MENTAL HEALTH NEEDS

 

Mental Health Problems:
 

Mental health problems are severe disturbances  in behavior, mood, thought processes and/or interpersonal relationships.  The Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR,  2000) lists the different types of mental disorders.
 The types of psychiatric disorders persons with intellectual or  developmental disabilities experience are the same as those seen in the  general population, although the individual's life circumstances or  level of intellectual functioning may alter the appearance of the  symptoms. Some of the common types are:
 Mood Disorders: The disorders are characterized by disturbance of mood  as a predominant feature. Depression, bi-polar and mania are the major  sub-categories of mood disorders.
 Anxiety Disorders: This group of disorders is indicated by the presence  of excessive fears, frequent somatic complaints and excessive  nervousness that can interfere with functioning. Panic attack,  agoraphobia, obsessive-compulsive and post traumatic stress disorder are  some of the major sub-categories of anxiety disorders.
 

Psychotic Disorders:
 

This group of disorders is characterized by any  of the following signs and symptoms: delusions, hallucinations,  disorganized behavior and impairment in reality testing. Schizophrenia,  schizoaffective disorder and schizophreniform are some of the major  sub-categories of psychotic disorders.
 Personality Disorders: The group of disorders refers to enduring  patterns of dysfunctional behavior. Symptoms typically present as  personality traits that are inflexible, maladaptive and cause  significant impairment or subjective distress. Paranoid, anti-social,  borderline and avoidant are some of the major sub-categories of  personality disorders.
 

Adjustment Disorders:
 

The essential feature of these disorders is the  development of clinically significant emotional or behavioral symptoms  in response to an identifiable psychosocial stressor(s). The clinical  significance of the reaction is indicated by either marked distress that  is beyond that which is expected or by impairment in social or  occupations functioning. Sub categories of adjustment disorders include  adjustment disorder with depressed mood, with anxiety, with disturbance  of conduct and with mixed disturbance of emotions and conduct.
 Other psychiatric disorders include: somatoform disorders, factitious  disorders, dissociative disorders, sexual and gender identity disorders,  eating disorders, sleep disorders, substance abuse related disorders,  impulse control disorders, dementia disorders, dissociative disorders,  and disorders usually first diagnosed in infancy, childhood or  adolescence.
 

Mental Health Aspects of Intellectual and Developmental Disabilities:
 

Why So Prevalent?
 

The causes of the increased vulnerability to  mental health problems in persons with intellectual or developmental  disabilities are not well understood. Several factors have been  suggested. Stress is a risk factor for mental health problems. Persons  with intellectual or developmental disabilities experience negative  social conditions throughout the life span that contribute to excessive  stress. These negative social conditions include social rejection,  stigmatization, and the lack of acceptance in general. Social support  and coping skills can buffer the effect of stress on mental health. In  persons with intellectual or developmental disabilities, limited coping  skills associated with language difficulty, inadequate social supports,  and a high frequency of central nervous system impairment, all  contribute to the vulnerability of developing mental health problems.  Another explanation for the increased prevalence of mental health  problems in this population relates to behavioral phenotypes. In  addition to the characteristic physiological signs associated with  genetic syndromes, many syndromes have characteristic behavior and  emotional patterns. These behavioral phenotypes may contribute to the  increased rate of behavioral and mental health problems among persons  with intellectual or developmental disabilities.
 

Is This a New Phenomenon?
 

The identification of psychiatric disorders in  persons with intellectual and developmental disabilities is not a new  phenomenon, but it has received much more attention in recent years. The  process of deinstitutionalization, by which many individuals with  intellectual and developmental disabilities were released from  institutions and placed in community residences, has increased the  visibility of dual diagnosis. Although psychiatric disorders have been  observed in persons with intellectual and developmental disabilities for  many years, there have been impediments to more widespread professional  recognition of dual diagnosis. One obstacle is "Diagnostic  Overshadowing" which occurs when a diagnostician overlooks or minimizes  the signs of psychiatric disturbance in a person with intellectual  disabilities. The psychiatric disorder may be overlooked because it is  considered less debilitating than intellectual disability or because it  is thought to be a result of intellectual deficits. Professionals who  are pressed to assign a "primary" diagnosis may focus on intellectual  functioning, ignoring the psychiatric problem.
 Another impediment to the recognition of mental illness in persons with  intellectual disabilities has been the tendency for the administration  and funding of mental health and intellectual or developmental  disability services to be separate. Each system may expect the other to  serve the person with a dual diagnosis. In addition, staff at both types  of agencies may feel ill equipped to provide adequate services. There  is a great need to train qualified personnel in the diagnosis and  treatment of psychiatric disorders among individuals with intellectual  or developmental disabilities.
 

