Transcript IDD and Mental Health: Communicating

Communicating Through
Behavior: Becoming
Better “Listeners”
Michael J. Parker, PhD
Clinical Director
IDD Eligibility, MHMR Tarrant
Medical, Behavioral, Psychiatric
Webinar
March 9, 2016
[email protected]
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Communicating Through Behavior
Learning Objectives
Attendees will:
1. Learn how people with limited language
constitute a diversity population
2. Identify meanings and functions of behaviors
3. Learn to identify mental health diagnoses
based on behavior
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Communicating Through Behavior
# 1:
Behavioral communication is
characteristic of a limited language
diversity population.
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Communicating Through Behavior
Language is far more than
communication.
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Communicating Through Behavior
Language regulates emotion.
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Limitations in oral language
leaves people prone to use
nonverbal means of
expression –
possibly with less inhibitory
control
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Communicating Through Behavior
Language is bound in culture.
Culture is a form of
community.
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Communicating Through Behavior
Being nonverbal is not the
same as lacking language.
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Communicating Through Behavior
Things to Remember:
 People who have limitations speaking tend to
act out.
 Acting out is not a substitution for language;
it is a language.
 Language is a form of interpersonal
relatedness.
 Behavior is an expression of preferences.
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Communicating Through Behavior
Objective 2:
Identify meanings and functions of
behaviors
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Communicating Through Behavior
What was your first behavior?
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Communicating Through Behavior
Examples of Common Reasons We Act:
• Catharsis
• Rejuvenation
• Social Acceptance
• Pleasure
• Satiation
• Nurturance
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Communicating Through Behavior
Just as there are multiple influences
upon how and why we act, there are
various schools of thought about how
and why we act.
Alfred Adler: Mental Health approach
People are “discouraged” rather than ill.
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Communicating Through Behavior
Alder’s 4 Motives
They can be either productive or “mistaken”.
 Attention
 Power
 Revenge
 Escape / Avoidance
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Communicating Through Behavior - Attention
Attention
The desire for attention is natural and normal.
People often mistake Attention as the motive
for a “misbehavior” because:
 All challenging behavior draws attention.
 The way to extinguish attention-seeking
behavior is to ignore it.
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Help!
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Communicating Through Behavior – Power
Power
The purpose of power is to get what you
want.
When a person uses power to dominate
others, to control them to gratify their own
wants at the expense of others, then it
becomes socially unacceptable.
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Communicating Through Behavior – Revenge
Revenge
Revenge is retaliation after being hurt.
While revenge is normally directed at the
perceived perpetrator, vengeance can be
displaced.
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Communicating Through Behavior – Escape
Escape / Avoidance
Escape is not about leaving a place or a task. The
intent is to avoid noxious feelings.
A person does not have to physically run away to
escape. A person can “tune out” or forget to show
up.
Examples of noxious feelings include fear [“Run
away!”], anxiety, worry, and discouragement.
A person can also push others away as a means of
escape.
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Communicating Through Behavior – Escape
Avoidance
In some models, Avoidance is viewed as
Inadequacy or Worthlessness.
Form this perspective, the person
actively pursues failure.
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Communicating Through Behavior
Activity
Imagine you’re sitting in a presentation.
A member of the audience stands up and makes very critical
remarks about the presentation. He tells the speaker why his
presentation is so weak. By showing his “superior knowledge” is
the person’s intent:
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to shift the focus of attention to himself?
to gain control of the session?
to get revenge for the agony he has endured?
to avoid being bored further?
As stated earlier, behaviors and their motives can be complex.
A behavior can fill more than one purpose.
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Communicating Through Behavior
Objective 3:
Identify mental health diagnoses
based on behavior
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Prevalence of Mental Health Issues
Approximately one-third of persons with IDD will be
identified with a comorbid mental health disorders during
their lifetime, and as many as 50% of children with IDD
will experience emotional problems.
NADD position paper. 2014.
• Accurate diagnosis is the foundation of effective
treatment.
• Symptoms of mental health disorders are often
displayed in different formats by persons with limited
ability for verbal self-report.
• With proper training, behaviors that otherwise impress
as aberrant may be recognized as ordinary in the
context of IDD and limited verbal language.
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Without proper training, diagnostic overshadowing can
result in important behavioral expressions, which are
actually reports of symptomology, being attributed to a
cause other than the true precipitating disorder.
Behavioral expressions of Major Depression, Bipolar
Disorder, Autism Spectrum Disorder and psychotic
features will be considered in order to facilitate accurate
diagnosis and case conceptualization.
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Communicating Through Behavior
Caution!
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What’s not Mental Illness
Things that are not Mental Illness
Always rule out medical causes.
