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Dual DiagnosisMental Retardation and
Psychiatric Disorders
By
Suzanne Collier
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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
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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.
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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.
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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.
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Anxiety Disorders
-Strong hereditary component
-Phobias, Panic, Separation anxiety
-(OCD) Obsessive- compulsive= biological basis, repetitive purposeful behavior and persistent senseless thoughts
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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.
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-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
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-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
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-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
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Medical Problems
- Hypothyroidism (common with Down
Syndrome) can cause
anxiety or depression
- Excessive Drugs
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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
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-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
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-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,
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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.
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-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
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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,
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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
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-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
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-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