Transcript Identification of Co-Morbid Mental Health Issues in Autism Spectrum

Mental Health Aspects of
Individual’s with Intellectual and
Developmental Disabilities (IDD/MI)
John J. McGonigle, Ph.D.
Assistant Professor of Psychiatry
University of Pittsburgh, School of Medicine
Director, Western Region ASERT Collaborative
Center for Autism and Developmental Disorders
Western Psychiatric Institute and Clinic of UPMC
Overview
Past Practices / Current Directions in supporting people with
Intellectual Disabilities and co-occurring mental health
conditions
 Incorporating Wellness Recovery and Positive Approaches
Philosophies into the plan of support
 Assessing Psychopathology in Persons with Intellectual and
Developmental Disabilities (IDD/Behavioral Equivalents)
(DM/ID)
 Barriers to obtaining an accurate diagnosis
 Influence of mental health conditions on processing,
emotional regulation, impulse control and challenging
behavior
 The role of Functional Behavior Assessments (FBA) in
differentiating diagnoses
 Presenting behavioral health information to the psychiatrist
and Interdisciplinary team
2

Dual Diagnosis (IDD/MI)

Mental Illness and Intellectual Disability are two different
and distinct disabilities

Intellectual Disability is characterized by the interaction of a
person with limited intellectual ability and adaptive
behavior, with his/ her environment

Mental Illness refers to the severe disturbances of behavior,
mood, thought process and/ or social and interpersonal
relationships

A person who has a dual diagnosis IDD/MI has two separate
conditions, and each diagnosis requires identification and
have its own treatment or intervention plan.
What do we know about the Impact
of psychiatric co-morbidity
Increased health care utilizations and costs
Increase in staffing patterns and levels of support
increase likelihood of contact with police
Increase likelihood of multiple placements
Increase likelihood of admission to a psychiatric hospital
Higher potential for drug interactions due to use of
multiple medication
Increased likelihood of medical complications
changing times
Past practices:
Culture of control
Isolated (Behavioral Homes)
Current and Best Practice:
Recovery model / culture of care
Living with families
Protocols (one size fits all)
Holistic- Treatment is individualized
Control (no voice /choice)
Negotiation (WARP plan)
Supported Decision Making
Family/caregiver involvement
Inaccurate diagnosis
Old generation medication
(sedation)
More accurate diagnosis
New generation meds (reconciliation)
(diagnosis / symptom specific)
Chemical restraint
Symptom Focused Treatment
Behavior modification (reduce)
Positive Behavior Supports (increase)
Suppression / reduction
Teaching alternatives
Limited knowledge of etiology
Functional Behavior Assessments (FBA)
Past
Negative Approaches
negative consequences /restrictions
about control
teach the person
a lesson
coercive
doing to
teaches what not to do
we wouldn’t want
done to us
may further emotional
distress / trauma
Present
Positive Approaches
Therapeutic
Empowering (choice/options)
Transparency
supportive / educational
Influencing (choice/options)
doing with
teaches alternatives
we wouldn’t mind
if done to us
helps in recovery and
heals emotional wounds
Shared components of
Positive Approaches and the Recovery Model



•

Individualized and Person-Centered: recovery is based on
individual’s unique strengths and experiences
Empowered Decision Making: Feel valued - Individual’s
should have the opportunity to choose from range of
options and participate in all decisions
Holistic: recovery encompasses an individual’s whole life,
including mind, body, spirit, in the context of family and
community
Non-Linear: recovery is not a clear trajectory; it is a
continual growth and learning with occasional setbacks.
People need opportunities to develop their ability to
restrain their impulses and gain self control
Strength-Based: focus is on building on the person’s
inherent strengths
Shared components of
Positive Approaches and the Recovery Model




Peer Support: Certified Peer Specialist / Peer Mentors /
Peer Supports – Individuals and families that have
accessed behavioral health services encourage and
engage other individuals in the recovery process or
navigating the system
Respect and Dignity: protecting individual’s rights and
eliminating discrimination and stigma
Responsibility: People need choices and may need
guidance in developing responsibility for their choices
towards their goals
Hope: providing motivating message of overcoming
barriers and having a better future
Individuals with Intellectual and Developmental
Disabilities are a highly heterogeneous groups, and
there is great clinical variability seen within each person.

