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
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:
(ii) Receptive and expressive language.
(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.