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DEVELOPMENTAL DISABILITY AND
MENTAL HEALTH:
ISSUES IN ASSESSMENT AND
MANAGEMENT
Dr Seeta Durvasula
seetad@med.usyd.edu.au
Dr Vivienne Riches
vriches@med.usyd.edu.au
7th October 2008
Developmental Disability

The term “developmental disability” means a
severe, chronic disability of a person which:
 is
attributed to an intellectual, or physical impairment or
combination of intellectual and or physical impairment;
 is
manifested before the person attains the age of 18;
 is
likely to continue indefinitely
 deficits
in adaptive behaviour
Intellectual disability/
Learning disability

Intellectual Disability refers to substantial limitations in
present functioning. It is characterized by significantly
sub-average intellectual functioning, existing
concurrently with related limitations in two or more of
the following applicable adaptive skill areas:
communication, self care, home living, social skills,
community use, self direction, health and safety,
functional academics, leisure, and work. Mental
retardation manifests before age 18.
*AAMR (2002). Mental Retardation: Diagnosis, classification, and systems of
support (10th Ed.). Washington, DC:AAMR
*Now AAIDD
Dual diagnosis
Currently between 20% to 35% of all
noninstitutionalized persons with intellectual
disability are diagnosed as “mentally
retarded/mentally ill, compared to 15 to 19%of the
general population who meet the criteria of mental
illness as defined by the American Psychiatric
Association.
(American Psychiatric Association, 1995; Einfeld & Tonge, 1991; 1992;
Iverson & Fox, 1989; Menolascino & Stark, 1984).
Issues that can adversely influence
assessment & treatment

Diagnostic overshadowing

Overemphasis on the intellectual disability at the
expense of the psychiatric condition

Attention to symptomatology rather than signs
(observed behaviour)

Additional stigmatization
(Luckasson et al, 1992; Reiss, Levitan, & Szysko, 1982).
Relevance to general practice




Prevalence of ID – 1.8% of population (AIHW,
1998)
Increasing life span - 50-60 years
Higher risk of physical and mental health
problems
Majority live in the community


with families / supported accommodation
Access generic health services
Prevalence: mental health
problems

41% have a mental health problem


Schizophrenia/delusional disorder


3 times higher than in general population
Depression


Einfeld & Tonge (1996)
3 times higher in people with Down Syndrome
Dementia

4 times more common than in general population
Types of mental health disorders


Same range as in general community
Some types of developmental disability associated
with specific conditions
Down Syndrome - depression, dementia
 Phenylketonuria - anxiety, depression
 Prader Willi Syndrome - psychosis, depression



Other problem behaviours/challenging
behaviours - consider other factors
Epilepsy common co-morbid condition
Clinical Presentation

May be different to that of general population
- especially those with severe/profound
disability due to:
reduced cognitive abilities
 communication difficulties
 high prevalence of co-morbidity


Some atypical clinical presentations:
aggression
 self injurious behaviour
 non compliance
 loss of skills

Possible aetiology

Organic causes

physical illness, pain, effects of medication



Psychiatric disorders
Behavioural phenotypes


e.g. Prader Willi Syndrome
Environmental


e.g. GORD, middle ear infection, sleep apnoea,
psychotropics,
lack of choice, change in routine, frustration
Life events - grief, loss, abuse
Clinical Assessment: history

History
of behaviour - where, when, precipitants/exacerbating
/ relieving factors; previous history
 new or changed behaviour, cyclic patterns
 accompanying behaviours
 past medical history / systems review
 medications: prescription/OTC/alternative
 functional abilities - esp. communication
 life circumstances - recent change?
 family history - medical, psychiatric

Clinical Assessment: history
For reliability, may need multiple sources:

patient if possible

simple short sentences, start with open-ended questions
family member / friend
 formal carer/s
 other support people - day placement, respite care
 health records
 behaviour observation chart

Behavioural measures



Checklists eg. DASS 21; DBC
Reports, files,
Observational data eg. A-B-C
Antecedents
 Behaviour
 Consequences

Sample Behaviour Chart
Clinical Assessment:
examination/ investigations



Full physical examination
Mental state examination
Investigations - as indicated
consider vision/hearing assessments
 thyroid function tests

