NADD Bulletin Volume VI Number 1 Article 2

Complete listing

POSTER PRESENTATIONS: A Generalization Analysis of Relapse Prevention Skills of Four Sex Offenders with Mental Retardation

J. A. Rea, M. Dixon, T. Parker, & C. Martin

Parsons State Hospital and Training Center and the University of Kansas

Relapse prevention has been the cornerstone of sex offender treatment programs for the last 15 years. Although studies have demonstrated its efficacy with non-disabled offenders, little is known about its effectiveness for offenders with mental retardation. In addition, its generalization to novel environments and individuals is unknown. An analysis of relapse prevention skills with four offenders and generalization of these skills to novel environments and individuals was conducted. All four offenders were initially taught to implement their avoidance skills with treatment staff. Treatment staff provided daily feedback to the offender regarding the offender's accuracy in following the relapse plans. Assessment probes were conducted periodically with non-treatment staff to determine if the offender followed their relapse plan. Non-treatment staff did not provide feedback to the offender about the accuracy of following their relapse plans. To date, all offenders have acquired relapse prevention skills, but only two of the four offenders have generalized their skills to novel environments and people. In addition, we are currently analyzing a series of interventions to assist in the facilitation of generalization.

For further information: jazr@srskansas.org

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A Protocol for Assessing OCD in Adults with Down Syndrome

Stephen Collins, Jane Summers, & Judith Adamson

Over the past eight years, more than thirty adults with Down syndrome (DS) have been referred to our outpatient mental health clinic in Southern Ontario. We have diagnosed obsessive-compulsive disorder (OCD) in one-third of this group. The frequency of this phenomenon and our own clinical interest led us to develop a protocol for assessing OCD in this population and for monitoring their response to treatment.

Our protocol takes into consideration a number of factors that have clinical relevance for individuals with developmental disabilities in general (e.g., the need to utilize objective measures to overcome limitations with subjective reporting of symptoms), as well as issues that have particular relevance for individuals with DS (e.g., recognition of medical conditions that are common in DS and which may have a bearing on the presenting problems). The protocol is used to structure and coordinate the activities of our interdisciplinary team members and is derived from a variety of sources. Individuals' response to treatment is evaluated through a combination of behavioral ratings, caregiver reports, and direct observation.

By following this protocol, we are able to coordinate our clinical activities in an efficient manner and to collect standardized information across our client base. The data we are gathering will add to the growing knowledge base on OCD in adults with DS.

For further information: stcollin@fhs.mcmaster.ca

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Adaptive Functioning in Adolescents and Young Adults with Autism: A Controlled Study

Jane Summers, Julie Rooke, & Elspeth Bradley

The purpose of the study was to examine patterns of adaptive functioning in adolescents and young adults with autism (14-21 years), relative to their age and ability-matched peers. The study was part of a larger epidemiological investigation in the Niagara Region of Southern Ontario regarding the prevalence of mental health problems in individuals with developmental disabilities. The Autism Diagnostic Interview - Revised (ADI-R) was used to diagnose the presence of autism and the Vineland Adaptive Behavior Scale (VABS) was used as the measure of participants' adaptive functioning. Thirty seven participants with autism were individually matched to participants with a developmental disability without a diagnosis of autism on the basis of nonverbal IQ, gender and chronological age.

The results indicated that the autism group scored significantly lower than the non-autism group on the adaptive behaviour composite of the VABS, which is composed of three domains (communication, daily living skills and socialization). The autism group also scored significantly lower on the socialization domain. There were no significant differences between the groups on the communication or daily living skills domains. Scores on the maladaptive behaviour domain were significantly higher in the autism group than the non-autism group. The results of this investigation extend previous studies of adaptive functioning in children with autism to include adolescents and young adults and point to the centrality of social deficits in the population.

For further information: jsummers@hhsc.ca

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A Survey of Mental Health Problems in Adolescents with Down Syndrome

Jane Summers, Marie Kim, Grace Ho, Kathleen Kitching, & Ruth Bolton

The purpose of the study was to conduct a survey of mental health problems in a group of adolescents with Down syndrome (DS). The participants consisted of the parents of 26 adolescents with DS who were recruited through a specialized outpatient clinic for children with DS as well as a parent led organization. Parents completed a demographic questionnaire along with the Aberrant Behavior Checklist (ABC) and the Developmental Behaviour Checklist (DBC).

The parents of 20 adolescents expressed concern about their child's mental well-being and 70% of this group had received some help is this regard. From the DBC, the overall prevalence rate of psychopathology among the DS group was 27%, which was lower than the 41% prevalence rate that was established in an epidemiological study of individuals with developmental disability. Seven adolescents with DS (6 of whom were male) were classified by the DBC as having significant psychopathology. On two subscales of the ABC, adolescents with DS scored significantly lower than a community comparison group.

Consistent with the assessment literature, adolescents with DS had lower rates of mental health problems than comparison groups with developmental disability of mixed etiology. On an informal level, however, the majority of parents did indicate concern regarding their adolescents' behavioral and emotional functioning and this finding warrants further investigation.