No two individuals are alike

Treatments and support services need to be
individualized and specific to each person, family and
support systems

Treatment is often multi-faceted and requires a cross
systems collaboration and a Interdisciplinary team
approach

Accurate diagnosis and treatment require, expertise,
time, patience and team work
Why is diagnosis important?
• Provides a common understanding of a condition
and how it is typically treated
• Diagnosis helps tailor the treatment plan and medical
management to each of the identified conditions
• Assists the person and family with education and
recovery
• Matches data collection / analysis to the presenting
concerns
• Necessary for reimbursement
Complexity
Health/
Medical
Mental Health
Life
Experiences
Genetics
Trauma
Neurological
Holistic Approach for Individuals with Dual Diagnoses and Complex Needs
Family
Thinking / Processing / Learning
Residence /Community
Environment / Home
Emotion/ Mental Health
Co-occurring
Emotional regulation
Developmental
Communication
Sensory
Diet /Nutrition
Spirituality
Interests / values
Assessment
of IDD/MI
Medical
Genetics / Pain
Behavior
Person / caregiver
interactions
Vocation / Employment
Education / School
Bonding / Friendships / Gender/ Relating
Bio-Psycho-Social - Holistic and Individual Approach
Medical / and Basic Health conditions
Family History (including Genetics)
Medication Reconciliation – (effects and side effects and drug interactions)
Psychological / Neuropsychological Evaluation - Learning style
Developmental - Cognitive Profile that includes strengths and weaknesses
Mental Health conditions (co-occurring)
Neurodiagnostics (if indicated) (EEG/f-MRI/CT)
Communication-SP/L
Trauma / Abuse – Trauma Assessments
Sensory domains - OT
Psycho-social Stressors: Problems with primary support group, social environment,
housing, work, access to medical care
Relationships / Sexuality / Gender
Cultural (dietary / religion / celebrations)
Environmental / Life space
Functional Behavior Assessments and Positive Behaviors Support/
Person Centered / Self Determination / Self Advocacy
Areas of concern in the evaluation of person’s
with IDD and co-occurring mental health challenges
• Importance of Initial and Ongoing Assessments
• Variability of the person’s presentation
• Understanding what the presenting symptoms and/or
Challenging Behaviors (CB) means to the person
• Understanding the complex needs of the individual
(most cases individual’s Dual Diagnoses are involved in three
or more service areas) Medical, MH, ID, Education/OVR,
D&A, Justice
• Critical need for partnerships to ensure success
Variables to consider in the Diagnostic Assessment
Challenging Behaviors and Mental Health Symptoms
 Biological Risk Factors (Behavioral Phenotypes)
 Developmental Risk Factors
 Psychological Risk Factors
Overlap between psychiatric symptoms
and Challenging Behaviors
Etiology
Expressions of Depression
Aggression
Physical/verbal
Oppositional
Agitation
yelling/screaming
Self Injury
self talk
Depression in Autism and Asperger’s Syndrome
Sterling, L., Dawson, G., Estes, A. & Greenson, J. (2008).
Diagnostic areas of concerns with depression overlap with some of the
core features of Autism Spectrum Disorder (ASD)
Neurovegatative, (peculiar eating / sleeping habits)
Affective (flat affect / withdraw / isolative / crying episodes)
Changes in verbal and nonverbal communication (perseverate,
echolalia, selective mutism)
Anxiety (rituals / routines/ Obsession / Compulsions)
Clinical Interview should focus on onset / regressions of symptoms and
behaviors
Clinicians working with Intellectual Disabilities are prone
to two types of errors Ghaziuddin (2005)
1. Fail to identify the presence of a mental health
problem
• Decomposition – addition of other psychiatric symptoms
• Isolation - Restrictive Interventions - Hospitalization
2. Risk of making and inaccurate diagnosis
•Increase in challenging behaviors
•Increase in medication PRN’s and (polypharmacy)
Factors that influencing an accurate Psychiatric Diagnosis in
persons with Intellectual and Developmental Disabilities
Belief that persons with Intellectual Disabilities can not have
Mental Illness
Having an Intellectual Disability does not cause mental illness
The psychiatrist can not secure an accurate diagnosis without
relying on the persons self report and input from a variety of
sources
The psychiatrist / psychologist must formulate the diagnosis
alone in one 45 minute office visit
“Diagnostic Overshadowing” All problems are related to the
Intellectual Disability (Down’s Syndrome, Autism, cognitive
Impairment)
Clinical issues for IDD across age groups
Clinical Issues
Lovell & Reiss (1993)
Intellectual distortion – person is unable to label
and report on his/ her own experience (feelings to words)
Psychosocial masking – as a result of improvised social skills,
mis-assumption of nervous and illness as psychiatric
symptoms (anxiety / paranoia)
Cognitive disintegration – a stress induced disruption of
information processing that presents as psychotic features
(self talk, or imaginary friend, thinking out loud)
More common types of psychiatric diagnoses in IDD








