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Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities Presented by: Presented by: Peg Schwartz LSW Peg Schwartz LSW Behavioral Services Behavioral Services Coordinator Coordinator Community Services Group, Inc Community Services Group, Inc

Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

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Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities. Presented by: Peg Schwartz LSW Behavioral Services Coordinator Community Services Group, Inc. Objectives. - PowerPoint PPT Presentation

Text of Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Page 1: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Presented by:Presented by:

Peg Schwartz LSWPeg Schwartz LSW

Behavioral Services CoordinatorBehavioral Services Coordinator

Community Services Group, IncCommunity Services Group, Inc

Page 2: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Objectives

• Review common misconceptions about Review common misconceptions about mental illness in adolescents with mental illness in adolescents with intellectual/ developmental disabilities.intellectual/ developmental disabilities.

• Analyze behavioral manifestations of Analyze behavioral manifestations of symptoms of illness.symptoms of illness.

• Discuss true case examples of Discuss true case examples of misdiagnosed individualsmisdiagnosed individuals..

Page 3: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

What is challenging behavior?

Any behavior that keeps a person from having a good quality of life.

Page 4: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Types of Challenging Types of Challenging BehaviorBehavior

• Social rule/norms violationSocial rule/norms violation• Verbal aggression/threats/false Verbal aggression/threats/false

accusationsaccusations• Property destructionProperty destruction• Self injurySelf injury• Physical aggressionPhysical aggression• Distracting…Disruptive…DestructiveDistracting…Disruptive…Destructive

Page 5: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Why are ID/DD individuals more vulnerable ?

• Slower learning = Impaired ability to learn and use Slower learning = Impaired ability to learn and use healthy coping skills. healthy coping skills.

• Skill deficits in critical functional areas lead to high Skill deficits in critical functional areas lead to high stress as a result inappropriate behavior is used stress as a result inappropriate behavior is used excessively as a means to cope. excessively as a means to cope.

• Communication, problem solving, rationalization, Communication, problem solving, rationalization, objectivity, object relations.objectivity, object relations.

• A high frequency of central nervous system A high frequency of central nervous system impairment.impairment.  

Page 6: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Why are DD individuals more vulnerable ?• Because of these hidden issues people Because of these hidden issues people

assume all challenging behavior is just assume all challenging behavior is just “Purposeful Bad Behavior” displayed as a “Purposeful Bad Behavior” displayed as a means to gain attention, tangible items or means to gain attention, tangible items or is escape/ avoidance motivated.is escape/ avoidance motivated.

• Other factors including mental illness Other factors including mental illness must always be considered and ruled out.must always be considered and ruled out.

Page 7: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Research

1: 4 will suffer from a mental illness every 1: 4 will suffer from a mental illness every year. (Kessler et. al.)year. (Kessler et. al.)

A national survey reported that half of all A national survey reported that half of all mental disorders begin by age 14 and three mental disorders begin by age 14 and three quarters began by age 24. (Kessler et. al.) quarters began by age 24. (Kessler et. al.)

Page 8: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Research

• For individuals with ID estimates vary For individuals with ID estimates vary between 1:3 to 2:3.between 1:3 to 2:3.

• Although the types of psychiatric Although the types of psychiatric

disorders experienced are the same, the disorders experienced are the same, the individual's life circumstances or level of individual's life circumstances or level of intellectual functioning may intellectual functioning may alter the alter the appearance of the symptoms. appearance of the symptoms.

Page 9: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

ResearchResearch

Individuals with an IQ less than 69 were Individuals with an IQ less than 69 were associated with a 4x increase in risk of associated with a 4x increase in risk of affective disorder…Richards et. al. (2001)affective disorder…Richards et. al. (2001)

Increase in severity of challenging behaviors Increase in severity of challenging behaviors was associated with increased prevalence was associated with increased prevalence of psychiatric symptoms… Moss et. al. of psychiatric symptoms… Moss et. al. (2000)(2000)

Page 10: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Typical Developmental TasksTypical Developmental Tasks

Adolescence 12-18 yrs Adolescence 12-18 yrs

Identity vs. Role ConfusionIdentity vs. Role Confusion

Opportunities for increased socialization, Opportunities for increased socialization, developing interdependence with family, developing interdependence with family, loyalty to peers, new freedoms are loyalty to peers, new freedoms are granted, autonomy, internalized sense of granted, autonomy, internalized sense of right and wrong.right and wrong.

Page 11: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Symptoms and Behavioral Manifestations/Equivalents

• Have you ever had a cold?Have you ever had a cold?

