Funded by the WITH Foundation
Psychiatric Assessment Considerations
L. Jarrett Barnhill, MD, DFAPA, FAACAP, Lauren R. Charlot, PhD, LICSW, and Dan Baker, PhD
- Communicating with Patients with IDD and Their Family Members
- Considerations for Waiting Rooms
- Sensory Considerations for Medical Providers
- Cultural Competency and Prescribing
- Abilities Based on Level of IDD
- Developmental considerations that impact psychiatric assessment
Best Practices in MH Diagnosis and Treatment
- Trauma and Stressor Related Disorders
- Anxiety Disorders
- Obsessive Compulsive and Related Disorders
- Depressive Disorders
- Bipolar Disorders
- Grief and Loss
- Schizophrenia and Other Psychotic Disorders
Epidemiological studies of people with Intellectual and Developmental Disabilities (IDD) suggest that a conservative estimate of the lifetime prevalence of behavioral and mental disorders is 30-40%.1 The accuracy of these data remains questionable due to the frequency of under-diagnosis and misdiagnosis of underlying medical/neurological disorders as mental health conditions. In addition, level of ID and adaptive functioning impacts the process of assessment, especially when related ecological, psychosocial factors increase vulnerability to stressors. The level of ID also affects communication of and capacity for self-reporting symptoms, and likelihood of diagnostic overshadowing. For example, pain and discomfort may present as externalizing, disruptive behaviors that can be misattributed to a psychiatric condition.
Each of these factors contributes to misdiagnoses and sets a chain of events in motion that culminates in ineffective psychological and psychopharmacological interventions. The task of the assessment team is to minimize these shortcomings. The most successful way to accomplish this involves integrating a comprehensive description of the presenting biopsychosocial issues; medical, familial, psychosocial, and treatment histories; and systematic genetic, medical/laboratory, psychological, and mental status examinations with observational data from the patient, family, and multiple care providers. Such an approach reinforces the reality that psychiatric disorders do not arise in a vacuum. Behavioral and psychiatric disorders represent evolving conditions that are profoundly influenced by ongoing transactions between biology and the environmental/social context. A comprehensive assessment requires a holistic-transactional mindset in order to look beyond simply treating an illness. It takes into account resilience and positive psychological forces to promote wellness and maximize adaptive skills.
1 Fletcher RJ, Barnhill J, Cooper S-A (Eds). Diagnostic Manual-Intellectual Disability 2: A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. Kingston, NY: NADD Press; 2017.
Initial Psychiatric Assessment
The goal of initial psychiatric assessment for a patient with IDD is to gain an understanding of the biopsychosocial vulnerabilities of the person, their symptoms and potential treatment options. Methods of assessment for someone with IDD varies slightly from the general population.
|General Population||Patients with IDD|
|Establish relationship with person||Relationship with the person and a team|
|Conversation, detailed questions & answers||Verbal ability may be limited; interview informants to gather additional information; use plain language to engage the patient in discussion|
|Evaluate overall presentation||Atypical presentation is likely, recognize behavioral phenotypes related to genetic syndromes, ASD, ID, etc.|
|Discuss diagnosis and treatment plan directly with the person||Along with consensus with the patient, a "team" treatment negotiation also occurs|
Components of Comprehensive Psychiatric Assessment for Patients with IDD
Several developmental, biological and psychosocial factors might influence altered mental status. These should be considered as part of regular assessment for patients with IDD.
As many as 40%1 of individuals with IDD referred for an inpatient psychiatric stay have a missed or under-treated medical problem that was the actual reason for challenging behaviors that led to the admission.
Syndromes associated with IDD
Several syndromes, primarily genetically-mediated, may give rise to an IDD and contribute to patterns of executive function deficits, increased risk for certain medical comorbidities, and even elevated risk for psychiatric symptoms and syndromes.
Psychosocial and systemic vulnerabilities
Vulnerabilities include challenges related to cognitive factors, information processing, and including executive functions; communication (especially functional and social-emotional communication); sensory sensitivities; restricted and repetitive behaviors; trauma histories; and residential and programmatic services. As suggested, such vulnerabilities may provoke problems or impact their expression.
Cognition/ Level of Intellectual Disability
It can be helpful to know a person’s level of intellectual disability (mild, moderate, severe, profound), however there is extreme variability within these characterizations in how people process information, problem solve, and plan. These differences influence what is experienced as stressful, the degree of stress experienced, and how a person responds.