Depression and Mood Disorders
Anxiety Disorders (General, Social Anxiety, Social Phobia,
Separation Anxiety D/O and OCD)
Intermittent and Impulse Control Disorders
Post Traumatic Stress Disorders (PTSD)
Adjustment Disorder
Schizoaffective and Schizophrenia Spectrum Disorders
Stereotypy / Movement Disorders
Personality Disorders (Histrionic and Borderline)
Diagnostic Principles
adapted from Sovner & Hurley (1989)
 Person’s with developmental disabilities suffer from the
full range of mental health conditions
 Psychiatric target symptoms usually present as
challenging behavior
 The origin of psychopathology (atypical behavior) is multidetermined
 Acute psychiatric symptoms may present as an
exaggeration of a longstanding challenging behavior
Diagnostic Principles
A target symptom or Challenging Behavior rarely occurs
alone or in the absence of other symptoms
The severity of the target symptom or challenging
behavior is not diagnostically relevant
The clinical interview alone is rarely diagnostic
It is extremely challenging to diagnose psychotic disorders
in persons who are nonverbal and have significant cognitive
impairment
DSM-5 Diagnostic Symptoms
and
IDD and Behavioral Equivalents
• Looks are deceiving
• What you see is not always what you get
Types of Symptoms
Neurovegetative: Sleep difficulties, changes in appetite,
weight loss or gain
Affective: Sadness, euphoria, grandiosity, mood swings,
decreased interest in pleasurable activities or excess
interest.
Cognitive/processing: Difficulty in concentrating, planning,
distractibility, short term memory and problem solving
Perceptual: Distorted thoughts , delusions, hallucinations,
racing thoughts
Behavior: Aggression, self injury, loss of ADL’s, changes in
speech patterns (volume, rate)
Mood Disorders in IDD
Depression - behavioral equivalents

depressed, irritable -
 decreased smiling; increased whining, short fuse,
negative response to requests, everything rubs the person
the wrong way
 decreased interests  decreased responses to preferred activity and passions;
increased time spent in room or alone (isolation).
For some subtle sings could be not carrying around
preferred items (magic markers)
 decreased, increased appetite  Fixate on measured weight (125 lbs), meal portions

decreased, increased sleep  sleep chart
Depression continued - behavioral equivalents

activity -slowed or agitated (aggression, SIB)
Increase in verbal confrontations, pacing, perseveration,
verbalizing, rituals that may do physical harm to the
person

worthlessness, negative self esteem -
verbalizations “I’m no good” “retarded” “marshmallow”

decreased concentration -
Failing grades, school, workshop performance, not
completing homework

death, suicidal thoughts -
focus on people who have died in the past,
perseveration on videos with dangerous acts
talk about not wanting to live or wish I was never born
Mania - behavioral equivalents

euphoric, elevated mood or irritable -
increased smiling, silly, spontaneous laughing, self
injury and self mutilation (tattoos / body piercing)

grandiose -
inappropriate inflated self esteem / know it all,
comparing self to celebrity status (Michael Jackson, Fire
Fighter/EMS)

decreased sleep -
Up all night on Internet (addiction), increased
preoccupation in passions - sleep chart

pressured, rapid speech -
changes in prosody (rate, volume), increased swearing,
singing, repeating end of sentences, stuttering
Mania continued - behavioral equivalents

racing thoughts rapid, disorganized speech and ideas
stammering, stuttering, sentences run together, end or
words are not clear or repeat

distractibility decrease in school performance and work productivity.
Decrease in grades pay checks are less

agitation increased negativism, aggression, immediate refusal on
demand and requests, including medications
• hypersexualincreased teasing, sexual behaviors (masturbation), stalking
(both male and female), physical intrusiveness, explicit sexual
conversations, Internet Porn and Sexting
Psychopathology Screening Questions Sovner

Is there a significant change in the person’s behavior or
mood that occurs in all settings rather than in some
settings? Home, day program, school, community

Is there little or no improvement in the person’s
behavior despite the application of consistent, high
quality behavior intervention?

