DUAL DIAGNOSIS

 

INTRODUCTION TO DUAL DIAGNOSIS


Persons  with a dual diagnosis can be found at all ages and levels of  intellectual and adaptive functioning. Estimates of the frequency of  dual diagnosis vary widely, however many professionals have adopted the  estimate that 30-35% of all persons with intellectual or developmental  disabilities have a psychiatric disorder. In addition, it is noted that  the full range of psychopathology that exists in the general population  also can co-exist in persons who have intellectual or developmental  disabilities. 

The  co-existence of intellectual or developmental disabilities and a  psychiatric disorder can have serious effects on the persons daily  functioning by interfering with educational and vocational activities,  by jeopardizing residential placements, and by disrupting family and  peer relationships. In short, the presence of behavioral and emotional  problems can greatly reduce the quality of life for persons with  intellectual or developmental disabilities.

Many  agencies supporting people with developmental disabilities are hesitant  to serve those with a co-existing mental disorder. Because traditional  supported living services (SLS) were not designed to meet the unique  needs of individuals with a dual diagnosis, these individuals are often  relegated to a more restrictive level of care than desired or needed.  The scarcity of research and available information has left providers  without the evidence-based treatment protocols necessary to provide  appropriate services. Also, the higher level of expertise required of  management and service staff has left agencies ill-equipped to provide  higher level treatment services. In the mean time, with prevalence rates  of dual diagnosis estimated to be as high as forty percent, the issues  associated with supporting people who have a dual diagnosis continues to  grow.

The  Northern California Center for Developmental Disabilities, (NCD), was  founded by Belinda White, MSW, with other professionals from the fields  of mental health and developmental disabilities. Along with standard SLS  services, NCD's Augmented Care and Treatment (ACT) Program actively  addresses the multifaceted issues of dual diagnosis. NCD embraces the  tenets of Applied Behavior Analysis in its treatment of challenging  behaviors and employs evidence-based behavioral approaches that are  scientifically grounded in the principles of learning and behavioral  change. The focus is positive behavioral change strategies that not only  seek to eliminate serious and challenging behavioral problems, but also  promote developmental skills and alternative behavior that is socially  adaptive and personally gratifying. The goal is to provide supports and  services in a compassionate way that upholds the dignity of service  recipients, in the least restrictive environment. All services and  supports are non-aversive!

NCD’s  intervention methods center on teaching skills that will replace  individuals' maladaptive and dependent behavior and provide them with  alternative, appropriate means of communicating, coping with  frustrations, participating in functional activities and socially  relating to others. The multidisciplinary team utilizes a variety of  behavioral and naturalistic teaching methods and interventions such as  role playing, modeling, antecedent control, schedules of reinforcement,  psychoeducational training, and behavioral relaxation. The entire team  will identify and respond to early signs of relapse. Rigorous  documentation is maintained, including data on: intervention methods,  behavior change, skill acquisition, outcomes achieved, satisfaction of  consumers, their Circle of Support, and other agencies supporting the  recipient.

Outcomes and Objectives for Challenging Behavior or Dual Diagnosis

Service  recipients with significant behavior issues may be referred to the ACT  Program after repeated unsuccessful attempts at resolving behavioral  challenges. Thus, a primary goal of NCD’s supported living ACT Program  is to gain an understanding of the reasons why problems are continuing,  and to develop a comprehensive approach which effectively addresses  these problems. A second goal of the ACT Program is to confirm that the  recipient's behavior will respond positively if the right therapeutic  methods and arrangements can be found. Additionally, for many  individuals whose placements have been principally determined by their  behavior problems, other areas of their lives are often neglected and  remain arrested. Therefore, a goal of support services is to accelerate  the development of skills, to reinstate enjoyable and constructive  activities, and to expand the recipient's ability to deal with more  naturalized environments without reverting to problematic behavior. 

