materialRapid mood swingsSeeking bodily contact with important

othersSelf-injurious behaviour when highly

frustratedRituals

18–36 months:Self-other differentiation

Constant attempts to attract attentionRestlessnessDistractibilityObstinacyNegativismDestructivenessNo interest in peersIrritability

3–7 years:Ego-forming

Dependent on important othersEgocentricImpulsiveExaggerated fantasyAnxiety to failConflict with authoritySomatic complaints




Case description

A -year-old woman with a moderate ID was referred for help in reducing her behavioural prob-lems. She was hyperactive, angry and negativistic; she exhibited rage outbursts and self-injurious behaviour. In addition, she had sleeping difficulties.

She lived in a group home together with seven other residents and several professional caretakers.

She was the third child in a family of low social economic status. After an uncomplicated pregnancy and delivery, her psychomotoric development appeared to be delayed. The behavioural difficulties began when she was years old. She was hyperactive and stubborn, and was always seeking attention. These behavioural problems were the reason for her placement in an institution for children with ID when she was years old. Shortly afterwards, her behaviour worsened; she displayed aggression, self-injurious behaviour and restlessness (at that time she also suf-fered from insomnia). For her behaviour she received sedative medication, without an appropriate result. From that time on, she changed institutes several times, and each time, her behaviour worsened. At the present group home she had no social contact with the other residents and had no special bond with the caretakers. Every once in a while she would go to her parents’ home for the weekend and she was very excited when these visits would take place. She would get very angry if the visits were cancelled.

The assessment yielded the following results: () the woman was in good physical health; and () the aetiology of her ID was unknown. Neurological examination revealed no relevant findings except that she had large lateral brain ventricles.

The psychiatric examination and observations made in different situations (by means of video

recordings) revealed that no hallucinations, delusions or other thought disorders were found. The impres-sion the woman made was one of an affectively labile person with a low frustration threshold who was con-stantly seeking attention and showing rapid mood swings, switching from positive to very desperate.

On the intelligence test (WISC-R) her perfor-mance IQ was , and her verbal IQ was (mental age, years). Social skill tests showed her to have a developmental age of approximately years old. The VABS Socialisation Domain showed a level of years. The SAED revealed the following results: of the aspects, one was found to be in the first phase (– months); four aspects were found to be in the second phase (– m); one aspect was found to be in between the second and third phases; and the other four aspects were in the third phase (– m). From the SAED findings we could conclude that the total emotional developmental level of the woman was lower than months, and, substantially speaking, to a great extent even lower than months. This cor-responded roughly with the findings of the VABS. The personality development of the woman was found to be discrepant, varying from the level of a -year-old with regard to her cognitive development to the level of a -year-old in the emotional realm. Such an indi-vidual may be viewed as labile and very vulnerable in unfavourable situations. The basic emotional needs and motivations of the woman were evaluated as apparent in the socialization level (needing to have a secure bond with the caretaker, a stable environment and structured activities) as well as in the individua-tion level (seeking to maintain a certain amount of distance from the bonding figure and wanting to be autonomous in making choices, but at the same time desiring acceptance and positive confirmation from important others).

The onset mechanism of the disorder was seen as the result of an enduring conflict between what the woman really needed (security base and a certain degree of autonomy) and what she actually received (repeated losses of security bases and restrictions). These conditions were experienced as a source of chronic stress, leading to maladaptive coping strate-gies and finally to a psychiatric disorder.

The symptoms encountered correspond to equiv-alent symptoms of depression as described by Sovner (). The depressive disorder had not been recog-nized as such by her previous professional helpers

Table 5 Basic emotional needs

Phase 1: Regulation of physiological needs, integration of sensory input, structuring of space, time and persons, socialinteraction

Phase 2: Bodily contact, attachment person, social stimulation,handling of material objects

Phase 3: Certain distance in contact, confirmation of autonomy,reward of social behaviour

Phase 4: Identification with important others, social acceptanceand support, social competence




and the consequence had been an inappropriate treatment strategy.

The treatment she received on the basis of the diagnosis depression and her basic emotional needs yielded favourable results.

Discussion

Different authors in the field of ID (Szymanski ; Glick & Zigler ; Sturmey ; Hardan & Sahl ; Charlot ) have pointed out the importance of taking the developmental level of persons with ID into account when interpreting and classifying the symptoms of psychopathology and establishing the psychiatric diagnosis. However, the phenomenologi-cal descriptive diagnostic categories that are currently being used to evaluate these individuals usually only take the level of cognitive development into consid-eration. In our opinion, solely measuring the cogni-tive level is not sufficient to acquiring a real insight into all the other relevant psychosocial aspects that may also play an important role in the onset and presentation of the psychopathology of these individ-uals. The levels of emotional and personality devel-opment should be routinely examined and taken into diagnostic consideration during the assessment pro-cess. Our experiences with the implementation of the developmental perspective have led us to believe that the three-dimensional ‘bio–psycho–social’ paradigm, currently being used for assessment and diagnosis, should be broadened by the developmental dimen-sion. A four-dimensional approach, ‘bio–psycho–socio–developmental’, could be beneficial to the effective assessment of this population.

The SAED, which we have developed for a better understanding of these processes, is just an example of how the perspective of a practitioner, by means of the appropriate tool, can be broadened and deepened to provide more insight into the inner, less visible psychosocial facets of these individuals. However, these insights have, in turn, given rise to a number of questions regarding the emotional and personality development of persons with various genetic and organic syndromes, functional disorders, different temperaments and others. The priority of future research, in our opinion, should be the development and refinement of a reliable instrument for measuring emotional and personality development.

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Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability: part I – assessment