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DSM vs. DM-ID: Mood Disorders
Factors Complicating Diagnosis in the IDD
Population:
“Internal” symptom criteria for diagnosis
 Difficulty relating abstract concepts with
limited or nonexistent expressive speech
Limited skills providing history
Similarity between problematic behaviors
and external symptoms of mental illness
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Communicating Through Behavior
Diagnostic Overshadowing
• Diagnostic overshadowing happens when a
person attributes behavioral, emotional and
social issues to one particular diagnosis while
not considering other possible reasons or
issues that might be the cause.
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Communicating Through Behavior
Diagnostic Overshadowing
• Diagnostic overshadowing occurs when a
professional allows one condition to
"overshadow" other aspects of the person and
thus fails to recognize symptoms or diagnoses
due to other conditions.
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Mental Health & IDD
Three Major Mental Illnesses frequently
experienced by persons with IDD:
Major Depression
Bipolar Disorder
Psychoses / Schizophrenia
Symptoms may present differently by people with
IDD compared to neurotypical people.
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Depression as Behavior
Depression
Depression is a mood, not a feeling.
It can be unipolar or bipolar; mild or major.
It has a global toxic impact on functioning.
Aaron Beck identified depression as
characterized by a negative view of:
• Self
• The world
• The future
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Depression as Behavior
“The 3 H’s”
Helpless * Hapless * Hopeless
 Doesn’t believe s/he can make things better.
 Life is miserable and there’s nothing good.
 Cannot see that things will ever get better.
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DSM vs. DM-ID: Major Depressive Episode
DSM-5 Criteria for Major Depressive Disorder:
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure
3. Significant weight loss or decrease or increase in
appetite
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or inappropriate guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death / suicidal ideation
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DSM vs. DM-ID: Major Depressive Episode
DM-ID Adapted Criteria:
Must include at least FOUR of the following
for a two week period:
Mood may be irritable OR depressed for
persons with IDD:
Depressed mood or irritable mood
*required*
Diminished interest or pleasure in almost
all activities *required*
Significant weight loss or gain without
dieting, or failure to gain weight in
children
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DSM vs. DM-ID: Major Depressive Episode
DM-ID Adapted Criteria (cont.):
Mood may be irritable OR depressed for
persons with IDD:
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive
guilt
Diminished ability to think or concentrate
Recurrent thoughts of death or suicide, or
a suicide attempt
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DSM vs. DM-ID: Manic Episode
DSM-IV Criteria for Manic Episode:
Mood must be elevated, expansive, or
irritable for at least 1 week (No duration is
required if hospitalization is necessary):
Plus three of the following (or four if mood
is only irritable):
Inflated self-esteem or grandiosity
More talkative than usual or pressure to
keep talking
Flight of ideas or racing thoughts
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DSM vs. DM-ID: Manic Episode
DSM-IV Criteria (cont.):
Plus three of the following (or four if mood
is only irritable) (cont.):
Easily distracted
Increase in goal-directed behavior
Excessive involvement in pleasurable, but
risky behaviors
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DSM vs. DM-ID: Manic Episode
DM-ID Adapted Criteria:
Mood must be elevated, expansive, or
irritable for at least 1 week (No duration is
required if hospitalization is necessary):
Plus TWO of the following for persons with
limited expressive language (or THREE if mood
is only irritable):
Inflated self-esteem or grandiosity
More talkative than usual or pressure to
keep talking
Flight of ideas or racing thoughts
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DSM vs. DM-ID: Manic Episode
DM-ID Adapted Criteria (cont.):
Plus TWO of the following for persons with
limited expressive language (or THREE if mood
is only irritable) (cont.):
Easily distracted
Increase in goal-directed behavior
Excessive involvement in pleasurable, but
risky behaviors
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IDD and Mood Disorders
Persons with IDD and a Mood Disorder are
more likely to:
Display obsessive-compulsive behaviors
Experience psychotic symptoms during mood
disturbances
Display anxiety with the mood disturbance
Demonstrate aggressive behaviors during a
mood disturbance
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Diagnoses Comorbid with IDD
Mental Status Examination addresses:
oAppearance
oMotor
oSpeech
oAffect
oThought Content
oThought Process
oPerception
oIntellect
oInsight
oInterpersonal
Relatedness
oSleep & Appetite
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Diagnoses Comorbid with IDD
Mental Status Exam: Items as Behavior
oAppearance
oIntellect
oSpeech
oEmotional
Expression
oThinking &
Perception
oInterpersonal
Relatedness
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Diagnoses Comorbid with IDD
Depression
Mood may be depressed or irritable for
persons with IDD:
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive
guilt
Diminished ability to think or concentrate
Recurrent thoughts of death or suicide, or
a suicide attempt
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Depression as Behavior
Appearance
• Neglect of appearance
• Decrease in grooming – uncombed hair, used to like to
have a fresh shirt on, now unclean clothes, wearing
the same thing, face not washed
• Decreased eye contact
• Staring off into space
• Staring down
• Also, no longer caring for belongings
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Depression as Behavior
Speech
• Limited
[Reduced verbalizations or vocalizations]
• Shrugs instead of talking
• Low volume
• Monotone
• Slow to respond
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Depression as Behavior
Interpersonal
• Withdrawn – avoids interacting
• Seems “aloof”
• Pushes people away – literally or with angry
words or acts
• Covers eyes or ears
• You may also see avoidance in the form of
hitting, pinching, shoving, etc.