Executive function (EF)
The term executive function is used to describe a set of cognitive functions that control and regulate other abilities and behavior. This includes planning, organizing, focusing and paying attention and problem solving. Patients with IDD tend to benefit from support with initiating activities, paying attention, finishing tasks, tolerating frustration and regulating emotions, all of which impact the ways the person navigates everyday life.
People with IDD present with a very wide range of abilities and challenges with regard to communication. It is critical to help caregivers understand that speaking is not the same as problem solving and planning. Many people with IDD learn “scripts” but may not have insight into the meaning.
Sensory sensitivities may occur in conjunction with a tendency to be easily over-aroused. Sensitivities to sounds is most common. Sensitivities to space (being too close), light touch, clothing tags on the skin, and overly stimulating visual environments are other examples.
Perseveration and repetitive tendencies are common concerns for many with IDD. In some cases, especially with ASD, there seems to be a deep need for things to remain the same, and increased stress when there is change. Repetition can be a way to understand something better, to resist change, which is upsetting, and at times to experience enjoyment (when the repetition has a self-stimulatory aspect). If a repetitive behavior is aimed at stress or anxiety reduction, a replacement must be provided if it is to be eliminated.
Don’t Forget the Power of Psychotherapy
There are many factors that contribute to the way a person feels or behaves. Most factors are not deterministic but are among a series of interactions through many life experiences. Psychopharmacologists should not assume that a psychotropic drug can teach someone social and adaptive skills, problem-solving, or methods for self-care. Psychotropic drugs can reduce behavioral excesses due to exaggerated brain-behavioral responses that frequently stand in the way of psychosocial well-being. Remember, it takes an interdisciplinary treatment village to promote wellness. Psychotherapy is a much more powerful tool for enhancing wellness, emotional well-being, and mastery while enhancing life skills. In the Appendix is a list of evidence-based, frequently used therapeutic modalities and resources for physicians regarding the efficacy of the modalities for persons with IDD.
Assessment is the most important part of any treatment program. It provides a comprehensive picture of a person’s symptoms in a biopsychosocial context and work towards holistic solutions to adverse life experiences. Psychopharmacological assessments are frequently reductionistic and limit consideration of the psychosocial and ecological forces that influence the emergence and course of psychiatric disorders. All too often, the efficacy of medication is overestimated; psychotropics are adjuncts, not solutions. While medication may be a piece to the wellness puzzle, it is not the only one. Medications offer an intervention designed to alter the underlying biology of behavior, but they do not take the place of primary care, educators, therapists, friends or family members. The goals of assessment are to identify and develop strategies to enhance adaptive skills, with psychopharmacologic treatment playing one role in the process.
Considerations for Psychotherapeutic Adaptations
The following are considerations for adapting psychotherapy and other intervention methods during treatment involving persons with IDD:
- Speed: Adaptations are often needed to provide intervention at a slower pace, allowing additional time to process the content and respond. This adaptation is commonly used in accommodations for academic testing when learners are given additional time during exams.
- Number: Either more or fewer examples might be appropriate for a patient depending on the learning abilities and profiles they have. If the patient requires additional practice for acquiring a skill or concept, the adaptation would be to increase the number of exemplars used. If the patient has difficulty generating responses, fewer responses could be required.
- Abstraction: Adaptation based on abstractness involves reducing the level of abstraction and improving concreteness of content. This is accomplished by using objects, drawings, and role play rather than lecture, discussion, or reading materials.
- Complexity: These adaptations generally involve breaking content down into smaller chunks or units. This is familiar to special educators in the instructional technique of “task analysis.” Plain language is used to improve comprehension.
Resources by Therapeutic Approach
There are many evidence-based practices that have been successfully adapted to improve health and wellness for persons with IDD. While the list below is not all-inclusive, it provides options for treating mental health conditions for persons with IDD.
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Positive Identity Development
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Interactive Behavioral Therapy
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- Tomasulo DJ. Positive group psychotherapy modified for adults with intellectual disabilities. J Ment Health Res Intellect Disabil. 2014;18(4):337-350.
Cognitive Behavioral Therapy
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Positive-Cognitive Behavioral Therapy
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Trauma-Focused Cognitive Behavioral Therapy
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Dialectical Behavioral Therapy
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Acceptance and Commitment Therapy
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Solution Focused Interventions
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Eye Movement and Desensitization Re-processing (EMDR)
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