Has the person experienced a decreased ability to adapt
to the demands of daily living (e.g., decrease in self care
and ADL’s)?

Has the person had an overall change in affect (the way
the person looks)? (Sad, bright eyed)
Psychopathology Screening Questions
continued

Has the person experienced a decrease in involvement
with others?

Has the person lost interest in previously preferred
activities?

Has the person had an overall change (increase or
decrease) in motivation levels?

Has the person shown/ expressed impairments in his/ her
perception of reality such as, responding to internal
stimuli (voices or false beliefs)?
Influence of Mental Health Conditions on Processing
Input
taking in information
Processing
comprehending the information
Output
translating into actions
Executive Functioning Deficits
Emotional Regulation and Impulse Control
Typically diagnosed with Impulse Control Disorder
or Intermittent Explosive Disorders
•Behavioral Flexibility
•Internal level of Arousal
•Impulse Control
Emotional Regulation and Impulse Control
Input
Setting
Events
Directives
People
Internal
Process
Output
Thoughts
Emotion
Perception
Clear
Internal Arousal
Increases
Behavior
Aggression
Self Injury
noncompliance
Decrease threshold
for Impulsivity
Role of Functional Behavior Assessments (FBA)
in Diagnostic Assessments
Functional Behavior Assessments (FBA)
in Differential Diagnosis
Behavior
Person
Environment
Most common Challenging Behaviors studied using FBA
Matson (2011)
 Self Injurious Behavior
 Aggression
 Stereotypies
 Tantrums
 Destruction of property
 Inappropriate speech / vocal tics
 Inappropriate meal time /food refusal /pica
 Noncompliance
Functions commonly reported in the behavioral literature
Attention
 Escape / Avoidance
 Gaining access to tangibles
 Sensory / alone / non social

Motivations / Etiology for Behavioral Concerns
Biological (Genetics – Behavioral Phenotypes)
• Physiological (Hunger, Thirst, Pain)
• Medical (Dental, Seizures, Apnea, IBS, Hypoglycemia)
• Psychiatric / Emotional / Behavioral (internal / psychoses)
• Medication (Side Effects)
• Developmental Delay
• Communication (Expressive / Receptive)
• Trauma
• Environment (including caregiver interactions)
• Cognitive / Executive Functioning Deficits (Processing)
• Social Skills Deficits
• Attention (gaining access to preferred items)
• Escape Avoidance (unpleasant situations / experiences)
•
•
Sensory (Repetitive Behavior patterns including Self Stimulation)
Functional Behavior Assessments (FBA)
in Differentiating Diagnosis
Using FBA in the assessment of the unobservable
When in Doubt – Rule it Out
Functional Assessment Recording Sheet
NAME: __________________________
date / time
location
when behavior
was noticed
Who was
there at time
of behavior?
activity
antecedent
Analyses
What happen
before behavior?
behavior
Analyses
Describe the
behavior
consequence
Analyses
What was done
when behavior was
noticed
Results
What
happened to
the
behavior?
Tics versus Self Stimulation and Repetitive Behavior patterns
Tics
• Brief and Intermittent
Stereotypies
Rhythmic and slower
• Face, neck, shoulders, arms and
whole body when complex
Whole body, head, trunk,
hands and fingers
• Not purposeful
May be purposeful
• Waxing and waning
More stable over time
• Urge and premonitory sensations
No premonitory sensation
Treatment Principles

Step 1: Conduct Functional Behavior
Assessment

Step 2: Develop Hypothesis about the etiology
of the Mental Health Symptoms / Challenging
Behavior

Step 3: Select a medication or behavioral
intervention which is directed to the primary
cause of the persons symptoms or challenging
behavior
Treatment Principles
continued

Step 4: Specify what will constitute a
therapeutic trial of selected drug or adequate
response time for a behavior plan to take effect

