Brian Tallant, LPC; Melissa Johnston-Burnham, LCSW
In the following paper, the special vulnerability of children with developmental disabilities to various forms of mental illness will be addressed, as well as the special characteristics and diagnostic considerations associated with dual diagnoses. After reviewing these issues, a model program that was specifically designed to meet the special needs of this population will be described, including the overall program structure and its treatment methods. Finally, the interagency collaboration necessary in every community to create seamless service delivery to dually diagnosed children will be presented.
There is a higher instance of mental illness in children who have a developmental disability than the general population. Persons with developmental disabilities have several characteristics that tend to increase their vulnerability to mental illness, as it is more difficult to cope with normal life stressors given the limited personal resources these clients have available. Developmentally disabled children have increased vulnerability to suffering abuse in their homes, as they are often more challenging to raise and can place a high level of stress on the family. They are also more vulnerable to abuse in the community because of their poor judgement and lack of self-protective skills. An additional stressor for higher functioning developmentally disabled children is their awareness of their intellectual disability, and many suffer from grief and loss issues associated with this awareness.
There are many common characteristics of people with developmental disabilities that are frequently mistaken as signs of mental illness. These include impulsivity, poor judgement and a lesser understanding of social conventions and societys unwritten rules. Together these result in frequent problems with uninhibited, socially inappropriate behavior. Finally, children with developmental disabilities also have a good ability to mimic interesting behaviors displayed by those around them (i.e., psychotic like symptoms if recently in the hospital), and for this reason often appear bizarre to outside observers.
The task of the service provider for this population is first to differentiate between behavior associated with the developmental disability and the mental illness. There are characteristics or symptoms of a learning disability such as low-frustration tolerance, the need for sensory stimulation, and communication problems that can be mistaken as mental illness symptomatology. There are other differentiations that must be made when assessing dual diagnoses. The provider must separate sexual inappropriateness from sexual offender issues, obsessive-compulsive behaviors from the perseverative qualities of autism, and psychosis from the elaborate imagination of a child with Down Syndrome. Other examples include separating Prader-Willi Syndrome from an eating disorder and Williams Syndrome from sound hypersensitivity. Assessments may be needed from other medical professionals to assist in proper diagnosis.
There are several identifying signs of mental illness that caretakers can be aware of to help determine when to seek treatment. A significant change in affect and speech patterns, unusual or bizarre speech, loose associations and delusional thinking could identify psychosis. A change in attention span and ability to focus, dramatic swings in mood, an increase in agitation, aggression, and irritability could indicate a mood disorder. Decreased motivation, listlessness, chronic sadness or crying are good indicators of depression. Significant changes in eating and sleeping patterns, increased anxiety, chronic or disabling fears, obsessive thoughts or compulsive behaviors, drug and alcohol use and abuse are all signals that mental health treatment should be sought. Delinquent behavior, precocious sexual behavior and somatic complaints may also indicate the need for mental health services. Again, these symptoms should be investigated with the help of medical doctors and, in some cases, even law enforcement officials.
Caregivers should also be aware of transition points where all youth are likely to experience increased stress that may lead to mental health difficulties. A change in school placement, transition between summer and regular school, changes in teachers or other service providers, and a move from self-contained to mainstreamed school programs are all high risk times for mental health issues. A change in a childs residential setting (i.e., family moving, a child enters foster care placement, etc.) is a particularly difficult adjustment for these children to make. Anniversary dates of trauma are also reoccurring periods of stress. In addition, particularly in children with autism, a simple change in daily routine can also bring about significant stress.
The development of coping skills is primary in reducing the vulnerability of people with developmental disabilities to mental illness. A sensory diet and occupational therapy can significantly reduce problems experienced by children with sensory integration dysfunction. Social skills training, boundary awareness, stranger awareness, sex education and self-esteem building can reduce the chances of abuse in the community. Stress management, therapeutic recreation, relaxation training, and the development of social supports can greatly reduce the stress that dually diagnosed children experience. Anger management skills can also be taught so that conflict resolution and problem solving skills replace angry outbursts.