For further information: jsummers@hhsc.ca

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New Beginnings

(accepted, not presented)

Joan Ester Levy

Grand Junction, CO

"New Beginnings" is the name given by clients to a group home (and adjunct vocational program) operated as a collaborative venture between Mesa Development Services (MDS) and Colorado West Mental Health (CWMH). The program serves five dually diagnosed individuals whose main barrier to success has been their mental illnesses, not their developmental disabilities. These individuals have previously been served primarily in the developmental disabilities system, whose strategies and methodologies have been inadequate to meet their needs. "New Beginnings" blends the best of both the mental health system and the developmental system into an integrated and holistic approach.

Both MDS and CWMH have had to adjust to new and expanded roles in this venture. CWMH's previous involvement with dually diagnosed individuals was limited to medication management and crisis intervention. Their role has now broadened to include proactive involvement in the psychosocial aspects of treatment in both the residential and vocational settings. They have taken a hands-on approach wherein they have gained knowledge of each individual beyond his or her diagnosis. CWMH has been an active participant in program design at all levels. They have conducted groups, facilitated individual counseling, shared their model for job development and integrated the individuals into the "clubhouse". They also have a regular presence at the group home to provide feedback to staff.

 Even though the program is operated with funding from and under the regulations of the developmental disabilities system, MDS has had to shift its orientation in providing service. The focus is now on assisting each individual to take responsibility for his or her own wellness and for symptom management, rather than focusing on staff-driven behavior management and skill development. The "recovery" model has been the impetus for the change in focus.

To evaluate the success of the project, the interagency team has developed a number of outcome measures. Data will be collected and evaluated quarterly.

oEach individual will exhibit a decrease in targeted behaviors.

oEach individual will increase participation in therapeutic activities.

oEach individual will have a community job.

oEach individual will have increased earnings.

oEach individual will have a job in his or her first or second occupational choice.

Though hard data are not yet available, anecdotal reports indicate that the individual are already benefiting from the program. Attendance at vocational program has improved and targeted behaviors appear to be down.

The poster session will provide MDS and CWMH staff with the opportunity to share information regarding the impetus for this project, the collaborative nature of the program design and initial data on outcomes. This collaborative approach to services is unprecedented in Colorado. Hopefully, it can serve as a model for others around the country facing similar challenges with their dually diagnosed clientele.

For further information: joan@mds.acsol.net

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Use of Behavioral Equivalents to Assess Inpatients with Mood and Anxiety Disorders : Results from a Pilot Investigation

Laurie Charlot, PhD and Michelle Foley, RN

Currently, there is great concern that people with developmental disabilities (DD) frequently receive incorrect diagnoses. It is critical that a reliable and valid psychiatric classification system be developed for individuals with DD, to maximize their access to effective treatment. At this time, there are virtually no data to support use of the system that is most frequently employed. Although DSM-IV is the most widely used system of classification of psychiatric disorders in the United States and many other countries, it has not been validated for individuals with DD. Many experts have complained that DSM-IV is difficult to use in this clinical population. To determine whether or not a patient has a given DSM symptom, the clinician often relies on the individual's description of experiences and feelings. People with DD characteristically have difficulty with expressive language and often cannot reliably describe their feelings. Even for the experienced clinician, use of DSM to assess people with DD is challenging at best. A new methodology that enhances validity and reliability of psychiatric diagnostic assessment must be developed and systematically investigated to improve quality of psychiatric care given to persons with DD. In this pilot study, the validity of modified DSM-IV diagnostic criteria was investigated in inpatients with DD using operationally defined symptom criteria in the form of behavioral equivalents, for three DSM-IV disorders: major depressive disorder, bipolar disorder, and generalized anxiety disorder. The behavioral equivalents were incorporated into a structured interview. These pilot data were collected in preparation for a larger investigation that will investigate six DSM-IV disorders. Behavioral equivalents would also be based on the NADD project to develop a DSM-IV companion guide. Additional methods will be employed to establish reliability and validity of the proposed methodology.

(Editor's note: This is a greatly abbreviated introduction to a very interesting project.)

For further information: charlotl@ummhc.org.

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Factors Associated with Long Lengths of Stay for Psychiatric Inpatients with Developmental Disabilities

 Michelle Foley, R.N. & Lauren Charlot, Ph.D.