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Depression as Behavior
Emotional Expression
• Sad Mood (This may present as Agitation or
Irritability.)
• Flat Affect – monotone voice & lack of facial
expression
• Loss of pleasure – Loss of ability to experience
pleasure [Anhedonia]
• Indifference – Does not want to do favorite
activities
• Statements of lowered Self-worth: “I bad.” “I
no good.”
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Depression as Behavior
Thinking & Perception
• Thoughts (acts) of harming self.
• World is a less interesting place.
• Lacks motivation. [Avolition]
“Get up!”
• Decreased Self-Esteem
[affects interpersonal relationships]
UNIQUE to Depression: “I am not worthy of being loved.”
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Depression as Behavior
Intellect
• Less able to figure things out (problem-solve)
• Impaired Memory
• Less able to Concentrate (stay on task)
• Poor memory & decreased concentration,
further reduce existing Low Frustration
Tolerance
• You may see it as “opposition” to complying
with requests.
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Depression as Behavior
Intellect
Less able to problem-solve:
Agitation (Pain) + low self-worth + reduced
frustration tolerance + decreased problem-solving
can lead to suicidal acts.
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Mental Health & IDD
Bipolar Disorder is frequently experienced by
persons with IDD.
What does Mania look like when a person has
ID?
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Mania as Behavior
Appearance
• Continued self-care BUT in a haphazard way
• Sloppy make-up
• “Weird” disheveled Hair & Clothing
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Mania as Behavior
Speech
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Pressured – very rapid
Boundless speech, cannot get to the point
Stream of thought inconsistent
“Flight of ideas”
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Mania as Behavior
Emotional Expression
Elated, Expansive Mood (may be irritable)
Intense “manic”
Boundless energy
Facial Expressions are extreme
Labile emotions – Rapid changes – sudden Crying or
Laughing – seemingly no reason.
• “Hair Trigger” Very easily annoyed or upset
• Irritable / Angry behavior
• Inflated Self-esteem “I’m the best in the world!”
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Mania as Behavior
Thinking & Perception
• Grandiose Ideas / Plans – relative to life experience
• Pleasure-seeking (Hedonistic Behavior) & Risk-taking
e.g., Binge Eating, Sexualized Behavior – “Streaking”
• Acts as if invincible
• Confusion
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Mania as Behavior
Intellect
• Internally Distractible
• Cannot attend or concentrate to complete tasks, even
preferred activities.
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Mania as Behavior
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Interpersonal
No one is a stranger
Immediate best friends
Unprotected sex
Gullible – take drugs
May object to you “rescuing” them.
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Autism
Autism “Spectrum” Disorder
DSM-5 Criteria:
• Deficits in communication and social interaction
• Poor back and forth conversation; fails to initiate or
respond to social interaction
• Impaired nonverbal communication (poor eye
contact, lack of gestures and facial expressions,
limited range or misuse of tone of voice, etc.)
• Deficits in developing and maintaining relationships
(lack of interest in others, cannot adjust behavior to
changing social contexts, lack of imaginative play)
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Autism
Limited and repetitive patterns of behavior,
interests and activities
• must have at least two of the following…
• Repetitive movements, speech, or use of objects
• Insistence on sameness; inflexible adherence to
routines and rituals
• Fixated interests that are very intense and overly
focused
• Unusually high or low sensitivity to the senses
(lighting, odors, textures, etc.)
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Autism
Things to consider when working with people with
Autism:
Poor eye contact, limited or odd speech, and lack of interest
in others is typical and does not necessarily indicate
noncompliance or avoidance.
Invasion of personal space usually does not indicate attempts
at aggression.
Socially inappropriate behavior typically does not suggest
attempts at attention or manipulation.
People with Autism are easily stressed and overstimulated.
Despite their limited speech, persons with Autism generally
understand a lot more than they are able to express.
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Communicating Through Behavior
Schizophrenia and Other
Psychotic Disorders
(Unfortunately the time allotted did not allow presentation
of this section during the webinar.)
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Communicating Through Behavior
What Can We Do?
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What Can Be Done
 Get to know the person.
 Understand what behaviors communicate.
 Teach additional ways to communicate.
 Share information across providers, staff,
and shifts.
 Ask people what they want.
 Offer people more opportunity – not just
forced choices.
 Meet social needs and the need for fun!
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What Can Be Done
 Schedule regular Dental and Physical exams.
 Accompany the person to appointments.
 Report significant changes to medication
managers, after ruling out situational factors.
 Treat your clients like people and not just
“consumers.”
 Prior planning – Focus on fixing the system
and not just the individual.
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Communicating Through Behavior
Thank you for your attention
and participation!
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