Psychiatric and Behavioral Challenges in Adolescents with Intellectual DisabilitiesPresented by:Peg Schwartz LSWBehavioral Services CoordinatorCommunity Services Group, Inc
ObjectivesReview common misconceptions about mental illness in adolescents with intellectual/ developmental disabilities.Analyze behavioral manifestations of symptoms of illness.Discuss true case examples of misdiagnosed individuals.
What is challenging behavior?Any behavior that keeps a person from having a good quality of life.
Types of Challenging BehaviorSocial rule/norms violationVerbal aggression/threats/false accusationsProperty destructionSelf injuryPhysical aggressionDistractingDisruptiveDestructive
Why are ID/DD individuals more vulnerable ?Slower learning = Impaired ability to learn and use healthy coping skills.
Skill deficits in critical functional areas lead to high stress as a result inappropriate behavior is used excessively as a means to cope.
Communication, problem solving, rationalization, objectivity, object relations.
A high frequency of central nervous system impairment.
Why are DD individuals more vulnerable ?Because of these hidden issues people assume all challenging behavior is just Purposeful Bad Behavior displayed as a means to gain attention, tangible items or is escape/ avoidance motivated.
Other factors including mental illness must always be considered and ruled out.
Research1: 4 will suffer from a mental illness every year. (Kessler et. al.)
A national survey reported that half of all mental disorders begin by age 14 and three quarters began by age 24. (Kessler et. al.)
Research For individuals with ID estimates vary between 1:3 to 2:3. Although the types of psychiatric disorders experienced are the same, the individual's life circumstances or level of intellectual functioning may alter the appearance of the symptoms.
ResearchIndividuals with an IQ less than 69 were associated with a 4x increase in risk of affective disorderRichards et. al. (2001)
Increase in severity of challenging behaviors was associated with increased prevalence of psychiatric symptoms Moss et. al. (2000)
Typical Developmental TasksAdolescence 12-18 yrs Identity vs. Role ConfusionOpportunities for increased socialization, developing interdependence with family, loyalty to peers, new freedoms are granted, autonomy, internalized sense of right and wrong.
Symptoms and Behavioral Manifestations/EquivalentsHave you ever had a cold?
What are the behavioral manifestations of your symptoms?
Symptoms and Behavioral Manifestations/EquivalentsWe must pay attention to the symptoms and the behavioral manifestations/ behavioral equivalents.
SymptomBehaviorRunny nosewipe with tissueCoughingcovering my mouth
Shift your Focus
Shift your Focus
Sovner & Hurleys Diagnostic Principles (1989) DD individuals usually lack good communication and defense mechanisms...they tend to express it behaviorally. The clinical interview alone is rarely diagnostic.Must rely on staff report, but without training staff report nonspecific behavior.
Sovner & Hurleys Diagnostic Principles (1989)The severity of the problem is not diagnostically relevant.
Maladaptive behavior rarely occurs aloneclients with psychiatric disorders often display multiple maladaptive behaviors.
Myths and Misconceptions Diagnostic OvershadowingEpisodic PresentationMedication MaskingBaseline ExaggerationIntellectual Distortion
Myths and MisconceptionsDiagnostic Overshadowing - bias negatively affecting the accuracy of clinicians' judgments about co-occurring mental illness in persons with intellectual disabilities and mental illness.
MYTH: Intellectually disabled people cant have a mental illness
Myths and MisconceptionsEpisodic Presentation symptoms in a cyclic illness like bipolar disorder wax and wane and sometimes go unnoticed or unreported.
Medication Masking medications cover up or mask true mental illness.
Myths and MisconceptionsBaseline Exaggeration The individual has previously existing maladaptive behaviors that increase in frequency and intensity during the course of a mental illness.
MYTH: Hes just acting more autistic than he usually does
Myths and MisconceptionsIntellectual Distortion because of intellectual limitations, the individual cannot accurately understand questions posed by the evaluator.
Do you hear voices?
Behavioral Manifestations/ EquivalentsMood: Irritable/ IrritabilityExcessive negative response/ short fuseScreaming. Swearing, aggressionCannot be only in response to limit settingOften disregarded as just a bad moodExamples: Request to come to dinner, to watch favorite TV show. Simple questions like: How are you today?