• What are the behavioral manifestations of What are the behavioral manifestations of your symptoms?your symptoms?

Page 12: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Symptoms and Behavioral Manifestations/Equivalents

• We must pay attention to the symptoms We must pay attention to the symptoms and the behavioral manifestations/ and the behavioral manifestations/ behavioral equivalents.behavioral equivalents.

SymptomSymptom BehaviorBehavior

Runny noseRunny nose wipe with tissuewipe with tissue

CoughingCoughing covering my mouthcovering my mouth

Page 13: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Shift your FocusShift your Focus

Page 14: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Shift your FocusShift your Focus

Page 15: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Sovner & Hurley’s Diagnostic Sovner & Hurley’s Diagnostic Principles (1989) Principles (1989)

• ““DD individuals usually lack good DD individuals usually lack good communication and defense communication and defense mechanisms...they tend to express it mechanisms...they tend to express it behaviorally.” behaviorally.”

• ““The clinical interview alone is rarely The clinical interview alone is rarely diagnostic.”diagnostic.”• Must rely on staff report, but without training Must rely on staff report, but without training

staff report nonspecific behavior. staff report nonspecific behavior.

Page 16: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Sovner & Hurley’s Diagnostic Sovner & Hurley’s Diagnostic Principles (1989)Principles (1989)

• ““The severity of the problem is not The severity of the problem is not diagnostically relevant.”diagnostically relevant.”

• ““Maladaptive behavior rarely occurs Maladaptive behavior rarely occurs alone…clients with psychiatric disorders alone…clients with psychiatric disorders often display multiple maladaptive often display multiple maladaptive behaviors.”behaviors.”

Page 17: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Myths and MisconceptionsMyths and Misconceptions

• Diagnostic OvershadowingDiagnostic Overshadowing• Episodic PresentationEpisodic Presentation• Medication MaskingMedication Masking• Baseline ExaggerationBaseline Exaggeration• Intellectual DistortionIntellectual Distortion

Page 18: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Myths and MisconceptionsMyths and Misconceptions

• Diagnostic Overshadowing - bias Diagnostic Overshadowing - bias negatively affecting the accuracy of negatively affecting the accuracy of clinicians' judgments about co-occurring clinicians' judgments about co-occurring mental illness in persons with intellectual mental illness in persons with intellectual disabilities and mental illness.disabilities and mental illness.

MYTH: “Intellectually disabled people can’t MYTH: “Intellectually disabled people can’t have a mental illness”have a mental illness”

Page 19: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Myths and MisconceptionsMyths and Misconceptions

• Episodic Presentation – symptoms in a Episodic Presentation – symptoms in a cyclic illness like bipolar disorder wax and cyclic illness like bipolar disorder wax and wane and sometimes go unnoticed or wane and sometimes go unnoticed or unreported.unreported.

• Medication Masking – medications cover Medication Masking – medications cover up or mask true mental illness.up or mask true mental illness.

Page 20: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Myths and MisconceptionsMyths and Misconceptions

• Baseline ExaggerationBaseline Exaggeration – The individual – The individual has previously existing maladaptive has previously existing maladaptive behaviors that increase in frequency and behaviors that increase in frequency and intensity during the course of a mental intensity during the course of a mental illness. illness.

MYTH: “He’s just acting more autistic than MYTH: “He’s just acting more autistic than he usually does”he usually does”

Page 21: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Myths and MisconceptionsMyths and Misconceptions

• Intellectual DistortionIntellectual Distortion – because of – because of intellectual limitations, the individual intellectual limitations, the individual cannot accurately understand questions cannot accurately understand questions posed by the evaluator. posed by the evaluator.

• Do you hear voices?Do you hear voices?

Page 22: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Mood: Irritable/ IrritabilityMood: Irritable/ Irritability• Excessive negative response/ short fuseExcessive negative response/ short fuse• Screaming. Swearing, aggressionScreaming. Swearing, aggression• Cannot be only in response to limit settingCannot be only in response to limit setting• Often disregarded as “just a bad mood”Often disregarded as “just a bad mood”

• Examples: Request to come to dinner, to watch favorite TV show. Simple questions like: How are you today?

