IDD-MH Prescriber Guidelines

Developmental considerations that impact psychiatric assessment

Lauren R. Charlot, PhD, LICSW

Download a PDF of this table

Executive Functions or Cognitive Skill Areas

What does this mean?

How problems develop that look psychiatric or behavioral (Case Examples)

Theory of Mind:

Understanding Competing Perspectives

  • May have challenges in social understanding and awareness, even when other cognitive capacities are less challenged
  • May struggle to pick up on language pragmatics and say things that appear socially odd (e.g., talk out loud to self, quote movies, talk at length about a topic that the other person is clearly not interested in, ask very personal questions)
  • May not realize they did something offensive

Mark, a 20-year-old with ASD, told the teacher what the kids did when she was out of the room. The kids got angry with Mark and he doesn’t understand why. He gets picked on and lashes out, so the school counselor thinks he is antisocial or conduct disordered.

Mark is seen as uncaring because he is aggressive when upset. Afterwards, he asks people to play cards with him, which frustrates people. Mark actually has panic attacks in response to loud noises. He expresses care for his housemates and support staff. His actions are not mean, plotted or planned.

Challenges to mental flexibility

  • Has a hard time switching from one way of doing things to another, despite simple, clear instructions
  • Does not easily incorporate new information so does not change the way something is done
  • The person may panic when unexpected changes occur in daily routines

David screamed and hit staff when told he cannot go to lunch using the same hallway as normal due to some building painting. He is described as “non-compliant.”

David’s frontal lobe and executive function are compromised, and switching to a new rule/path is difficult.

Understanding time concepts, waiting

  • Has limited sense of the passage of time and needs things to be anchored to concrete events
  • May not understand how long is “in an hour” or “next week” or in a “few days” is
  • Schedules may need to be laid out (e.g., "After you wake up we will have breakfast. When breakfast is finished, we will...")
  • Avoid planning events with a person too soon, as this can provoke anxiety

Cindy loves the park and got excited when she heard her group was going there. She had a major outburst because she wanted to go to the park immediately and didn’t realize that they weren’t going for another 2 hours.
Cindy didn’t realize what 2 hours means or feels like. She was described as “throwing a tantrum because she didn’t get her way.”
Her “outburst” was similar to what happened last month at her ISP meeting when they discussed her 5-year plan to move. She became very upset because she thought she was moving soon and wasn’t ready.

Differences between speaking and understanding

  • May learn a variety of “scripts” or things to say in various situations, without actually understanding the full meaning or implications
  • May not admit that they don’t understand because they are embarrassed. This leads to agreeing to things without really knowing what it means
  • May be viewed as purposefully doing ill-intentioned things when independent problem solving is a major challenge
  • Ability to use past experiences to inform current choices (generalization) is greatly impaired
  • Create a structure of reminders and rehearsals, to support positive responding

People say that Damien has a great memory and can recall anything because he can describe all of the stores at the mall that sell tech items, gaming software and other things he likes in great detail.

Damien had a major event with a housemate this week because he was teased. He promised his staff that he would walk away and ask for help if it happened again.

A couple days later it happened again, and Damien ended up striking the teasing housemate. People thought he was ignoring their guidance and direction.

Thinking in pictures

  • Learn new things best by using a combination of words and pictures.
  • May speak in complete sentences and complete many tasks independently, but may have difficulty understanding verbal instructions, especially multiple step instructions.
  • Using pictures (real pictures are best), create communication tools and schedules, especially for changes in routines or multi-step processes

Deneesha speaks in complete sentences and completes all of her daily self-care independently. She was told about a new assessment and seemed anxious. When she got to see pictures of the evaluation showing what would happen, she relaxed.

Functional Communication (FC)

  • Might not use speech functionally to reliably describe what they need or want
  • May repeat many words or sentences, but not ask for water when thirsty
  • Some speech may be “cue dependent” (requires a prompt)
  • May communicate better in pictures or with multiple forms (signing, showing a picture, and speaking)

Data collection to determine function of communication can be very helpful.