Step5: Start treatment / intervention only after
an objective monitoring system is in place

Step 6: Decide in advance what will constitute a
positive treatment response
Example: Habilitative /Treatment/Support Plan Matrix
Name: _____________
Target Symptom
Challenging Behavior
PTSD
Flashbacks
Self-Injury
Cutting wrist
Goals
Improve coping skills
Reduce Flashbacks
Keeping self-safe and
healthy
Reduce self-harm
Poor Impulse Control
Yelling
Screaming
Partial Complex
Seizure D/O
Depression
Impulse Control D/O
Anxiety D/O
PTSD
Family / Home Visits
Improve coping skills
Seizure Control
Reduce Depressive
Symptoms
Begin 2 hour visit on
weekends
Method
Habilitation
Treatment
Individual
Trauma Focused Therapy
Positive Behavior
Support Plan
Positive Behavior Support Plan
Anger Management
Staff Training
Depakote
Celexa
Klonopin
Inderal
Prepare preferred activities
Have safety plan in place
How often and
Date of
Person providing the service Review
or support
2 X weekly
Dr. Johnson
Outpatient Clinic
Direct Support staff
24X7
Residential Program
Behavior Specialist
BCBA
Weekly Home Visits
Support staff
Residential program
Neurologist
Monthly
Neurology Clinic
Dr. Roberts
Psychiatrist
Monthly visit
Clinic
Immediate and extended
family
Residential staff
Goal
Completed
__yes
__no
Date: ___
Wellness Toolbox
Wellness Toolbox – A list of resources used to develop your WRAP. It includes things like:
contacting family, friends and supporters (including peer mentors) and community resources.
Addresses all life domains including; relaxation and stress reduction techniques, physical
exercise, diet, light, spirituality and getting a good night’s sleep.
Triggers – External events or circumstances that, if they occur, cause increase stress and anxiety may
that can be expressed in an exacerbation in negative symptoms or challenging behavior..
Early Warning Signs – Internal, subtle signs that let you know you are beginning to feel worse.
Reviewing Early Warning Signs regularly helps us to become more aware of them and allow us to take
action before the person begins to decompensate.
When Things are Breaking Down – List subtle signs or behaviors that let you know you that there are
emotional and behavioral changes occurring, like feeling sad all the time, staying in your room, yelling
or are hearing voices. Using the Wellness Toolbox, can help develop an action plan to help you feel
better and prevent an even more difficult time.
Crisis Plan – Identify signs that let others know they need to take over responsibility for your care and
decision making. Outline a plan for who you want to take over and support you through this time,
healthcare, staying home, things others can do to help and things they might choose to do that would
not be helpful. This kind of proactive advanced planning keeps you in control even when it seems like
things
47 are out of control.
Case Presentations
Presenting Information to the
Interdisciplinary Team
Things to consider
Organizing your information before meeting with the
Interdisciplinary team
 Know the team members and their roles in supporting the
individual and family
 Understand the importance of defining collecting
information on mental health symptoms and challenging
behaviors
 Make sure everyone is speaking the same language
 Understand the importance of being part of a team and
communicating accurate information with the each
member
 Inaccurate information can result in increase in both
symptoms and unwanted behavior
 If you do not understand or disagree be respectful in
challenging the team member

Psychiatric Story
Psychiatric Diagnosis
Bipolar Disorder
Symptoms / Behaviors
Depression Symptoms – looks sad, wanting to be
alone, picking scabs / infections
Manic Symptoms – rapid speech, Physical
Intrusiveness (touching / grabbing others),
decrease sleep
Anxiety Disorder
Worrying about getting ill
Panic attacks (trouble breathing)
Heart racing
Intermittent Explosive Disorder
Banging Head
Throwing Furniture / Breaking Windows
Providing Good Clinical Care includes:
Establishing trust between all partners
 Respect the opinions of all team members
 Be consistent and predictable
 Include the consumer and family in developing the plan
 Secure expertise when necessary (consultants)
 Communicate / Disseminate latest research and treatment
information
 Treatment is fully intergraded with other disciplines
(medicine neurology, sleep, GI)
 Treatment plans are team based and developed in the
Positive Approaches Philosophy
 Treatment plans are team based and developed in Positive
Behavior Supports
 Be Creative / Think out of the box
 Team work

