Transcript Children with co-occurring Developmental Diagnoses and

Children with co-occurring
Developmental Diagnoses and
Mental Health Disorders
EMHI
1/26/2011
Penny Knapp MD
[email protected]
Outline
I.
II.
III.
IV.
V.
VI.
ETIOLOGIES OF DD/DI
OVERLAP of DD/DI WITH SED
SCREENING
DIAGNOSIS
TREATMENT
CA SERVICES
I - ETIOLOGIES OF DD/DI
• Genetic
• Intra-uterine toxins: alcohol, nicotine,
cannabis
• Acquired Childhood Diseases
--infection (HIV, meningitis, encephalitis)
--cranial trauma (automobile accident,
shaken baby syndrome)
• Other (asphyxia, near drowning,
intoxications)
QuickTime™ and a
decompressor
are needed to see this picture.
Fetal Alcohol Syndrome: FAS
• FAS is the most frequent preventable
cause of MR
• But, most individuals with FAS are not
retarded; only 25% have IQ < 70
• Children with more dysmorphic features
tend to have lower IQ scores.
Cognitive and behavioral
features in FASD
• Impairment of both verbal and nonverbal learning &
memory.
• Language: marked deficits in word comprehension &
naming ability.
• Attention (often meet criteria for ADHD), visuo-spatial
and executive function impairment
• Motor: fine and gross motor
• Adaptive functioning: social, aggression, beyond
what can be explained by low IQ
Mental Health problems in
FAS (90%)
Conduct problems in school >60%
 Trouble with the law or incarceration 4560%
 Alcohol or drug dependence 30-45%
 Dependent living >80%

II - OVERLAP of DD/DI WITH
SED
• Mental disorders more common in persons
with DD/ID than general population.
• The disorders themselves are essentially the
same - hence use DSM IV-TR (or after 2012,
DSM-V.
• Clinical presentations may be modified by
poor language skills & life circumstances, so
DX might derive more from report &
observable behavioral symptoms.
III - SCREENING
• Standardized tools should be used
• (e.g. ASQ, ASQ-SE, PEDs, PEDS DM,
MCHAT)
• AAP has published algorithms for
screening/treating developmental disorders
(PEDIATRICS 2001,2006) and mental health
disorders (2010)
• http://pediatrics.aappublications.org/content/vol12
5/Supplement_3 plus toolkit - see AAP.org
• California First 5 Special Needs project has
developed a protocol:
Statewide Screening
Collaborative
• The CSSC is supported via facilitation & TA
provided by First 5 California, CDPH, MCAH,
and the WestEd Center for Prevention and
Early Intervention (CPEI).
• Participating agencies and organizations
include state &local public and private entities
concerned with early childhood health, mental
health, child development, developmental
disabilities, and social services.
• http://www.cdph.ca.gov/programs/ECCS/Pag
es/StatewideScreeningCollaborative.aspx
Comorbidity of MR and mental
illness
• PDD, ADHD, CD, Tic disorders, stereotypic
movement disorders, Schizophrenia, Mood
disorders, Anxiety disorders, PTSD, OCD,
Eating disorders, Personality disorders
Practice Parameters for the Assessment and Treatment
of Children, Adolescents, and Adults With Mental
Retardation and Comorbid Mental Disorders. J. Am.
Acad. Child Adolesc. Psychiatry, 1999, 38 (12
Supplement):5S-31S.
Virtual DD/ID?
Environmental Problems and Behavioral
Syndromes can interfere with normal
development
• Psychosocial deprivation
• Neglect & attachment disorders
• Maltreatment
• Emotional and behavioral disorders
Evaluation should include both development
and social-emotional development
Developmental Disorders that may not
have developmental delay
Autistic spectrum
• Aspergers syndrome, high-functioning PDD
• Multisystem Developmental Disorder (MSDD)
- sensorimotor, attention & organization,
regulatory, communication development
problems with autistic features
• http://www.dbpeds.org/articles/detail.cfm?Text
ID=96).
IV - DIAGNOSIS
• Dx assessment synthesizes biological,
psychological and psychosocial context
of mental disorders for….
• ….comprehensive Tx planning
integrating family counseling,
pharmacological, educational,
habilitative, and milieu interventions
AACAP (1999) Practice Parameters
Rating scales
Standardized scales should be used: examples:
• Reiss Screen for Maladaptive Behavior
8 psychopathology scales, 6 maladaptive
behavior scales. Total core helps discriminate
if a psych. DX.
• Aberrant Behavior Checklist (ABC)
58 items rating behaviors --> 5 subscales,
informant-based (useful w non-verbal pts)
DM-ID
• The Diagnostic Manual – Intellectual Disability
(DM-ID): A Textbook of Diagnosis of Mental
Disorders in Persons with Intellectual Disability,
developed by the National Association for the
Dually Diagnosed (NADD) with (APA), is a
diagnostic manual designed to be an adaptation of
the DSM-IV-TR.
• Diagnostic Manual – Intellectual Disability (DMID): A Clinical Guide for Diagnosis of Mental
Disorders in Persons with Intellectual Disability,
has been abridged for clinical usefulness.
DM-ID (2)
Derived from literature review, evidence base,
and expert consensus.
Response to these problems:
• Individuals with ID are 2-4x likelier to have
psychiatric disorders
• Self report (per DSM) is compromised by
verbal limitations, “cloak of competence,”
“acquiescence bias”, intellectual distortion,
psychosocial masking & cognitive
disintegration.