Interdisciplinary Team Approach

The  ACT Program is guided by a multidisciplinary team of professionals who  may include a licensed clinical social worker, psychologist, physician,  registered nurse, and a recreation therapist. In addition, the team may  be enhanced with other professionals, including a Board Certified  Behavior Analyst and psychiatric technician, as needed. The team meets  (at least) quarterly and focuses on stabilization strategies, developing  and monitoring recipient service/support plans, etc. Team meetings are  also called to address emergency situations. Through the use of  non-aversive, evidence-based intervention protocols, the  multidisciplinary team assists service recipients to: 

*  increase their ability to productively manage their environment;
 *  live successfully in the least restrictive manner possible;
 *  attain full community integration; and
 *  live regular lives with dignity.

Information on Dual Diagnosis

Prepared by Dr. Robert Fletcher, NADD Chief Executive Officer and the NADD Research Committee
 

Introduction:
 

The mental health needs of persons with  intellectual or developmental disabilities have been increasingly  recognized in recent years. In this section, we will define some terms  and point out pertinent information concerning mental health aspects of  intellectual or developmental disabilities.
 

What is Dual Diagnosis?
 

Dual Diagnosis is a term applied to the  co-existence of the symptoms of both intellectual or developmental  disabilities and mental health problems. We will clarify the meaning of  dual diagnosis in the paragraphs that follow.
 Intellectual or developmental disabilities:
 The American Psychiatric Association defined intellectual disabilities  as significantly below average intellectual and adaptive functioning  with onset before age 18 years (DSM-IV-TR, 2000). General intellectual  functioning is measured by an individually administered standardized  test of intelligence that results in an overall intelligence quotient  (IQ) for the individual Significantly subaverage functioning is defined  as an IQ score of 70 or below. Adaptive behavior refers to the  effectiveness with which an individual meets society's demands of daily  living for individuals of his/her age and cultural group. The  measurement of adaptive behavior may include an evaluation of an  individual's skills in such areas as eating and dressing, communication,  socialization and responsibility.
 

DSM-IV-TR's Four degrees of severity are solely related to the individual's level of intellectual impairment:
 Mild, Moderate, Severe and Profound:
 

Mild Intellectual Disabilities: IQ level 50-55 to approximately 70
 Moderate Intellectual Disabilities: IQ level 35-40 to 50-55
 Severe Intellectual Disabilities: IQ level 20-25 to 35-40
 Profound Intellectual Disabilities: IQ level below 20 or 25
 

The definition, classification, and systems  of supports Manual of the American Association on Mental Retardation  (AAMR; Luckasson et al., 2002) includes the same three diagnostic  criteria (i.e., significant limitations in intellectual functioning,  significant limitations in adaptive functioning, and onset prior to age  18 years). In the AAMR System, the criterion of significantly subaverage  intellectual functioning refers to a normative score that is at least 2  standard deviations below the population mean.. Furthermore, DSM-IV-TR  specifies levels of severity of intellectual disabilities, whereas the  AAMR 2002 System specifies that intellectual disabilities is present or  not. The AAMR 2002 System encourages the use of its multidimensional  classification system that includes: level of intellectual functioning  limitations (mild, moderate, severe, profound), levels of adaptive  behavior limitations (mild, moderate, severe, profound), intensity of  support needs (intermittent, limited, extensive and pervasive),  etiology, etc. Luckasson et al., (2002) discourages the classification  of the condition of intellectual disabilities based solely on  individual's severity of intellectual deficits.
 The definition of Developmental Disabilities in Public Law 106-402  (2000) is not limited to Intellectual disabilities and is based on  functional criteria. The Developmental Disabilities Act defines the term  developmental disability as a severe, chronic disability of an  individual that:
 (I) is attributable to a mental or physical impairment or combination of mental and physical impairments;
 (II) is manifested before the individual attains age 22;
 (III) is likely to continue indefinitely;
 (IV) results in substantial functional limitations in 3 or more of the following areas of major life activity:
 (i) Self-care.
 (ii) Receptive and expressive language.
 (iii) Learning.
 (iv) Mobility.
 (v) Self-direction.
 (vi) Capacity for independent living.
 (vii) Economic self-sufficiency; and
 (V) reflects the individual's need for a combination and sequence of  special, interdisciplinary, or generic services, individualized  supports, or other forms of assistance that are of lifelong or extended  duration and are individually planned and coordinated.