Johnny L. Matson, Ph.D., David E. Kuhn, Stephen B. Mayville
The development of appropriate and effective treatments for psychopathology is largely dependent on the accuracy of assessment to establish topography, frequency, severity, and function of the disorder and associated behaviors. Similarly, assessment instruments are needed to establish replacement behaviors, evaluate the effectiveness of treatment outcome, and side-effects of interventions. The present paper presents a brief review of a system developed to accomplish these goals.
Psychopathology and behavior disorders are of great concern regarding persons with mental retardation. Such conditions impede the persons ability to be integrated successfully into society, and may result in job failure and the inability to establish fulfilling social relationships. In a substantial group of individuals these problems can be chronic and recalcitrant. Therefore, active attempts to intervene are needed. These interventions require the use of reliable tools to assist the professional. The purpose of this paper is to describe tools and methods designed specifically to assist in the assessment of persons dual diagnosis.
Unfortunately, much of the research on dual diagnosis presents assessment and treatment tools which may be effective but which are not easily implemented, are not cost effective, and require the services of well trained staff. To the detriment of the clientele, many services for persons with mental retardation are funded with the assumption that the client has minimal health or mental health needs. When significant mental health needs are present, the system is rapidly overwhelmed. Quite frequently, the amount of funding available and the expertise and numbers of staff available only allow for minimal services. Therefore, assessments must be efficient and need to be simplified significantly to allow staff with limited training to be able to participate in the evaluation.
Without an adequate assessment, treatment selection may be absent or inappropriate. Unfortunately, medications and psychological interventions are often initiated and then changed repeatedly due to a lack of diagnostic information. The assessment process should be separated into diagnosis, functional assessment, establishment of replacement behaviors, evaluation of treatment effects, and evaluation of treatment side-effects. This approach will increase the likelihood that an appropriate link is made between assessment and treatment, and assist with the monitoring of treatment effectiveness.
The principle goals of diagnosis are to first identify the problem behavior(s), and determine the variables that maintain them. The majority of referrals brought to the attention of a clinician consist of complaints regarding self-injurious behavior and aggression directed towards others. Given the nature and prevalence of these behaviors it is important to not only assess the social variables maintaining the behavior (i.e., functional assessment), but it is also essential to screen for mental disorders that may contribute to or exacerbate the problem. This step in assessment helps identify those individuals whose psychopathology is less obvious and less disruptive to the environment of others (e.g., anxiety disorders, depression, and feeding problems), yet problematic for the mental health of the client. Identification of mental health disorders and variables contributing to behavior problems can be accomplished through the use of indirect assessment, where persons familiar with the client are questioned regarding observable behavior.
The Diagnostic Assessment for the Severely Handicapped (DASH-II) (Matson, 1995a) (for severe and profound mental retardation) or the Assessment of Dual Diagnosis (ADD) (Matson & Bamburg, 1998) (for mild and moderate mental retardation) would be administered in the initial assessment phase. These assessments allow for the identification of discrete disruptive behaviors such as hitting, loud vocalizations, property destruction, etc. The Questions About Behavior Function (QABF) (Matson & Vollmer, 1995) should subsequently be filled out through staff interview (this same format is used with all the scales) for each target behavior identified by the DASH-II or ADD. The QABF has 25 items, broken down into five categories; attention, escape, non-social (no observable external cause but appears to be self-stimulating and resulting in pleasure), physical (the person is experiencing pain or discomfort), and tangible (person is able to obtain items they like). The information obtained from this measure suggests possible variables responsible for behavior maintenance, and thus guides treatment with respect to environmental versus biological causes.
The DASH-II and ADD are keyed to DSM-IV criteria and should be used in conjunction with direct observation, review of records, and clinical interviews to arrive at a diagnosis, if appropriate. The DASH-II also identifies problem behaviors which may be sensitive to environmental manipulations such as aggression, SIB, elimination problems, sleep disturbance, problematic sexual behavior, and eating behaviors that can be assessed using the QABF, and would typically be treated behaviorally. Behaviors that may respond to medication and/or environmental treatments (e.g., mood stabilizers or differential reinforcement procedures) are categorized by the DASH-II into subscales representing disorders associated with impulse control, organic etiologies, anxiety, mood disturbance, mania, PDD/autism, schizophrenia, and stereotypies. A similar set of disorders is evident in mild and moderately mentally retarded persons, and the ADD reflects these differences. No specific behavior problems are assessed as with the ADD. Rather, all behaviors are grouped into subscales according to constellations indicative of disorders. The subscales include mania, depression, anxiety, post-traumatic stress disorder, substance abuse, somatoform disorder, dementia, conduct disorder, PDD, schizophrenia, personality disorder, eating disorder, and sexual disorder (fetish, sexual assaultive, public exposure). Symptoms identified by the DASH-II or ADD that have associated low scores on all categories of the QABF may respond better to pharmacological interventions than behavioral interventions. Conversely, identified symptoms associated with elevations on the QABF may suggest implementation of a behavioral intervention. Observational data and clinical interviews will provide additional information which can provide more specificity.
While both the DASH-II and the ADD (among other behavior rating scales) include items targeting behaviors related to feeding and mealtime problems, they are not comprehensive in scope. The Screening Tool of fEeding Problems (STEP) (Matson & Kuhn, 2001) is a measure designed to identify feeding and meal time behavior problems commonly exhibited by individuals with mental retardation. The STEP separates feeding problems into five categories including behaviors that place the individual at risk of aspiration, behaviors associated with selectivity (e.g., food type selectivity, food texture selectivity), behavioral skills deficits and excesses (e.g., inability to chew, eating too rapidly), behaviors related to food refusal (e.g., pushing food away), and nutrition related behavior problems (e.g., pica, eats too little).