Page 23: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Mood: EuphoricMood: Euphoric• Over aroused/ excessive smiling/ laughterOver aroused/ excessive smiling/ laughter• Person seems “way too excited”Person seems “way too excited”• Often personalized by TSS as “I’m his/her Often personalized by TSS as “I’m his/her

favorite”favorite”• Missed in PDD due to baseline exaggerationMissed in PDD due to baseline exaggeration• Child is so excited it results in an aggressive Child is so excited it results in an aggressive

outburstoutburst

Page 24: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Mood: Lability or fluctuationMood: Lability or fluctuation• Rapid shifts between moods: calm to angry,Rapid shifts between moods: calm to angry,

laughing to tears, etc.laughing to tears, etc.• For staff it feels like “For no apparent For staff it feels like “For no apparent

reason……”reason……”• Can result in aggression both verbal/physicalCan result in aggression both verbal/physical

Page 25: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Pressured Speech/ hyper verbalPressured Speech/ hyper verbal• Non stop talking/ rapid speech/ excessive Non stop talking/ rapid speech/ excessive

noise making in nonverbal individualsnoise making in nonverbal individuals• Described as a “motor mouth”Described as a “motor mouth”• Disregarded as “trying to get attention or wear Disregarded as “trying to get attention or wear

staff down to get his/her way”staff down to get his/her way”

Page 26: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Flight of IdeasFlight of Ideas• Ideas flow b/c of energy. Switching from Ideas flow b/c of energy. Switching from

topic to topic/ poor concentrationtopic to topic/ poor concentration• Difficulty responding to topics initiated by Difficulty responding to topics initiated by

others. others. • Disregarded as “ID/DD behavior” or Disregarded as “ID/DD behavior” or

“selective inattention”“selective inattention”

Page 27: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Psychomotor agitation Psychomotor agitation • appears in constant motion/pacing/ moving appears in constant motion/pacing/ moving

around/ excessive rocking, elopementaround/ excessive rocking, elopement• Described as “ants in his pants” by TSSDescribed as “ants in his pants” by TSS• Often the focus of info in psychiatric Often the focus of info in psychiatric

appointments.appointments.• Missed in PDD due to baseline exaggerationMissed in PDD due to baseline exaggeration

Page 28: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Excessive DriveExcessive Drive• Excessive intensity or drive for pleasurable Excessive intensity or drive for pleasurable

activities: likes / desires/ hobbies/ collectionsactivities: likes / desires/ hobbies/ collections

• Excessive Drive Examples:Excessive Drive Examples:• Keys, DVD’s/CD’s, T-shirts, toilet flushing, Keys, DVD’s/CD’s, T-shirts, toilet flushing,

telephone, laundry, counting money, menus telephone, laundry, counting money, menus phone books, shopping, food, beauty productsphone books, shopping, food, beauty products

Page 29: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Obsessions/Compulsions (OCD)Obsessions/Compulsions (OCD)• Anxiety provoking thoughts Anxiety provoking thoughts • Compelling need to perform activity/ritual but Compelling need to perform activity/ritual but

brings NO PLEASUREbrings NO PLEASURE• Pleasure question often not investigatedPleasure question often not investigated

Page 30: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Excessive Drive often mistaken for OCD Excessive Drive often mistaken for OCD followed by a prescription for followed by a prescription for antidepressants making a mood disorder antidepressants making a mood disorder worse.worse.

• Excessive Drive/ OCD question often Excessive Drive/ OCD question often missed in PDD population due to baseline missed in PDD population due to baseline exaggeration.exaggeration.

Page 31: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Delusions: fixed false beliefs despite Delusions: fixed false beliefs despite evidence to the contraryevidence to the contrary

• Delusions about staff adopting him and Delusions about staff adopting him and taking him home.taking him home.

• Grandiose delusion about abilities. Grandiose delusion about abilities. Driving a car, violent acts/ gang Driving a car, violent acts/ gang membership.membership.

Page 32: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Behavioral Manifestations/ Behavioral Manifestations/ EquivalentsEquivalents

• Depression/ Depressed moodDepression/ Depressed mood• Sadness/ confusion/ withdrawal from Sadness/ confusion/ withdrawal from

activities often unnoticed as a symptom but activities often unnoticed as a symptom but viewed as “noncompliance” or in others viewed as “noncompliance” or in others viewed as “content” viewed as “content”

• More easily seen as a decrease in academic More easily seen as a decrease in academic performanceperformance

Page 33: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example #1Case Example #1

• Past Diagnosis: Psychotic Depression and Past Diagnosis: Psychotic Depression and ADHDADHD

• Reports that issues were “all behavioral”Reports that issues were “all behavioral”• Physical aggression, property destructionPhysical aggression, property destruction• Multiple psychiatric admissions.Multiple psychiatric admissions.• multiple medication changes/ poor multiple medication changes/ poor

continuity of care/ staff turnovercontinuity of care/ staff turnover

Page 34: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example #1Case Example #1

