Transcript Challenging Behavior…Is It a Mental Illness or Learned

Psychiatric and Behavioral
Challenges in Adolescents
with Intellectual Disabilities
Presented by:
Peg Schwartz LSW
Behavioral Services Coordinator
Community Services Group, Inc
Objectives
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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.
What is challenging behavior?
Any behavior that keeps a person from
having a good quality of life.
Types of Challenging Behavior
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Social rule/norms violation
Verbal aggression/threats/false accusations
Property destruction
Self injury
Physical aggression
Distracting…Disruptive…Destructive
Why are ID/DD individuals
more vulnerable ?
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Slower learning = Impaired ability to learn and use
healthy coping skills.
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Skill deficits in critical functional areas lead to high
stress as a result inappropriate behavior is used
excessively as a means to cope.
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Communication, problem solving, rationalization,
objectivity, object relations.
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A high frequency of central nervous system
impairment.
Why are DD individuals more
vulnerable ?
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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.
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Other factors including mental illness must
always be considered and ruled out.
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.)
Research
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For individuals with ID estimates vary
between 1:3 to 2:3.
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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.
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)
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.
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Symptoms and Behavioral
Manifestations/Equivalents
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Have you ever had a cold?
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What are the behavioral manifestations of
your symptoms?
Symptoms and Behavioral
Manifestations/Equivalents
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We must pay attention to the symptoms
and the behavioral manifestations/
behavioral equivalents.
Symptom
Runny nose
Coughing
Behavior
wipe with tissue
covering my mouth
Shift your Focus
Shift your Focus
Sovner & Hurley’s Diagnostic
Principles (1989)
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“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.
Sovner & Hurley’s Diagnostic
Principles (1989)
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“The severity of the problem is not
diagnostically relevant.”
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“Maladaptive behavior rarely occurs
alone…clients with psychiatric disorders
often display multiple maladaptive
behaviors.”
Myths and Misconceptions
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Diagnostic Overshadowing
Episodic Presentation
Medication Masking
Baseline Exaggeration
Intellectual Distortion
Myths and Misconceptions
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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”
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.
Myths and Misconceptions
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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”
Myths and Misconceptions
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Intellectual Distortion – because of
intellectual limitations, the individual
cannot accurately understand questions
posed by the evaluator.
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Do you hear voices?
Behavioral Manifestations/
Equivalents
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Mood: Irritable/ Irritability
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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?
Behavioral Manifestations/
Equivalents
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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
Behavioral Manifestations/
Equivalents
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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
Behavioral Manifestations/
Equivalents
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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”
Behavioral Manifestations/
Equivalents
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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”
Behavioral Manifestations/
Equivalents
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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
Behavioral Manifestations/
Equivalents
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Excessive Drive
• Excessive intensity or drive for pleasurable
activities: likes / desires/ hobbies/ collections
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Excessive Drive Examples:
• Keys, DVD’s/CD’s, T-shirts, toilet flushing,
telephone, laundry, counting money, menus
phone books, shopping, food, beauty products
Behavioral Manifestations/
Equivalents
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Obsessions/Compulsions (OCD)
• Anxiety provoking thoughts
• Compelling need to perform activity/ritual but
brings NO PLEASURE
• Pleasure question often not investigated
Behavioral Manifestations/
Equivalents
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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.
Behavioral Manifestations/
Equivalents
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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.
Behavioral Manifestations/
Equivalents
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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
Case Example #1
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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
Case Example #1
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Flight of ideas/ pressured speech by constant
argumentativeness and false accusations
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Mood lability/irritability which turned into
threats to harm, verbal aggression and
physical aggression toward both peers and
staff
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Risk taking behavior which included
attempting to jump out of a moving vehicle
Case Example #1
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Grandiose delusions about family, children,
and money left to him in a will.
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Psychomotor agitation including constant
pacing and decreased need for sleep
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Excessive drive for the pleasurable
activities of making phone calls, collecting
others keys, and eating any available food to
the point of vomiting/diarrhea
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
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
Case Example # 2
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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.
Case Example # 3
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Adolescent diagnosed with Asperger’s disorder,
Tic disorder and Obsessive Compulsive
Disorder. Taking Paxil and Risperdal.
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Individual did not have OCD. Asperger’s traits
were inappropriately attributed to OCD.
Medication was discontinued and bimonthly
behavioral therapy was initiated.
Action Plan
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Staff Training
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Mental health disorders
Symptom identification/manifestations
Symptom tracking/ reporting
Team meeting prior to psychiatric
appointments
Treatment plans that address psychiatric
symptom management
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.
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
Conclusion
Questions & Answers
For More Information:
Peg Schwartz LSW
[email protected]
References
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Fletcher, R.,(2000) Therapy Approaches
for Persons with Mental Retardation:
NADD Press, Kingston, NY
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Gardner, W. Psychiatric disorders and
nonspecific behavioral symptoms.
Presented at NADD 14th Annual
Conference. 1997
References
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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.
References
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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, 593602.
References
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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.
References
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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
References
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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: 523527
References
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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
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