Questions and Answers
References
Aman, M. G., Lam, K. S. L., & Collier-Crespin, A. (2003).Prevalence and patterns of use of psychoactive
medicines among individuals with autism in the Autism Society of Ohio. Journal of Autism and Developmental
Disorders, 33,527–534
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.
Briere, J., Johnson, K., Bissada, A., Damon, L., Crouch, J., Gil, E., Hanson, R., & Ernst, V. (2001). The Trauma
Symptom Checklist for Young Children (TSCYC): Reliability and association with abuse exposure in a multi-site
study. Child Abuse & Neglect: The International Journal, 25, 1001-1014.
Bonfardin, B., Zimmerman, A., & Gaus, V. (2007). In R.Fletcher, E. Loschen, C. Stavrakaki, & M.First (Eds.),
Pervasive Developmental Disorders. Diagnostic Manual – Intellectual Disability: The Text Book of Diagnosis of
Mental Disorders in Persons with Intellectual Disability, New York, NADD Publishing.
Brereton, A. V., Tonge, B. J., & Einfeld, S. L. (2006). Psychopathology in Children And Adolescents with Autism
Compared to Young People with Intellectual Disability. Journal of Autism and Developmental Disorders, 36, 863870.
Campbell, M., Locascio J., Choroco, M. C., Spencer, E. K., Malone, R. P., Kafantaris, V., & Overall, J. E. (1990).
Stereotypies and tardive dyskinesia: Abnormal movements in autistic children. Psychopharmacology Bulletin, 26,
260–266.
Copeland, M.E., (2014). A Wrap Workbook: For people with Developmental Distinctions. Peach Press
Publishing, Vermont.
References
De Bruin, E. I., Ferdinand, R.F., Meester, S. de Nijs, P. F. A., Verheij, F. (2007). High rates of Psychiatric CoMorbidity in PDD-NOS. Journal of Autism and Developmental Disorders, 37, 877-886.
Fuller, C., & Sabatino, D. (1998). Diagnosis and treatment considerations with developmentally disabled
populations. Journal of Clinical Psychology, 54, 1-10.
Ghaziuddin, M. (2002). Asperger’s Syndrome: Associated Psychiatric and Medical Conditions. Focus on Autism
and Other Developmental Disorders, 17(3),138-144.
Gillott, A. Furniss, F. & Walter, A. (2001). Anxiety in High Functioning Children with Autism. Autism, 5 (3), 277286.
Holden, B., & Gitlessen, J., P. (2008). The relationship between psychiatric symptomology and motivation of
challenging behavior: A preliminary study. Research in Developmental Disabilities, 29, 408-413.
Hurley, A., Tomasulo, D., & Pfadt, A. (1998). Individual and group psychotherapy approaches for persons with
intellectual disabilities and developmental disabilities. Journal of Developmental and Physical Disabilities, 10,
365-386.
Iwata, B. A., Dorsey, M. F., Stifler, K. J., Bauman, K. E., & Richman, G. S. (1982). Toward a Functional Analysis
of Self-Injury. Journal of Applied Behavior Analysis, 27, 197-209.
Iwata, B., A., et.al. (1994). The Functions of Self-Injurious Behavior: An Experimental- Epidemiological Analysis,
Journal of Applied Behavior Analysis, 27, 215-240.
References
Kim, J. A. Szartmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The Prevalence of Anxiety and Mood
Problems Among Children with Autism and Asperger Syndrome. Autism, 4 (2) 117-132.
Lainhart, J. E. (1999). Psychiatric problems in individuals with autism, their parents and siblings. International
Review of Psychiatry, 11, 278-298.
Leyfer, O. T., Folstein, S. E., bacalman, S., Davis, N. O., Tager-Flusberg, H., & Lainhart, J. E., (2006)
Comorbid Psychiatric Disorders in Children with Autism: Interview Developmental and Rates of the Disorder.
Journal Of Autism and Developmental Disorders, 36, 849-861.
Lowell , R., W., & Reiss, A., L. (1993). Dual diagnoses. Psychiatric disorders in developmental disabilities.
Pediatric Clinics of North America, 40, 579 – 592.
Masi, G., Brovedani, P., Mucci, M., & Favilla, L. (2002). Assessment of Anxiety and Depression in Adolescents