For the professional implementing mental health interventions, the following are suggestions for individual cognitive therapy sessions. To begin, slowing down speech is paramount in working with people who have problems with auditory processing. The use of visual cues is important to reinforce your verbal message and will help to increase retention. It is also helpful to present points one at a time, asking for verbal feedback after each item to ensure clear comprehension. It is necessary to be specific in making suggestions for change, and practicing or role-playing different ways of handling situations. It is important to work on coping skills instead of insight with a developmentally disabled client. Therapy sessions should be formatted so that information can be reviewed several times, as repetition is necessary for comprehension and retention. Also, it is of utmost importance to remember that change occurs more slowly with developmentally disabled clients and that success needs to be measured with a micrometer, not a yardstick.
A Model Program
Intercept Center and Day Treatment Program (IDT) was created in 1996 as a collaborative effort between Aurora Mental Health Center and the Aurora Public Schools special education department to meet the specific needs of dually diagnosed children in Aurora and the Metro Denver area. IDT was created to serve dually diagnosed youth between the ages of six and 21 whose behavior was unable to be managed in a regular educational setting. IDT has the capacity to serve up to 13 children in the day treatment portion of the program, and currently serves approximately 100 families as outpatients. IDTs staff is composed of a multidisciplinary team of professionals, which includes a psychologist, a psychiatrist, a licensed professional counselor, a licensed clinical social worker, two case managers, a special education teacher, therapeutic aides, educational assistants, a speech pathologist, a registered nurse, an adaptive PE teacher and an occupational therapist.
The day treatment program at Intercept strives to provide comprehensive services to its dually diagnosed children. Both functional academics and life skills are taught within the classroom milieu. Based on their individual I.E.P.s, children in the day treatment program also receive occupational therapy and speech therapy. The children participate in adaptive physical educational as well as therapeutic recreation and community activities. All of IDTs day treatment clients receive medication monitoring, extensive case management, and behavior programming. Each child has access to individual therapy, family therapy, art therapy, and group therapy for anger management, social skills, sex education and coping skills. With the exception of art, occupational and speech therapy, the outpatient portion of the program also offers the same services to its clients. Mentoring, respite care, and consultation for the development of plans to maintain children in their home school are also offered at IDT
IDT has several programmatic goals for its dually diagnosed clients. IDT strives to provide a structured environment for behavioral change while maintaining a supportive and challenging functional academic curriculum. Teaching coping and adaptive skills is stressed so that each client and their family can function adequately within the home. Intercept also helps to maintain children in a stable foster home who have already been placed. The center provides specific support groups for parents and foster parents who have dually diagnosed children. Empowerment is a goal for parents so that they may assist in providing therapeutic change. IDT is a transitional program that serves to help children in day treatment be mainstreamed back into a regular public school, but also to help children who are in public schools be successful in remaining there. Another mission of Intercept is to reduce the number of hospitalizations and reduce the clients length of stay in the hospital when inpatient treatment is necessary. The center also works to stabilize children on psychotropic medication and maintain them on a minimal effective dose. IDT staff also serves as advocates and representatives on interdisciplinary teams to coordinate the involvement of all community agencies required for the childs treatment.
In order to address the multiple treatment and educational needs of dually diagnosed children, multiple agencies and systems must work together to build comprehensive services. There are several different players and agencies that have a vested interest in working together to close the service gaps that are often experienced by the families of dually diagnosed children. The following agencies and systems have been identified as necessary players when building seamless services for people with dual diagnoses: community mental health systems, special education departments, social service (child protection agencies), community developmental disability services, advocacy groups, physicians and local hospitals. Other community resources that can also be included are local parks and recreation and day care centers.
It is often the norm that resources must be created in order to adequately serve dually diagnosed children. This is why interagency resource teams are needed to address the needs of this underserved population. In Arapahoe County, Colorado, DDIRT (Developmental Disability Interagency Resource Team) was developed to discuss systemic problems and needs of the community in regard to services for dually diagnosed children. This team worked to oversee the creation of Intercept Center and continues to meet every two months to review community needs and individual cases so that these children receive the comprehensive services they need. Interagency resource teams can be created in any community, and they begin with personal relationships between people who work in the affiliated service agencies that provide for developmentally disabled people. It is the philosophy of the DDIRT group in Colorado that there are not systems, but people. Likewise, children do not fall through cracks, they slip through fingers. This is why interagency groups must be created in every communityto properly serve this special population of children.
For further information, please contact:
Brian D. Tallant
Aurora Community Mental Health Center
11023 E. 5th Avenue, Aurora, CO 80010