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Chapter: Essentials of Psychiatry: Childhood Disorders: Mental Retardation

Mental Retardation: Variations in Presentation, Behavior Disorders, Assessment

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.

Variations in Presentation


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.


Behavior Disorders


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.




Special Issues in the Psychiatric Assessment of Persons with Mental Retardation

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).


Approaches to Obtaining a History


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


Approaches to the Patient’s Interview


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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