Co-occurring Conditions of Serious Emotional Disturbance and Developmental Disorders/Mental Retardation/Disabilities of Cognitive/Adaptive Functioning in Children and Youth
DEFINTION
The guidelines apply to children and youth who meet criteria for serious emotional disturbance (SED) and who require specific treatment considerations due to disabilities of cognitive/adaptive functioning.
Note: Guidelines in quotation are from the American Academy of Child and Adolescent Psychiatry Practice Parameters for Assessment and Treatment of Children, Adolescent, and Adults with Mental Retardation and Co-morbid Mental Disorders,1999. Those cited have been ratified as preferred practices by UPMHS concensus panel.
OPTIMAL OUTCOME OF TREATMENT
The client and his/her family manage the illness and disability by learning skills to compensate for or accommodate to symptom fluctuations. Client and family report satisfaction with quality of life.
ASSESSMENT
Mental retardation does not preclude mental illness. Mental illness is frequently co-morbid with mental retardation, with the prevalence estimated at 30% to 75%. People with disabilities may meet criteria for any DSM diagnosis. Diagnostic criteria are not different for persons with different cognitive capacities.
1) "The psychiatric diagnostic evaluation of persons who have MR(DD) is in principle the same as for persons who do not... The diagnostic approaches are modified, depending on the person's communication skills...The poorer the communication skills, the more one has to depend on information provided by care-givers..."
2) "The clinician should be alert to developmental, and medical history, past etiological assessments, and coexisting general medical disorders and their treatments. It is not uncommon for even simple problems like constipation, infection, or even occult [not readily observable] injury, to set the stage for behavioral problems." A physician consultation should be sought as indicated.
3) Identify agencies currently providing services for the child/adolescent in order to obtain historical information pertinent to understanding previous assessments and interventions.
4) Within a given IQ range, language ability may vary significantly. Both receptive and expressive language abilities should be assessed (either formally through psychometric assessment or informally through clinical observation and review of historical and collateral information). It is not uncommon for receptive language ability to exceed expressive ability, or for the child/youth who displays verbal fluency to not understand the meaning of the words. The use of a support person may be required to assist in communication with the child/adolescent. If a support person is required, the clinician should consider the influence that person may have on the communication.
5) "Mental Status may be assessed in the context of conversation, rather than in a formal examination. It is often helpful to start the interview with a discussion of a patient's strengths and interests rather than problems and later focus on the patient's understanding of disability, limitations, and reasons for the referral."
6) Consider the possibility of sexual, physical, and emotional abuse that the client cannot report or has not reported.
TREATMENT GUIDELINES
1) "The principles of psychiatric treatment are the same as for persons without (cognitive dysfunction), but modification of techniques may be necessary according to the individual's communication skills. Medical, habilitative, and educational interventions should be coordinated within an overall treatment program. Mental Health clinicians should actively work with other professionals in the development of the various treatment interventions."
2) A primary service coordinator should be designated due to complexity of coordinating treatment between agencies for individuals with co-morbid conditions. The treatment setting or placement does not relieve agencies from responsibility to be active participants in the service team.
3) The MR/DD condition neither indicates nor contraindicates the need for psychotherapy, some children/adolescents with lower IQs can benefit from psychotherapy. Group, individual, family, play therapy, or expressive therapy may be of benefit to the person. Both chronological and developmental age should be considered in determining a therapeutic choice appropriate to the client. (The clinician should consider using the approach that he/she would use for a child who is the age that corresponds to the client's developmental age.)
4) Psychopharmacology: (Adapted from AACAP guidelines)
"The adage "start low, go slow", reflects the observation that [the mechanism of action of a medication is likely to be the same as for any other person, but the dose-response may be different). For example, persons with Down syndrome may be exquisitely sensitive to anticholinergic drugs, and some persons with MR may be more sensitive to the disinhibiting effects of sedative/hypnotic agents."
Symptom suppression should not be at the expense of habilitative function or overall quality of life.
Medication should be appropriate to the diagnosis of record as well as the targeted symptoms.
Medication should be regularly reviewed and consideration should be given to the possibility that other active treatment or environmental supports could alter the need for medication.
Risks and benefits for the medication should be fully considered within the context of informed consent.
5) "A common problem in the treatment of persons with MR(DD) is assessing its effectiveness which may be viewed differently by various [service providers] and caregivers." Therefore, target symptoms and indicators and treatment goals should be collaborative and reviewed.
6) The client should be helped to understand his/her disability, to the extent possible, while focusing on strengths.
7) Clinicians working with children/adolescents with co-morbid SED and cognitive/adaptive disabilities may be assisted by specific approaches and strategies for this population, e.g., Person-Centered Planning.
THESE GUIDELINES
HAVE BEEN DEVELOPED BY:
THE UTAH PREFERRED PRACTICE
CONSENSUS PANEL
UNDER THE AUSPICES OF THE
UTAH DIVISION OF MENTAL HEALTH
Approved August 13, 1999