• Flight of ideas/ pressured speechFlight of ideas/ pressured speech by constant by constant argumentativeness and false accusationsargumentativeness and false accusations

• Mood lability/irritabilityMood lability/irritability which turned into which turned into threats to harm, verbal aggression and physical threats to harm, verbal aggression and physical aggression toward both peers and staff aggression toward both peers and staff

• Risk taking behaviorRisk taking behavior which included which included attempting to jump out of a moving vehicleattempting to jump out of a moving vehicle

Page 35: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example #1Case Example #1

• Grandiose delusionsGrandiose delusions about family, children, about family, children, and money left to him in a will. and money left to him in a will.

• Psychomotor agitationPsychomotor agitation including constant including constant pacing and decreased need for sleeppacing and decreased need for sleep

• Excessive drive for the pleasurable Excessive drive for the pleasurable activitiesactivities of making phone calls, collecting of making phone calls, collecting others keys, and eating any available food to others keys, and eating any available food to the point of vomiting/diarrheathe point of vomiting/diarrhea

Page 36: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example #1Case Example #1

New diagnosis Bipolar disorder with New diagnosis Bipolar disorder with psychotic featurespsychotic features

Staff training to identify psychiatric Staff training to identify psychiatric symptoms and track them daily on a chart symptoms and track them daily on a chart for psychiatrist. for psychiatrist.

New medication regimenNew medication regimen

New behavior planNew behavior plan

Page 37: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example # 2Case Example # 2

18 yr old boy with autism and OCD taking two 18 yr old boy with autism and OCD taking two antidepressant medications and an antipsychoticantidepressant medications and an antipsychotic

SymptomsSymptoms::• Psychomotor agitation: excessive spinning,Psychomotor agitation: excessive spinning,• Pressured speech: excessive squealing and Pressured speech: excessive squealing and

humminghumming• Irritability: unwilling to be touched…first thought Irritability: unwilling to be touched…first thought

to be attributed to his Autism until his to be attributed to his Autism until his antidepressants were discontinuedantidepressants were discontinued

Page 38: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example # 2Case Example # 2

• Sleep disturbanceSleep disturbance• Medication changes:Medication changes:• Both antidepressants were discontinued Both antidepressants were discontinued

and replaced with Depakote. Risperdal and replaced with Depakote. Risperdal lowered.lowered.

• Spins minimally for Self stimulation, Spins minimally for Self stimulation, welcomes touch, can sit still and has a welcomes touch, can sit still and has a significantly improved attention span.significantly improved attention span.

Page 39: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Case Example # 3Case Example # 3

• Adolescent diagnosed with Asperger’s disorder, Adolescent diagnosed with Asperger’s disorder, Tic disorder and Obsessive Compulsive Tic disorder and Obsessive Compulsive Disorder. Taking Paxil and Risperdal.Disorder. Taking Paxil and Risperdal.

• Individual did not have OCD. Asperger’s traits Individual did not have OCD. Asperger’s traits were inappropriately attributed to OCD. were inappropriately attributed to OCD. Medication was discontinued and bimonthly Medication was discontinued and bimonthly behavioral therapy was initiated.behavioral therapy was initiated.

Page 40: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Action PlanAction Plan

• Staff TrainingStaff Training• Mental health disordersMental health disorders• Symptom identification/manifestationsSymptom identification/manifestations• Symptom tracking/ reportingSymptom tracking/ reporting• Team meeting prior to psychiatric Team meeting prior to psychiatric

appointmentsappointments• Treatment plans that address psychiatric Treatment plans that address psychiatric

symptom managementsymptom management

Page 41: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

SampleSample

DelusionsDelusions: fixed false belief despite evidence to the : fixed false belief despite evidence to the contrary. Jimmy displays paranoid delusions that contrary. Jimmy displays paranoid delusions that others are after him, talking about him.others are after him, talking about him.

GrandiosityGrandiosity: will often demonstrate excessive self : will often demonstrate excessive self esteem about his ability to drive a vehicle. He will esteem about his ability to drive a vehicle. He will try to take staff’s keys and try to drive your car.try to take staff’s keys and try to drive your car.

HypersexualityHypersexuality: excessive or inappropriate touching : excessive or inappropriate touching of himself or others. Must differentiate from of himself or others. Must differentiate from touching TSS inappropriately just for a touching TSS inappropriately just for a shock/attention response.shock/attention response.

