Daniel J. Baker, Ph.D.
The Boggs Center on Developmental Disabilities
UMDNJ - Robert Wood Johnson Medical School
Richard Blumberg, Ph.D.
The College of New Jersey
The Boggs Center on Developmental Disabilities
UMDNJ - Robert Wood Johnson Medical School
Support for persons with the dual diagnoses of developmental disabilities and mental illness generally includes two primary modes of intervention for: behavioral intervention and psychiatric intervention (Baker, Blumberg, & Freeman, 2002). Behavioral interventions were developed from early research in experimental and applied behavior analysis (Allyon, 1959, Bijou & Peterson, 1961). These research efforts emphasized the importance of considering the interaction between behavior and environment in order to identify and verify the variables that reinforced problem behaviors (Carr & Newsome, 1985, Mace, 1994). Psychiatric interventions typically include counseling or pharmacotherapy, and are selected based on a diagnosis of the mental illness experienced by the individual. These psychiatric and behavioral interventions often are managed separately in community settings. Effective treatment of problem behaviors for persons with developmental disabilities and mental illness dual diagnoses requires inter-disciplinary collaboration between psychiatric professionals and persons with experience in behavior support. Consideration of these theoretical and conceptual perspectives regarding behavior is necessary.
The purpose of this article is to encourage an interdisciplinary approach for supporting individuals with developmental disabilities and mental illness (DD/MI) by discussing how an underlying psychiatric disorder can be seen an establishing operation (i.e., an event which changes the likelihood of problem behavior by altering the reinforcing and punishing value of consequences in an individual's environment). One way to identify an establishing operation is by using functional assessment, a process used by professionals providing behavioral intervention.
A functional assessment of problem behavior is defined as a set of processes that gather information about an individual's behavior and the variables that predict and maintain the occurrence of that behavior (Horner, 1994). In recent years, functional assessments have become common in efforts to support positive behavior in schools and community settings for persons with disabilities (O'Neill et al., 1997). A functional assessment has four goals: (a) to define the problem behavior in a clear and measurable manner, (b) to describe the events, times, and situations that predict both the occurrence and nonoccurrence of problem behavior, (c) to identify the consequences maintaining problem behavior, and finally, (d) to generate and confirm hypotheses regarding the function(s) maintaining problem behavior (O'Neill et al., 1997).
Antecedent Events and Establishing Operations. The functional assessment process includes a significant focus on two categories of events that precede the occurrence of problem behavior: antecedent events and establishing operations (O'Neill et al., 1997). Antecedents are events that immediately precede the occurrence of problem behavior and are assumed to be controlling relations. Demands, critical feedback, or the types of tasks presented to an individual are all examples of antecedents that may occasion problem behavior. Events or internal states that alter momentarily reinforces and punishers in the environment are described as establishing operations (Catania, 1992; Kennedy, 1999; Michael, 1988) or setting events (Kantor, 1959; Gardner,& Sovner, 1994). These terms come from two theoretical backgrounds, the operant analysis of behavior and interbehavioral psychology. Although the two concepts do not overlap entirely, they both refer to an event or internal state which occurs at one point in time and which changes the likelihood of a problem behavior occurring at a later point by momentarily altering the value of consequences (Iwata et al., 1994).
Establishing operations can include three potential categories: environmental, social, or physiological factors (Catania, 1992; Gardner & Sovner, 1994; Kennedy, 1999; Michael, 1988). Environmental establishing operations include factors such as disruption of routines or common events. Social establishing operations may include factors such as too much interaction, too little interaction, or unpleasant interactions with others. Illness, pain, sleep deprivation, hunger and medication changes are just a few examples of internal factors that increase the likelihood of problem behaviors. It is important to note that establishing operations affect the reinforcing or punishing qualities of consequences, thereby influencing the likelihood of an antecedent event occasioning problem behavior.
Care providers must be aware of both types of events and examine controlling relationships that exist. An individual may become upset and engage in aggressive acts when prompted to participate in a non-preferred task only when already tired. A complexity occurs when the care provider does not have access to private states, such as exhaustion, or is not aware of observable phenomena, such as sleep patterns.
