Mental Retardation: Evaluation of Clinical Data, Aggression

Evaluation of Clinical Data

The clinical observations should be interpreted in light of a pa-tient’s life experiences, learning, understanding and communica-tion level. The global IQ or overall mental age alone is not a good guide here. In particular, the psychiatrist should:

·   Assess clinical presentation in light of the patient’s com-munication ability, cognitive level, associated disabilities (e.g., sensory), life experiences, environmental factors and cultural background. One should differentiate between be-haviors appropriate for an earlier age and those that are patho-logical in any age (e.g., true hallucinations). Not all disruptive behaviors are an expression of a mental disorder: for example, an overworked staff might promote aggressive acting out by attending to the patients only when they become aggressive. However, one should not simply explain all such behaviors as attention-seeking behaviors. Conversely, persons who do not manifest disruptive behaviors might have a mental disorder, for example, a depressed individual who is considered behav-ing well because he is very quiet.

·    Obtain, if needed, evaluations and consultations with other disciplines, for example, language pathologists, psychologists and neurologists.

·   Assess and understand the dynamic, ongoing transactional relationships among the various factors contributing to the person’s development (see Figure 24.1).

·           Try to make a formal Axis I and/or Axis II DSM-IV diagnosis (besides mental retardation) whenever clinically justified. The diagnostic criteria can usually be adapted to the patient’s de-velopmental level, just as one does with child patients). How-ever, diagnosis does not mean listing the disorder’s code and name only. To be constructive, the diagnostic statement should include description of strengths, impairments, and need for supports and services in each discrete domain of the individu- al’s functioning, as well as in the environment (community and family). It should not merely copy the diagnostic criteria but describe how they are satisfied in the particular case by history and clinical observation, as well as why other diag-noses in the differential are ruled out.

Aggression

“Aggression” to people or property (destructiveness) is one of the most frequent reasons (if not the most frequent) for refer-ring persons with mental retardation to a psychiatrist. On closer investigation, the actual behavior ranges from occasional swearing (verbal aggression) to serious violence (Harris, 1995). Whether a particular behavior is called aggression (except for clear physical aggression) depends on the caregiver’s perception. Thus, in ob-taining the history it is necessary to obtain a concrete description of the behavior in question, preferably from several informants. Prolonged direct observation of the patient may be necessary to resolve unclear cases. There is no single entity called aggression in this population that would have one explanation. It would be a mistake to talk about a single treatment for aggression (except for symptomatic emergency measures). Psychiatrists are often asked how they treat aggression in persons with mental retardation. The answer is, of course, that it is done in the same manner as in persons without mental retardation: an accurate diagnostic as-sessment comes first. Different factors must be considered in as-sessing the cause of aggressive behavior (Harris, 1995). It might be associated with a defined mental disorder, for example, ag-gression following a command hallucination, paranoid delusion, anxiety, borderline or antisocial personality, or depression. The factor of learning will reinforce aggressive behavior if it brings a desired response by the caregivers. A pathological brain condi-tion, such as rage attacks after brain trauma or associated with temporo-limbic seizure disorder, may also lead to aggression. Often, several causative factors are involved, all of which require evaluation and intervention.

The DSM-IV-TR has a category of intermittent explosive disorder that can be used provided that another mental disorder has been ruled out as the cause of the aggressive behavior.