Behavioral Manifestations/ EquivalentsMood: EuphoricOver aroused/ excessive smiling/ laughterPerson seems way too excitedOften personalized by TSS as Im his/her favoriteMissed in PDD due to baseline exaggerationChild is so excited it results in an aggressive outburst
Behavioral Manifestations/ EquivalentsMood: Lability or fluctuationRapid shifts between moods: calm to angry,laughing to tears, etc.For staff it feels like For no apparent reasonCan result in aggression both verbal/physical
Behavioral Manifestations/ EquivalentsPressured Speech/ hyper verbalNon stop talking/ rapid speech/ excessive noise making in nonverbal individualsDescribed as a motor mouthDisregarded as trying to get attention or wear staff down to get his/her way
Behavioral Manifestations/ EquivalentsFlight of IdeasIdeas flow b/c of energy. Switching from topic to topic/ poor concentrationDifficulty responding to topics initiated by others. Disregarded as ID/DD behavior or selective inattention
Behavioral Manifestations/ EquivalentsPsychomotor agitation appears in constant motion/pacing/ moving around/ excessive rocking, elopementDescribed as ants in his pants by TSSOften the focus of info in psychiatric appointments.Missed in PDD due to baseline exaggeration
Behavioral Manifestations/ EquivalentsExcessive DriveExcessive intensity or drive for pleasurable activities: likes / desires/ hobbies/ collectionsExcessive Drive Examples:Keys, DVDs/CDs, T-shirts, toilet flushing, telephone, laundry, counting money, menus phone books, shopping, food, beauty products
Behavioral Manifestations/ EquivalentsObsessions/Compulsions (OCD)Anxiety provoking thoughts Compelling need to perform activity/ritual but brings NO PLEASUREPleasure question often not investigated
Behavioral Manifestations/ EquivalentsExcessive Drive often mistaken for OCD followed by a prescription for antidepressants making a mood disorder worse.Excessive Drive/ OCD question often missed in PDD population due to baseline exaggeration.
Behavioral Manifestations/ EquivalentsDelusions: fixed false beliefs despite evidence to the contraryDelusions about staff adopting him and taking him home.Grandiose delusion about abilities. Driving a car, violent acts/ gang membership.
Behavioral Manifestations/ EquivalentsDepression/ Depressed moodSadness/ confusion/ withdrawal from activities often unnoticed as a symptom but viewed as noncompliance or in others viewed as content More easily seen as a decrease in academic performance
Case Example #1Past Diagnosis: Psychotic Depression and ADHDReports that issues were all behavioralPhysical aggression, property destructionMultiple psychiatric admissions.multiple medication changes/ poor continuity of care/ staff turnover
Case Example #1Flight of ideas/ pressured speech by constant argumentativeness and false accusations
Mood lability/irritability which turned into threats to harm, verbal aggression and physical aggression toward both peers and staff
Risk taking behavior which included attempting to jump out of a moving vehicle
Case Example #1Grandiose delusions about family, children, and money left to him in a will. Psychomotor agitation including constant pacing and decreased need for sleep
Excessive drive for the pleasurable activities of making phone calls, collecting others keys, and eating any available food to the point of vomiting/diarrhea
Case Example #1New diagnosis Bipolar disorder with psychotic features
Staff training to identify psychiatric symptoms and track them daily on a chart for psychiatrist.
New medication regimen
New behavior plan
Case Example # 2 18 yr old boy with autism and OCD taking two antidepressant medications and an antipsychoticSymptoms:Psychomotor agitation: excessive spinning,Pressured speech: excessive squealing and hummingIrritability: unwilling to be touchedfirst thought to be attributed to his Autism until his antidepressants were discontinued
Case Example # 2Sleep disturbanceMedication changes:Both antidepressants were discontinued and replaced with Depakote. Risperdal lowered.Spins minimally for Self stimulation, welcomes touch, can sit still and has a significantly improved attention span.
Case Example # 3Adolescent diagnosed with Aspergers disorder, Tic disorder and Obsessive Compulsive Disorder. Taking Paxil and Risperdal.
Individual did not have OCD. Aspergers traits were inappropriately attributed to OCD. Medication was discontinued and bimonthly behavioral therapy was initiated.
Action PlanStaff TrainingMental health disordersSymptom identification/manifestationsSymptom tracking/ reportingTeam meeting prior to p