There is no evidence that mental disorders seen in
persons who have mental retardation are basically different from mental
disorders seen in the general population. However, the clinical manifestations
may be modified by many factors that include: cognitive impairment;
communication skills; associated sensory, motor, and other disabilities;
environment; life experiences and circumstances. The most important of these
factors is the presence or absence of verbal language. This is to be expected
since many if not most of current diagnostic criteria of mental disorders are
based on a patient’s verbal productions. For instance, it might be impossible
to recognize the presence of thought disorder in a nonverbal person (similar
problems are encountered with young children.
A common reason for referral for psychiatric
consultation is to determine whether a person with mental retardation has “a
be-havior disorder or a mental disorder”. The DSM-IV does not have the
diagnostic category of “behavior disorder”, although it is in-cluded in the
ICD-10 (World Health Organization, 1992).
Although there is no clear definition of “behavior disor-der”,
it is usually meant to refer to a behavioral problem that is severe enough to
warrant intervention, but which is not a part of diagnosable mental disorder.
It is often applied to a deliber-ate misbehavior, learned response and
“attention-getting” be-havior. However, in the clinical presentation of every
defined mental disorder, there might be elements of learned behavior, for
example, caused by the responses of persons in the patient’s en-vironment. The
danger of such ill-defined, nonspecific category is that clinicians faced with
a difficult case might be tempted to use it, rather than attempt to make a more
specific diagnosis that might lead to a more focused treatment. Thus, it is
preferable to avoid dichotomizing abnormal behaviors into “behavior” and
“mental” disorders, but rather to try to decide to which mental disorder the
behavioral manifestations form a part (Szymanski, 1994). Possibly “behavior
disorder” could be employed to denote a maladaptive behavior that is clearly a
function of situation and environment, and not primarily the individual. A
commonly seen example might be an individual living in a large residential
in-stitution who, in a well-staffed workshop, is very cooperative, happy and
hardworking, but becomes irritable, negativistic, even aggressive in the
afternoon, when he returns to the overcrowded and understaffed ward where he
lives. A maladaptive behavior may also serve as a form of communication if the
person has poor language skills or when the carers do not respond to other
attempts to communicate. In any case, it is essential that a com-prehensive
psychiatric diagnostic assessment be made to ensure that the behavior in
question is not a part of a diagnosable mental disorder.
The basic principles of the psychiatric diagnostic
assessment of persons who have mental retardation are the same as those for
persons who do not have mental retardation. However, the clini-cal approaches
may have to be modified. The scope of the assess-ment might have to take into
account multiple needs and problems and, in addition, these individuals depend
on multiple providers for multiple services. The clinical techniques have to be
modified according to the patient’s discrete developmental levels in vari-ous
domains, and in particular, communication skills (Szyman-ski, 1980). In
accordance with the principle of biopsychosocial integration, all factors and
their mutual interaction and contribu-tion to the patient’s problems and
general functioning must be considered. Thus, the presenting problems must be
assessed in the comprehensive context of a patient’s abilities and disabilities
and not as an isolated issue (Szymanski and Crocker, 1989).
All involved caregivers should be interviewed if
possible (parents, teachers, direct care workers, supervisors in workshops).
Direct care staff members (e.g., from the group home and workshop su-pervisors)
are particularly important because they can provide a firsthand description of
a person’s behavior. Exploring the fol-lowing areas is important.
Reasons for Current Referral
Behavioral Symptoms
Medication History
General History
Nature of the Disability
Medical History
Past and Current Services
Milieu Events
The Family
The way in which the patient’s interview is
approached will de-pend on the patient’s communication skills and cooperation
and might range from an age-appropriate verbal interview to obser-vation only.
The communication skills have to be explored first through brief, noncommittal
conversation and questioning of the caregivers. If necessary, the caregivers
might be used as inter-preters of the patient’s poorly intelligible speech or
sign language. Directiveness and structure are often necessary to help the
patient focus, but leading questions or suppression of spontaneous ex-pression
must be avoided. While firm and clear behavioral limits may have to be
established at the interview’s onset if necessary, a great deal of support is
needed. Noncondescending verbal and social reinforcement, as appropriate for
developmental age, will let the patient know that the interviewer is
appreciative of her or his abilities. The patients should be approached
respectfully – if possible, in a manner appropriate to the chronological age –
and not as children. However, communication with them should be on the level
they can understand, and their understanding should be ascertained. For
instance, persons with mental retardation are afraid to be perceived as
inadequate and instead of saying that they did not understand the question,
they tend to agree with the interviewer’s last statement. Thus, asking
open-ended questions is preferable to giving a choice of answers. For the same
reason structured mental-status type of questions might be counter-pro-ductive.
Leading questions should be avoided. One should ex-plore the patient’s
self-image, including understanding of his or her own disability as well as
strengths.
Nonverbal interviewing techniques include
behavioral ob-servations, spontaneous and directed (structured) play (as
devel-opmentally and age appropriate), and other structured tasks.
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