Page 42: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Psychiatric Symptom Psychiatric Symptom Management SampleManagement Sample

When Jimmy is displaying an increase in psychiatric When Jimmy is displaying an increase in psychiatric symptoms:symptoms:

• Maintain safe boundaries…keep personal spaceMaintain safe boundaries…keep personal space• Decrease stimulation to decrease irritabilityDecrease stimulation to decrease irritability• Offer highly preferred activities when Jimmy is Offer highly preferred activities when Jimmy is

experiencing mood shiftingexperiencing mood shifting• If Jimmy is grandiose do not challenge him and If Jimmy is grandiose do not challenge him and

say they are untrue, instead passively say they are untrue, instead passively acknowledge with a “no kidding” and move on…acknowledge with a “no kidding” and move on…

• If delusional focus on being safeIf delusional focus on being safe

Page 43: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

Conclusion

Questions & Answers

For More Information:

Peg Schwartz LSWPeg Schwartz LSW

[email protected]@csgonline.org

Page 44: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

ReferencesReferences

• Fletcher, R.,(2000) Fletcher, R.,(2000) Therapy Approaches Therapy Approaches for Persons with Mental Retardationfor Persons with Mental Retardation: : NADD Press, Kingston, NYNADD Press, Kingston, NY

• Gardner, W. Psychiatric disorders and Gardner, W. Psychiatric disorders and nonspecific behavioral symptoms. nonspecific behavioral symptoms. Presented at NADD 14Presented at NADD 14thth Annual Annual Conference. 1997Conference. 1997

Page 45: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

ReferencesReferences

• Griffiths, D., Gardner, W., Nugent, (1998) Griffiths, D., Gardner, W., Nugent, (1998) Behavioral Supports: Individual Centered Behavioral Supports: Individual Centered Interventions, A Multimodal Functional Interventions, A Multimodal Functional ApproachApproach, NADD Press, Kingston, NY., NADD Press, Kingston, NY.

• Kessler et. al., (2005) Prevalence, severity and Kessler et. al., (2005) Prevalence, severity and comorbidity of twelve month DSM-IV disorders comorbidity of twelve month DSM-IV disorders in the National Comorbidity Survey Replication in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 62, (NCS-R). Archives of General Psychiatry. 62, 617-627.617-627.

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ReferencesReferences

• Kessler, R.C. Berglund, P.A. Demler, O., Kessler, R.C. Berglund, P.A. Demler, O., Jin R. and Walters, E. E. (2005) Lifetime Jin R. and Walters, E. E. (2005) Lifetime prevalence and age of onset distributions prevalence and age of onset distributions of DSM-IV Disorders in the National of DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R). Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 62, 593-Archives of General Psychiatry. 62, 593-602.602.

Page 47: Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

ReferencesReferences

• Levitas, A. and Hurley, A. The history behind Levitas, A. and Hurley, A. The history behind antipsychotic medications in persons with antipsychotic medications in persons with intellectual disability: Part 1. Mental Health intellectual disability: Part 1. Mental Health Aspects of Developmental Disabilities. 2006: Aspects of Developmental Disabilities. 2006: 9:1: 26-329:1: 26-32

• Lovett, H., (1997) Lovett, H., (1997) Learning to Listen: Positive Learning to Listen: Positive Approaches and People with Difficult BehaviorApproaches and People with Difficult Behavior, , Brookes Publishing Co., Baltimore, MD.Brookes Publishing Co., Baltimore, MD.

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ReferencesReferences

• Moss, S. (et. al.) Psychiatric symptoms in adults with learning disability and challenging behaviour. The British Journal of Psychiatry (2000) 177: 452-456

• Pary, R. (et. al.) Diagnosis of bipolar disorder in persons with developmental disabilities. Mental Health Aspects of Developmental Disabilities (1999) 2:2 38-49

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ReferencesReferences

• Sovner, R. & Hurley, A. Ten diagnostic principles for recognizing psychiatric disorders in mentally retarded persons, Psychiartic Aspects of Mental Retardation Reviews 1989 8:2 9-14

• Richards, M. (et. al.) Long term affective disorder in people with mild learning disability. The British Journal of Psychiatry 2110 179: 523-527

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ReferencesReferences

• Sovner, R. and Lowry, M. A behavioral Sovner, R. and Lowry, M. A behavioral methodology for diagnosing affective methodology for diagnosing affective disorders in individuals with mental disorders in individuals with mental retardation. The Habilitative Mental retardation. The Habilitative Mental Healthcare Newsletter 1990: 9:7Healthcare Newsletter 1990: 9:7

• www.thenadd.orgwww.thenadd.org