Psychiatric and Behavioral Challenges in Adolescents with Intellectual Disabilities

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

2. Objectives • Review 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.

3. What is challenging behavior? Any behavior that keeps a person from having a good quality of life.

4. Types of Challenging Behavior • Social rule/norms violation • Verbal aggression/threats/false accusations • Property destruction • Self injury • Physical aggression • Distracting…Disruptive…Destructive

5. 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.

6. 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.

7. Research 1: 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.)

8. 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.

9. Research Individuals with an IQ less than 69 were associated with a 4x increase in risk of affective disorder…Richards et. al. (2001) Increase in severity of challenging behaviors was associated with increased prevalence of psychiatric symptoms… Moss et. al. (2000)

10. Typical Developmental Tasks • Adolescence 12-18 yrs Identity vs. Role Confusion Opportunities for increased socialization, developing interdependence with family, loyalty to peers, new freedoms are granted, autonomy, internalized sense of right and wrong.

11. Symptoms and Behavioral Manifestations/Equivalents • Have you ever had a cold? • What are the behavioral manifestations of your symptoms?

12. Symptoms and Behavioral Manifestations/Equivalents • We must pay attention to the symptoms and the behavioral manifestations/ behavioral equivalents. SymptomBehavior Runny nose wipe with tissue Coughing covering my mouth

13. Shift your Focus

14. Shift your Focus

15. Sovner & Hurley’s 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.

16. Sovner & Hurley’s Diagnostic Principles (1989) • “The severity of the problem is not diagnostically relevant.” • “Maladaptive behavior rarely occurs alone…clients with psychiatric disorders often display multiple maladaptive behaviors.”

17. Myths and Misconceptions • Diagnostic Overshadowing • Episodic Presentation • Medication Masking • Baseline Exaggeration • Intellectual Distortion

18. Myths and Misconceptions • Diagnostic 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 can’t have a mental illness”

19. Myths and Misconceptions • Episodic 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.

20. Myths and Misconceptions • Baseline Exaggeration – The individual has previously existing maladaptive behaviors that increase in frequency and intensity during the course of a mental illness. MYTH: “He’s just acting more autistic than he usually does”

21. Myths and Misconceptions • Intellectual Distortion – because of intellectual limitations, the individual cannot accurately understand questions posed by the evaluator. • Do you hear voices?

22. Behavioral Manifestations/ Equivalents • Mood: Irritable/ Irritability • Excessive negative response/ short fuse • Screaming. Swearing, aggression • Cannot be only in response to limit setting • 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?

23. Behavioral Manifestations/ Equivalents • Mood: Euphoric • Over aroused/ excessive smiling/ laughter • Person seems “way too excited” • Often personalized by TSS as “I’m his/her favorite” • Missed in PDD due to baseline exaggeration • Child is so excited it results in an aggressive outburst

24. Behavioral Manifestations/ Equivalents • Mood: Lability or fluctuation • Rapid shifts between moods: calm to angry, laughing to tears, etc. • For staff it feels like “For no apparent reason……” • Can result in aggression both verbal/physical

25. Behavioral Manifestations/ Equivalents • Pressured Speech/ hyper verbal • Non stop talking/ rapid speech/ excessive noise making in nonverbal individuals • Described as a “motor mouth” • Disregarded as “trying to get attention or wear staff down to get his/her way”

26. Behavioral Manifestations/ Equivalents • Flight of Ideas • Ideas flow b/c of energy. Switching from topic to topic/ poor concentration • Difficulty responding to topics initiated by others. • Disregarded as “ID/DD behavior” or “selective inattention”

27. Behavioral Manifestations/ Equivalents • Psychomotor agitation • appears in constant motion/pacing/ moving around/ excessive rocking, elopement • Described as “ants in his pants” by TSS • Often the focus of info in psychiatric appointments. • Missed in PDD due to baseline exaggeration

28. Behavioral Manifestations/ Equivalents • Excessive Drive • Excessive intensity or drive for pleasurable activities: likes / desires/ hobbies/ collections • Excessive Drive Examples: • Keys, DVD’s/CD’s, T-shirts, toilet flushing, telephone, laundry, counting money, menus phone books, shopping, food, beauty products

