Dual DiagnosisMental Retardation and

Psychiatric Disorders

By

Suzanne Collier

Table of ContentsI. History II. CausesIII. Disorders A. Affective B. Anxiety C. Psychosis D. Social Communication

and Pervasive Developmental Disorders

E. Attention-Deficit/ Hyperactivity

F. Adjustment G. Posttraumatic Stress

Disorder H. Conduct Disorders I. Substance Abuse J. Maladaptive Behavior

Disorders IV. Medical ProblemsV. Genetic Syndromes and

Behavioral PhenotypesVI. Treatments

History

-Since the1960s diagnosis

and treatment of psychiatric disorders has improved.

-1980s Dual Diagnosis

to move away from wards of Mental Hospitals or Residential Facilities.

-Many mislabeled

with schizophrenia.

Causes

-7%-10% of children have psychiatric disorders.

-30%-42% of children with Mental Retardation have them.

-Caused by an interaction amongbiological, environmental, and

psychosocial factors.Ex. TBI (traumatic brain injury)

neurotransmitterAlterations with post-injury peer

acceptance can develop into depression.

Affective or Mood Disorders-2%-5% of children and5%-15% of children with Mental Retardation-3 Syndromes: 1. Dysthymia= 2 years chronic low-

grade depression with functional impairments 2. Major Depression=Emotional withdrawl, lack of interest in

daily activities, sleep and appetite problems, poor concentration, worthlessness, guilt, and thoughts of death and suicide. This has a hereditary precipitated by life stresses.

3. Bipolar Disorder = all of the above with depression and with the mania comes inflated self-esteem, decreased sleep, pressured talking, distractibility, racing thoughts, excessive pleasurable activities. This has a strong hereditary component and a gene locus.

Anxiety Disorders

-Strong hereditary component

-Phobias, Panic, Separation anxiety

-(OCD) Obsessive- compulsive= biological basis, repetitive purposeful behavior and persistent senseless thoughts

Psychosis

Delirium- sudden confusion associated with TBI, drugs, and medical disorders like encephalitis

Schizophrenia= Catatonic, delusions, inappropriate emotional expressions, hallucinations, and loosening speech for 6 months onset typically in adolescence.

-Social Communication (Pervasive Developmental Disorders or PDD)= poor social interactions, communication problems, and impaired imagination ¼ of people with Mental Retardation- Attention-Deficit/ Hyperactivity= impulsivity, inattentiveness, functional impairments, 11% of people with MR have ADHD Behavior rating scales, clinical history, and direct observation for diagnosis.-Post Traumatic Stress Disorder (PTSD)= threat of harm or death causing intense fear or helplessness with recurrent and intrusive recollections of a trauma

-Conduct Disorders = aggressive, destructive, rule-violating, persistent patterns of bullying, intimidating, initiating fights, setting fires, stealing, and truancy 12% to 45% of people with MR Causes: inability to verbalize feelings, poor impulse control, depression, pain, and fear-Substance Abuse = genetic and familial factors typically adolescents MR associated with Fetal Alcohol Syndrome predisposition to substance abuse Causes: immature judgment, impulsiveness, and a desire for social acceptance

-Maladaptive Behavior Disorders- repetitive self-stimulating behavior or self injury (SIB), -Stereotypic Movement Disorder -5% of people with MR -environmental and biological factors (Neurotransmitters) - attention, autism, depression, mania, and schizophrenia or medical conditions -Pica- eating nonfood items

Medical Problems

- Hypothyroidism (common with Down

Syndrome) can cause

anxiety or depression

- Excessive Drugs

Genetic Syndromes and Behavioral Phenotypes

-Fragile X= males: MR, poor eye contact,

communication impairments, stereotyped movements

- females: less severe modest cognitive

impairments, shyness, impulsivity, distractibility, and personality disorder

-Rett Syndrome= in girls, X-linked dominate neurological disorder, autistic features, loss of purposeful hand movements, at onset wringing and hand flapping, and hyperventilation -Prader- Willi Syndrome= microdeletion of chromosome #15, decreased muscle tone, short stature, obesity, MR, underdeveloped gonads, almond-shaped face, upslanted eyes, narrow forehead -impulsive, obstanant, and disinhibited

-Lesch-Nyhan Syndrome= X-linked disorder, metabolism of purines (DNA building blocks), MR, progressive neurological disorder, boys bite lips and fingers, neurotransmitter abnormalities in dopamine and serotonin (causing self-injury in animals), no success yet with medication -Williams Syndrome= MR with “cocktail party” speech, Down Syndrome maybe with dementia in young adulthood,

Treatments- Referral to Mental Health

Professionals for a detailed history of current

symptoms, behaviors, individual and family

medical history, interview parents and child for direct

observation, psychological and behavior assessment, functional behavior analysis (natural setting), a treatment plan on developmental level, medical conditions, and family’s strengths and weakness.

-Comprehensive Plan= Rehabilitation, Education, emotional needs, social stressors, family’s needs, Psychiatric diagnosis and behavior problems, interdisciplinary teamwork with Special Education Program, Rehabilitation Therapy, Psychotherapy, Social Skills Training, Behavior Therapy, and Pharmacological Management

Special Education Programs -Small class size and one on one supervision

-Record behavior, incorporate behavior management techniques, emotional support,

modify curriculum, guidance counselor support.

Rehabilitation Therapy

-Evidence for language impairments or inabilities effecting behavior problems like aggressiveness and SIB

-Speech-language therapy and alternative communication systems

-Physical and Occupational Therapy

Psychotherapy

-MR underserved

-Provides: supportive relationship, self-esteem, social skills, emotional conflicts and problem solving,

Social Skills Training-inappropriate interactions, may be secondary to developmental delays or disabilities, or part of a Psychiatric disorder-to improve eye-contact, smiling, and sharing, appropriate affection, awareness of others’ emotions,Behavior Therapy-data-based assessment in a person’s natural social environment with events, -functional behavior, minimize reinforcement of inappropriate behavior and reward adaptive-operant functional analysis manipulates variables, and designs interventions for control

-Cognitive Behavior Therapy= MR with high functioning for anxiety disorder, phobias, or depression - techniques to master compulsive rituals-Pharmacological Management = -1950s tranquilizer abuse -Antidepressants, newer agents serotonin reuptake inhibitor like Prozac, Zoloft, and Paxil -OCB lessened by Anafranil -Stereotypic Behavior with Autism and MR with serotonergic medication -Stimulant Ritalin and Dexedrine for ADHD (side effects irritability, sleep, stereotypies, and maybe ineffective with MR

-Antipsychotic= Mellaril and Haldol for mania and schizophrenia (debated with MR) -several have serious side effects on a long-term-Mood Stabilizers = lithium and antiepileptic drug (Tegretol, Depakene, and Depakote) for Bipolar and cyclical mood with MR -evidence in controlling SIB and aggression with opiate antagonists and beta adrenergic blockersPsychoactive medication: identified, periodically reevaluated, adequate trial, avoid multiple medications, and careful monitoring