with Mental Retardation. Child Psychiatry and Human Development, 32, 227-237.
Matson, J. L., & Minshawi, N.,F. (2006). Functional Assessment of challenging behavior: Toward a strategy for
applied settings. Research in Developmental Disabilities, 28, 353- 361.
Matson, J. L., Sipes, M., Horovitz, M., Worley, J. Shoemaker, M. E., & Kozlowski, A. M. (2011). Behaviors and
Corresponding functions addressed via functional assessment, Research in Developmental Disabilities, 32, 625629.
References
Melville, C., A., Cooper, S., A., Morrison, J., Smiley, E., Allan, L., Jackson, A., Finlayson, J. Mantry, D. (2008).
The Prevalence and Incidence of Mental Ill-Health in Adults with Autism and Intellectual Disabilities, Journal of
Autism and Developmental Disorders, 38, 1676-1688.
McBrien, J., A. (2003). Assessment and diagnosis of depression in people with intellectual disability. Journal of
Intellectual Disability Research, 47, 1-13.
Muris, P., Steerneman, P., Merckelbach, H., Holdrinet, I., & Meesters, C. (1998). Co-morbid anxiety symptoms in
children with pervasive developmental disorder. Journal of Anxiety Disorders, 12, 387-393.
Prout, R., & Nowak-Drabik, K., M. (2003). Psychotherapy with persons who have mental retardation: An
evaluation of effectiveness. American Journal on Mental Retardation, 108,82-93.
Rojahn, J., Matson, J., L., Lott, D., Ebsensen, A., J., & Smalls, Y. (2001). The Behavior problems Inventory: An
Instrument for the assessment of Self-Injury, stereotyped behavior and aggression/destruction in individual with
developmental disabilities. Journal of Autism and Developmental Disorders, 31, 577-588.
Rush, A., J., &Frances, A. (2000). Treatment of Psychiatric and Behavioral Problems in Mental Retardation:
Expert Consensus Guideline Series. American Journal on Mental Retardation, 105, (3), 165-188.
Rush, K., S., Bowman, L., G., Eidman, S,. L. Toole, L., & Mortenson, B., P. (2004). Assessing Psychopathology
in Individuals with Developmental Disabilities. Behavior Modification, 28, 621-637.
Reference
Scahill, L., McDougle, C. J., Williams, S., Dimitripoulos, A.,Aman, M. G., McCracken, J., Tierney, E., Arnold, L.
E.,Cronin, P., Koenig, K., Kohn, A., Lam, K. S. L., & Vitiello,B. (in press). The Children’s Yale-Brown ObsessiveCompulsive Scale modified for Pervasive Developmental Disorders. Journal of the American Academy of Child
and Adolescent Psychiatry.
Shay, J., Sanchez, L., Cueva, J., Armenteros, J., Overall, J., & Campbell, M. (1993). Neuroleptic-related
dyskinesia and stereotypies in autistic children. Psychopharmacology Bulletin, 29, 359–363.
Sterling, L., Dawson, G., Estes, A. & Greenson, J. (2008). Characteristics Associated with Presence of
Depressive Symptoms in Adults with Autism Spectrum Disorders, Journal of Autism and Developmental Disorders
38, 1011-1018.
Sovner, R., & Hurley, A.D. (1983). Do the mentally retarded suffer from affective illness? Archives of General
Psychiatry, 40, 61-67.
Sturmey, P. (2002). Mental retardation and concurrent psychiatric disorder: assessment and treatment. Current
Opinion in Psychiatry, 15, 489-495.
Tsiouris, J.,A., (2001). Diagnosis of depression in people with severe / profound intellectual disability.
Journal of Intellectual Disability Research, 45, 115- 120.
Van der Putten, A., & Vlaskamp, C. (2011). Pain assessment in people with profound intellectual and multiple
disabilities; a pilot study into the use of the pain behaviour Checklist in everyday practice. Research in
Developmental Disabilities, 32, 1677 – 1684.
Whiatker, S., & Read, S. (2006). The Prevalence of Psychiatric Disorders among People with Intellectual
Disabilities: An Analysis of The Literature. Journal of Applied Research in Intellectual Disabilities, 19, 330-345.