Individuals with developmental disabilities (DD) receiving inpatient psychiatric services tend to have longer lengths of stay (LOS) than people without DD, for a variety of reasons. At the UMass Memorial Medical Center, in Worcester MA, inpatients without a DD have a mean LOS of 7 days, the neighboring unit that specializes in serving adults with DD, LOS is about 13 days. In some cases, a longer stay is required because the patient needs further psychiatric or medical care; in other instances, the patient may be clinically ready for discharge but the residential caretaker is unwilling or unable to have the individual return. In the present investigation a number of demographic, medical, psychiatric and psychosocial factors were examined for two groups of psychiatric inpatients with DD: (1) patients with long stays (> 10 days) due to continued need for treatment and (2) patients with long stays due to loss of placement. The goal was to determine if there were any common characteristics among members of each group. There are a number of reasons to try to learn more about people who experience a prolonged psychiatric hospitalization. First, patients who are required to stay after being ready for discharge may decompensate while awaiting placement. The inpatient service is not designed for chronic care. Individuals who are ready to be out in the community, but are "stuck" on a locked inpatient unit, must live within a highly restrictive setting. The restrictions and limitations on an inpatient locked unit may lead to decompensation. Second, there is the financial burden, as third party payers will refuse to fund stays after the patient no longer requires "hospital level of care." If there are too many individuals receiving care on the small DD service whose stays are not funded, the entire service could be in jeopardy. A long-term goal would be to develop strategies collaboratively, with the Department of Mental Retardation, to prevent long stays that are due to loss of placement through an increased understanding of the impacting factors.

A retrospective chart review was conducted for 75 psychiatric inpatients with DD who were served on a specialized, 10 bed, short-stay, locked inpatient unit. Twenty-six individuals had a LOS >10 days due to clinical reasons (pt's condition unstable medically or psychiatrically) and 49 had a long LOS (>10 days) due to non-clinical reasons (pt's caretakers refuse to accept back to residential placement). Data were recorded from chart reviews including demographic factors, medical factors, psychiatric factors and psychosocial factors.

Patients with disposition problems were found to be younger, more often were male, had more diagnostic confusion, were more often diagnosed at discharge with PTSD and Bipolar disorder, had more previous admissions and had come from living environments which had limited supports or had been living with their families. Comparatively, patients with long lengths of stays due to clinical reasons were found to be older, more often female, more medically complex, more behaviorally complex, and were frequently diagnosed with depressive disorders.

For further information: Foleymol@ummhc.org.

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Using Music in Play Therapy: A Rationale for a Combined Approach to Treating Children with a Dual Diagnosis

Paula Francis, M. S. & Ashley Badger, M. S.

Children with mental retardation often experience the same range of psychological disorders as children with normal intelligence. Play therapy is a common treatment modality for normally developing children with emotional difficulties, and the research suggests that it is an effective treatment option. There has been a growing interest in play therapy as a treatment option for children with mental retardation. There are a variety of factors that play therapy can accommodate (e.g. for example, developmental age, language delays) that make it a good therapeutic intervention for children with a dual diagnosis. Music has also been used therapeutically to effect changes in specific, non-musical areas of functioning. A proposed alternative therapy approach to children with a

dual diagnosis is to use music in play therapy. There are a variety of ways that this treatment approach may be beneficial.

Music can be used to provide structure during play therapy sessions. Its rhythmic qualities provide a timing aspect to activities. For example specific songs can be used to open and close sessions. Music can also be used to reduce potential anxiety before and during play therapy sessions. Classical music for example has been used as a calming agent in classroom as well as in hospital settings. Music poses as a non-verbal medium for communication. Musically assisted prompts can be used as a substitute for limited speech and language skills. It is likely that children with mental retardation may have difficulty describing and talking about the various feelings that they experience. Music can be used to label and reflect affective states that may emerge during play therapy sessions.

For further information: paulafrancisco@hotmail.com

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SSRI Switch Rates to Hypomania in an MR/MI Outpatient Population

Thaddeus P. M. Ulzen M.D., FRCP(C) & Jim Hughes, B.A.

A retrospective analysis of 106 MR/MI outpatients receiving one of four SSRI's, for depression, OCD, and anxiety were studied. The switch rate was up to 12 times greater than the industry reported benchmarks for the general population. Switching to maniform states appeared more frequent in MR/MI patients on SSRI's.

For further information: ulzent@mail.ecu.edu

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Californa Mental Health and Developmental Disabilities Center: Update from the First Three Years

(accepted, not presented)

C. Sammons

With California's bifurcated developmental disabilities and mental health service systems, service providers' awareness, knowledge, and skills tend to be "either-or" rather than integrative. Under the auspices of the UCLA Tarjan Center (a University Center of Excellence in Developmental Disabilities), and in collaboration with more than forty community agencies, the Californai Mental Health and Developmental Disabilities Center (MHDDC) in 1999 launched its web site, www.mhddc.ucla.edu to provide a technical assistance hub to service providers, as well as consumers and families.

The MHDDC team presented its web site concept in a NADD Conference Workshop in 2998, where participants from various states shared their relevant experiences and provided feedback on our plans. Our poster presentation is intended as a stimulus for dialogue among conference participants, as we share what we call "learnings": our successes, or ongoing challenges, and our future plans. Presentation topics will include:

"An analysis of 100 emailed parent inquiries

"A discussion of the multiple funding issues, including how to balance an international mode of communication (internet) with a state-based target user group

"Recommendations for managing clinical advice-seeking emailed inquiries in a manner that is both ethical and caring

"Request for feedback from other states about the use of bulletin boards and chat rooms in university-hosted web settings

For further information: csammons@MEDNET.ucla.edu