Management

Often need multidisciplinary approach





Treat physical disorders
May need to review medication
Refer/ treat psychiatric disorders
Address environmental issues




e.g psychologist, psychiatrist, speech therapist
structure, consistency
Effective communication methods
Counselling and social support
MONITOR AND REVIEW
How to make the consultation
work

Good planning is essential
plan long consultation
 insist on all records accompanying patient
 request carer with knowledge of patient to accompany
 may need more than one consultation to obtain all
information from variety of sources


Give explicit written instructions/information

especially for prn medications
Working with formal caregivers

Issues
high turnover of staff
 frequent use of casual staff
 range of knowledge / experience / skills
 incomplete information often given
 record keeping

Psychotropic medication: principles


Comprehensive assessment first
Where possible, treat the underlying condition, don’t
merely suppress the behaviour



Consider non-pharmacological treatment options
Medication is seldom the sole solution - other
therapeutic modalities may be required


avoid using medication as a restraint
behavioural intervention, counselling, environmental changes
Baseline observations and reliable documentation of
response to Rx is vital : checklists, rating scales
Psychotropic medication: principles



Continue medication only if documented improvement
Response to medication may be idiosyncratic - start
with small doses and watch for side effects
Consider reducing dose if symptoms absent for
reasonable period


reduce slowly / may need extra support at this time
monitor and document response
Adapted from: Einfeld SL “Guidelines for the use of psychotropic
medication in individuals with developmental disabilities”
Australia and New Zealand Journal of Developmental Disabilities, 1990
16(1):71-73
Psychotropic medication:side effects


More vulnerable to CNS side effects
S/E can be missed/misinterpreted:
tardive dyskinesia may be mistaken for stereotypic
behaviour
 akathisia can be misdiagnosed as anxiety and
neuroleptic dose increased



Beware paradoxical response to benzodiazepines increased agitation
Seizure threshold lowered by some
neuroleptics/antidepressants
Issues to consider


Beware of “diagnostic overshadowing”
Consider psychiatric disorders




Communication difficulties
Acquiescence/ nay saying
Functional aspect of behaviour


ask about appetite, sleep patterns, tearfulness,
hallucinations, delusions
attention seeking, protesting, escaping
Consent to treatment
Resources

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Local DADHC office
Local mental health service
Statewide Behaviour Intervention Service (SBIS) :
Ph: (02) 8876 4000
Private practitioners eg psychologists,
psychiatrists, speech pathologists
NSW Developmental Disability Health Unit Ph:
(02) 9808 9287
Brain & Mind Research Institute
(University of Sydney) Ph: (02) 9351 0799
www.bmri.org.au/cc_ptfmly.html
Summary




High prevalence of mental health problems in
people with developmental disability
Beware of “diagnostic overshadowing”
Consider physical, psychiatric, psychological
and environmental factors
Multiple approaches to management are
required - medical, behavioural,
environmental, social
Case Scenario A




Michael, 42 yrs
Down Syndrome, mild level of ID
Lives in group home
“Not himself” for last 3 months
losing skills- e.g. self care, independent travel
 work placement threatened - slow, forgetful
 not interested in social activities
 irritable, aggressive

Case Scenario A …




Wears glasses for myopia
On thioridazine for “behavioural problems” started 10 years ago, after moving into group
home
Father died of MI 18 months ago
Case worker recently changed jobs
Case Scenario A : differential
diagnosis

Sensory impairment
vision
 hearing





Hypothyroidism
Depression
Neuroleptic induced symptoms
Alzheimer’s Disease
Case Scenario B

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
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
Phillip - 32 year old man
Down Syndrome – moderate intellectual disability
Lives with mother, older siblings moved out
Works 2 days per week supported employment –fast
food outlet
Psychiatrist treating for schizophrenia past two years




Slowed performance, loss of skills
Reduced communication
Aggressive behaviour – shouting at neighbour – unknown
provocation
Talking to imaginary people
Case Scenario B ….



Falling asleep in waiting room 9am
Father died when child – left taped message
which Phillip listens to regularly
Grandmother died 2 years previously
Case Scenario B : differential
diagnosis





Behaviour of concern – aggression
Depression
Schizophrenia
Fantasy
Grief