What Treatments are Available?
 

Most experts agree that treatment requires a  comprehensive plan with several components. An interdisciplinary  evaluation of the individual is necessary to obtain an accurate  diagnosis and to establish habilitation and treatment needs. A thorough  medical and neurological evaluation should be included to identify acute  or chronic conditions that may need attention. A psychiatric evaluation  can determine if medication is appropriate. Follow-up interviews are  required to monitor the individual's response to the various treatments.
 Psychopharmacology: Medication treatment is appropriate for many  psychiatric disorders(i.e., mood disorders and psychotic disorders).  Medication treatment should not be a total treatment approach per se,  but rather part of a comprehensive bio-psycho-social-developmental  treatment approach.
 Psychotherapy: Individual, group and/or family psychotherapy may be  included in the treatment plan. Psychotherapists may draw techniques  from many theoretical orientations, including behavioral, cognitive,  cognitive-behavioral, gestalt, psychodynamic, nondirective, or systems.  ,. Group therapies include skills training groups such as social skills,  dating skills, assertiveness, and anger management training.
 

Other therapy groups may focus on specific  developmental tasks such as independence or bereavement. The groups may  be structured or unstructured, time-limited or ongoing. Verbal  psychotherapies are most appropriate for persons with mild to moderate  intellectual disabilities.
 Behavioral Management: Behavior management plans are developed to deal  with inappropriate behaviors and to teach adaptive skills. A functional  analysis of behavior is conducted to determine the best approaches to  use in the behavior plan. Systematic behavior programs may be  implemented by individuals in the person's environment. The person who  is dually diagnosed may participate in the design of the behavioral  program.
 Many treatment modalities and approaches have been tried, with varying  degrees of effectiveness, with persons with intellectual and  developmental disabilities. Evidence-based treatment approaches are  those that have been empirically tested and proven effective for persons  with intellectual and developmental disabilities. It is considered best  practice to use evidence-based treatments.

What Other Services might be needed?

Day  Treatment: Day treatment, or partial hospitalization, programs for  persons who are dually diagnosed have been established in many  communities. The programs serve individuals with intellectual or  developmental disabilities who have difficulty functioning in a  traditional school or vocational program due to behavioral or  psychiatric problems. Day treatment programs are generally designed for  both rehabilitation and education, and include small group activities  that focus on independent living skills, interpersonal skills,  vocational preparation, and enrichment activities. Small group and  individual psychotherapy are usually scheduled as part of the weekly  program.
 

Social Skills Training:
 

Social skills training is usually a time  limited approach that helps persons to improve the quality of their life  by enhancing interpersonal interactions. Individuals are taught  effective and appropriate social behaviors.
 Residential Services: Residential treatment programs have also been  developed. These include inpatient units with intensive treatment  programs for those individual who require 24-hour supervision in a  secured environment. In community settings, a range of residential  options is available, although the demand often exceeds the available  supply. Community placements include group homes, foster care, and  supervised apartments, as well as programs that provide in-home family  services and respite care.
 

Crisis Intervention Services:
 

Additional services may be called upon in  emergency situations. These services are designed for short-term use to  stabilize immediate crises. These services may include Assertive  Community Treatment Teams, Crisis Homes, or short-term hospital  admissions.
 Other services provided to individuals with intellectual and  developmental disabilities and mental health problems may include  physical therapy, speech therapy, art therapy and occupational therapy,  among others, depending on individual needs. The coordination of  services is an essential task.

Bibliography:
 American Psychiatric Association (2000). Diagnostic and Statistical  Manual of Mental Disorders, Fourth Edition Test Revision (DSM-IV-TR).  Washington, DC: Author.
 Luckasson, R., Borthwick-Duffy, S., Buntinx, W. H. E., Coulter, D. L.,  Craig, E. M., Schalock, R. L., Snell, M. E., Spitalnik, D. M., Spreat,  S., & Tassé, M. J. (2002). Mental retardation: Definition,  classification, and system of supports. Washington, DC: American  Association on Mental Retardation
 Developmental Disabilities Assistance and Bill of Rights Act of 2000. Publi Law 106-402. October 30, 2000.