Adapted criteria – example
Major Depressive Episode
DSM-TR: 4 or more of the following symptoms
1 depressed mood, loss of interest
• Adapted criteria : observable signs, e.g. sad
facial expression, flat affect,, appearing angry,
agitated
2 diminished interest in activities (no adaptation)
3 significant (5%) weight loss (in children, failure
of expected weight gain) (no adaptation or
possibly agitation or obsession about food)
4 Insomnia etc (no adaptation)
DM-ID, Major Depression,
continued
5 Psychomotor agitation (no adaptation,
but add reported behavior)
6 Fatigue, loss of energy (no adaptation)
7 Feelings of worthlessness or
excessive guilt (no adaptation, but
observers may note negative selfstatements etc)
Behavioral Phenotypes of
genetic disorders
• Specific and characteristic behavior
repertoire exhibited by patients with a
genetic or chromosomal disorder.
• Consistently associated with the
condition
Donna (2 years)
•
•
•
•
“Stubborn”
Attention problems
Non-compliant
Repeats certain
actions, has to
arrange things in
certain ways
• Delayed language
Trisomy 21
• Developmental language delay
• Expressive language more affected
than receptive
• Good language pragmatics
• Visual processing better than auditory
Trisomy 21
• SIB, injury of others
• Difficulty acquiring new skills
• Challenging behavior that causes social
isolation
• Anxiety, depression, withdrawal
Trisomy 21 - Medical
• Congenital Heart disease (up to 50%): AV
septal defects, VSD, PDA, other)
• GI - duodenal atresia (2%), Hirschsprung
disease
• Hearing loss (40-75%)
• Eye disorders (60%)
• Leukemia 1:150
• Thyroid disorders (occasional)
Medical Checklist
www.ndsccenter.org/resources/healthcare.pdf
Why study behavioral
phenotypes?
• Helps DBPs and CHPs to identify
conditions, make referrals for genetic
diagnosis and counseling
• treatment planning
• contribute to research and syndrome
delineation.
Moldavsky - J. Am. Acad. Child Adolesc.
Psychiatry, 2001, 40(7):749-761.
Understanding genetic
underpinning of behavior
• Altered genetics --> metabolism of
neurotransmitters or their receptors (e.g.
influence of MAO-A/B on aggression)
• Genetic influence on brain development (e.g.
altered temporal lobe, decreased vermis in
Fragile X)
• Abnormal hormonal influence on brain
development (e.g. Turners)
V - TREATMENT
•
•
•
•
Treatment planning
Behavioral emergencies
Psychosocial interventions
Pharmacotherapy
Treatment Planning
Children 0-3 years:
• Develop individual family service plan (IFSP)
• Early Intervention (EI) through local RC
• Provide supportive services: physical therapy
(PT), occupational therapy (OT), speech and
language (S/L) as needed
Children 3 years and older:
• transition from IFSP to school-based services
-provide an individualized education plan
(IEP)
• continue PT, OT, S/L as needed
Behavioral Emergencies
• Ensure safety first
• Evaluate medical causes (e.g. constipation,
infection --> irritability --> crisis)
• Evaluate if adverse effects of existing
medications
• Consider Rx medications that worked in past.
• Evaluate/re-evaluate environmental triggers
• Plan to prevent recurrence of crises
Psychosocial interventions
Tailor the modality to the patient e.g.
psychotherapy (if verbal), group
therapy, milieu interventions, behavioral
(e.g. ABA, PBS)
Parent support & parent-to-parent
networking
Parents
• Confusion - alleviate with solid
information
• Stigma, guilt, apprehension
• Isolation - alleviate with parent
networking
• Difficulty finding services - assist,
advocate
• Extra challenges navigating
adolescence
Psychopharmacology
• Review nonpsychiatric drugs that may
--> behavioral or emotional symptoms, e.g. beta
blockers, which may --> depressive
symptoms, and phenobarbital (epilepsy) -->
may result in impulsive, aggressive behavior.
• “The medication evaluation:” avoid
“affectionless control” that interferes with
capacity; incorporate review with team of the
whole patient.
Medication for DD/ID
• Before RX: rule out non-psych causes of
behavior, collect behavioral data, consider
least intrusive intervention (may be
medication).
• When prescribing:
• Integrate with overall treatment
• Do not diminish functional status
• Use lowest effective dose
• Monitor outcomes
IV Services in CA public
system
• Eligibility for RS services: disability that begins
before 18th birthday, expected to continue
indefinitely and --> substantial disability as
defined in Section 4512 of the California Welfare
and Institutions Code.
• Early Start: children 0-36 months: per Section
95014 of the California Government Code.
• Prevention Program:
www.php.com/services/early-intervention-infantstoddlers-0-3
Modification of Early Start
service eligibility 7/09
• For children aged 0-23 months, a significant
delay is a 33% delay in one or more areas.
•
For children aged 24-36 months, a
significant delay is 50% in one area or 33% in
two or more areas.
•
The areas of delay are unchanged and
are: cognitive development, physical and
motor development, communication
development, social or emotional
development, or adaptive development.
Mental Health Services
• Regardless of whether the individual
has a Dx of DD/ID and/or is a Regional
Center client, they are eligible for
mental health services if they are a
Medical beneficiary and meet “medical
necessity” ie Axis 1 diagnosis (DSM
TR) + functional impairment + care
required is beyond scope of PPCP.
Other References
http://www.nlm.nih.gov/medlineplus/developme
ntaldisabilities.html
Crosswalk of DSM codes to ICD-9 codes:
http://www.qualitycareforme.com/documents/pr
ovider_careconnection_icd_9crosswalk.pdf
DSM-V (due out in 2012)
http://www.psych.org/MainMenu/Research/DSM
IV/DSMIVTR/CodingUpdates.aspx
overview article on developmental disabilities:
• http://www.mentalhelp.net/poc/view_doc.php?
type=doc&id=10322&cn=208