Establishment of Replacement Behaviors
Current practice in the treatment of dually diagnosed persons typically consists of suppression of the aberrant behavior(s) without consideration of adaptive behavior training. Individuals are often treated using poly-pharmacy which sedates the individual, and the effect is considered therapeutic. In actuality, the medications function as a form of restraint. A successful intervention should consist of multiple components, including increasing positive social behavior to replace the maladaptive behaviors being eliminated, and discontinuing reinforcement following the maladaptive behavior. For example, an individual who engages in SIB to get the attention of staff may be taught to use sign language to get the attention, and staff should be instructed to withhold attention for SIB.
One method for identifying possible replacement behaviors, as well as identifying social behavior excesses and deficits is the Matson Evaluation of Social Skills in Individuals with sEvere Retardation (MESSIER) (Matson, 1995b). Items on the MESSIER are divided into six categories of social behavior including positive verbal, positive non-verbal, general positive, negative verbal, negative non-verbal, and general negative. Typical items are says hello when entering a room, thanks or compliments others, shares without being told to do so, follows facility rules, cooperates with caregivers, disrupts activities of others, does the opposite of what he is told, and touches others inappropriately. Given the value of replacement behaviors in the development of comprehensive interventions, the identification of these behaviors and the MESSIER in particular may be viewed as the most important component of assessment
Evaluation of Treatment Effects
To ensure interventions are effective, close monitoring of target behaviors is essential. Currently, this practice is not widely implemented, or is implemented with limited integrity. Behavior rating scales are useful in identifying behaviors amenable to treatment, however they can also be used for the purpose of monitoring dimensions of behavior (e.g., frequency, severity) over time. As described above, the DASH-II and ADD serve as screening tools for maladaptive behaviors, though data can also be charted across time (e.g., every month) to evaluate the ongoing effects, or lack of effects, of treatment. When assessing treatment progress with the DASH-II and ADD, the subscale score in combination with the total score may yield useful information regarding the overall effects of the treatment as well as the effects specific to the area of psychopathology being targeted.
Side-effects are evident with all interventions, but are of particular concern with psychotropic medications because significant long-term health problems may result. For example, antipsychotics, both typical and atypicals, have distinct side-effect profiles implicated in the development of neurological conditions such as tardive dyskinesia and akathesia. Though the atypical antipsychotics were developed in response to the side effects associated with the typicals, studies in Europe (where atypicals have been available for a longer period of time) report many of the same side-effects noted with typical antipsychotics. Additionally, even if the side-effects of this second class of antipsychotics are less, and people are all switched to these drugs (best case scenario) the clinician must still deal with the side effects created by many years of typical antipsychotic drug use.
Various measures have been used to assess the side effects associated with psychotropic drug use. The Dyskinesia Identification System-Condensed User Scale (DISCUS) (Sprague & Kalachnik, 1991) is a well established measure for the assessment of tardive dyskinesia among individuals with mental retardation. The Matson Evaluation of Drug Side effects (MEDS) (Matson & Baglio, 1998) may provide useful and complementary information to the DISCUS on possible side effects of psychotropic medications including symptoms related to cardio-vascular function, hematologic effects, gastrointestinal problems, endocrine and genitourinary functions, eyes-ears-nose and throat problems, skin allergies and temperature irregularities, general CNS disturbance, dystonia, parkinsonian dyskinesia, and behavioral akathesia. Careful assessment of side effects is essential to any pharmacological intervention to ensure that the benefits of the intervention outweigh any untoward collateral effects of pharmacotherapy.
We have found that multiple assessments are useful to develop an overall plan of habilitation for persons with mental retardation and mental illness. The assessment of mental illness, behavior problems (e.g., SIB), treatment effects, drug and behavioral side effects, and the establishment of replacement behaviors are all important components of a thorough evaluation. The approach we have briefly reviewed is one way to accomplish this goal.
Matson, J. L. (1995a). The Diagnostic Assessment for the Severely Handicapped-II. Baton Rouge, LA: Scientific Publishers Inc.
Matson, J. L. (1995b). The Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER). Baton Rouge, LA: Disability Consultants, LLC.
Matson, J. L., & Baglio, C. S. (1998). Administrators manual: Matson Evaluation of Drug Side effects (MEDS). Baton Rouge, LA: Scientific Publishers.
Matson, J. L., & Bamburg, J. W. (1998). Reliability of the Assessment of Dual Diagnosis (ADD). Research in Developmental Disabilities, 19, 89-95.
Matson, J. L., & Kuhn, D. E. (2001). Identifying feeding problems in mentally retarded persons: Development and reliability of the Screening Tool of Feeding Problems (STEP). Research in Developmental Disabilities, 22, 165-172.
Matson, J. L., & Vollmer, T. R. (1995). Users guide: Questions About Behavioral Function (QABF). Baton Rouge, LA: Scientific Publishers, Inc.
Sprague, R. L., & Kalachnik, J. E. (1991). Reliability, validity, and a total score cutoff for the Dyskinesia Identification System: Condensed User Scale (DISCUS) with mentally ill and mentally retarded populations. Psychopharmacology Bulletin, 27, 51-58.
For further information:
Johnny L. Matson, Ph.D.
Department of Psychology
Louisiana State University
236 Audubon Hall
Baton Rouge, LA 70803-5501