29. Behavioral Manifestations/ Equivalents • Obsessions/Compulsions (OCD) • Anxiety provoking thoughts • Compelling need to perform activity/ritual but brings NO PLEASURE • Pleasure question often not investigated

30. Behavioral Manifestations/ Equivalents • Excessive 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.

31. Behavioral Manifestations/ Equivalents • Delusions: fixed false beliefs despite evidence to the contrary • Delusions about staff adopting him and taking him home. • Grandiose delusion about abilities. Driving a car, violent acts/ gang membership.

32. Behavioral Manifestations/ Equivalents • Depression/ Depressed mood • Sadness/ 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

33. Case Example #1 • Past Diagnosis: Psychotic Depression and ADHD • Reports that issues were “all behavioral” • Physical aggression, property destruction • Multiple psychiatric admissions. • multiple medication changes/ poor continuity of care/ staff turnover

34. Case Example #1 • Flight 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

35. Case Example #1 • Grandiose 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

36. Case Example #1 New 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

37. Case Example # 2 18 yr old boy with autism and OCD taking two antidepressant medications and an antipsychotic Symptoms: • Psychomotor agitation: excessive spinning, • Pressured speech: excessive squealing and humming • Irritability: unwilling to be touched…first thought to be attributed to his Autism until his antidepressants were discontinued

38. Case Example # 2 • Sleep disturbance • Medication 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.

39. Case Example # 3 • Adolescent diagnosed with Asperger’s disorder, Tic disorder and Obsessive Compulsive Disorder. Taking Paxil and Risperdal. • Individual did not have OCD. Asperger’s traits were inappropriately attributed to OCD. Medication was discontinued and bimonthly behavioral therapy was initiated.

40. Action Plan • Staff Training • Mental health disorders • Symptom identification/manifestations • Symptom tracking/ reporting • Team meeting prior to psychiatric appointments • Treatment plans that address psychiatric symptom management

41. Sample Delusions: fixed false belief despite evidence to the contrary. Jimmy displays paranoid delusions that others are after him, talking about him. Grandiosity: will often demonstrate excessive self esteem about his ability to drive a vehicle. He will try to take staff’s keys and try to drive your car. Hypersexuality: excessive or inappropriate touching of himself or others. Must differentiate from touching TSS inappropriately just for a shock/attention response.

42. Psychiatric Symptom Management Sample When Jimmy is displaying an increase in psychiatric symptoms: • Maintain safe boundaries…keep personal space • Decrease stimulation to decrease irritability • Offer highly preferred activities when Jimmy is experiencing mood shifting • If Jimmy is grandiose do not challenge him and say they are untrue, instead passively acknowledge with a “no kidding” and move on… • If delusional focus on being safe

43. Conclusion Questions & Answers For More Information: Peg Schwartz LSW schwartzp@csgonline.org

44. References • Fletcher, R.,(2000) Therapy Approaches for Persons with Mental Retardation: NADD Press, Kingston, NY • Gardner, W. Psychiatric disorders and nonspecific behavioral symptoms. Presented at NADD 14th Annual Conference. 1997

45. References • Griffiths, D., Gardner, W., Nugent, (1998) Behavioral Supports: Individual Centered Interventions, A Multimodal Functional Approach, NADD Press, Kingston, NY. • Kessler et. al., (2005) Prevalence, severity and comorbidity of twelve month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 62, 617-627.

46. References • Kessler, R.C. Berglund, P.A. Demler, O., Jin R. and Walters, E. E. (2005) Lifetime prevalence and age of onset distributions of DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 62, 593-602.

47. References • Levitas, A. and Hurley, A. The history behind antipsychotic medications in persons with intellectual disability: Part 1. Mental Health Aspects of Developmental Disabilities. 2006: 9:1: 26-32 • Lovett, H., (1997) Learning to Listen: Positive Approaches and People with Difficult Behavior, Brookes Publishing Co., Baltimore, MD.

48. References • 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

49. References • 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

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