Psychiatric Illness and Problem Behavior
The authors argue that in many cases, psychiatric illnesses may act as an establishing operation for the problem behavior in individuals with developmental disabilities (Baker, Blumberg, & Freeman, 2002). Physiological influences can be conceptualized as internal events within a person's biological system that partly determine an individual's response to the environment (Catania, 1992; Singh, Ellis & Axtell, 1998). When a physiological event increases the likelihood that a person will engage in problem behavior, it can be thought of as an establishing operation (Carr & Smith, 1995; Iwata, 1994). The following case illustrates this point: consider the example of a person who lived in a small group home with three other individuals. On a given day, four staff persons were scheduled to work so that people could attend a long anticipated community event. Unfortunately, two of the staff people were sick leaving only two staff on-duty, and insufficient staffing precluded attending the community event. Most of individuals were disappointed, but one man with a diagnosed mental health disorder reasoned that the two sick staff feigned illness and the other two were too busy to pay attention to him. He became suspicious whenever they interacted with others. When he and others were asked to assist in a household task, he refused and began to verbally assault staff the individuals around him. When asked to calm himself, he physically attacked the staff on duty.
The example illustrates how a common establishing operation (staff calling-in sick, denying a preferred outing) and an antecedent (request to perform a common household task) evoked problem behaviors for the person with the diagnosed mental health disorder. Privately occurring events described as delusional thought patterns served as an additional establishing operation affecting both the evoking properties of the antecedent event, the intensity of his response, and the internal reinforcing effects of the consequences.
Now consider the enigmatic and often misunderstood role of depression in the occurrence of problem behavior in persons with dual diagnoses. A young woman with mild mental retardation has been increasingly withdrawn. She lives in a small group home and spends most of the day in her room. She is in danger of losing her job due to frequent absences. In the morning, the group home care providers awaken her and give her prompts to get ready for work. She refuses and uses some profanities. A little time passes, and concerned that she will be late again, a preferred staff member repeats the prompt to be up and get ready. The young woman screams at her, and hits the staff member. The staff member retreats, frustrated and angry in response to the assault. Staff begin to speak of her as lazy, resistive and aggressive. They meet and decide to develop a behavioral intervention using a mixture of incentives (access to preferred activities) and punishments (loss of preferred activities) to get her to go to work and be more involved in social activities. The intervention is unsuccessful. The young woman becomes increasingly withdrawn and aggressive. She refuses food and is eventually hospitalized.
In this case, the young woman's depressive illness serves as an establishing operation that reduces the reinforcing value of work (paycheck) and social activities (interaction). Due to her depression, the young woman experiences increased feelings of fatigue and lack of enjoyment in previously preferred activities. Prompts to go to work or engage in activities are perceived as aversive events triggering refusals and aggression. When the young woman displays physical aggression, staff become fearful and cease prompting her, making it more likely that aggressive behavior will be repeated. Because staff lack an understanding of the relationship between depressive symptoms and the young woman's behavior, their attempts at intervention not only fail, but make matters worse.
Consideration of Psychiatric Disorders in Functional Assessment. Including consideration of psychiatric disorders as an establishing operation in the functional assessment process will assure that attention is paid to all aspects of the individual's life. In the absence of this type of step, concerns related to behavior and concerns related to mental health will separately considered, leading to a lack of inter-disciplinary understanding and separate management of interventions. Each theoretical perspective has much to offer. The functional assessment process can be valuable in gathering information about the relationship between the mental health factors in a person's life and other factors occurring in the person's environment (e.g., home, work, family, and social life). Information related to an individual's psychiatric disorders assists professionals in understanding the interaction between physiological and environmental factors that influence behavior and wisely selecting complementary interventions. Considerations of behavior typically focus on the environmental influences while excluding private events (i.e., internal events known only to one-self). The authors argue that consideration of private events has a significant place within both functional assessment and treatment for persons with DD/MI. Gardner and Sovner noted this theme previously in an examination of self-injury in which this behavior was considered from a clinical psychologist's perspective (Gardner) and from a psychiatrist's perspective (Sovner) (Gardner & Sovner, 1994). They integrated the relative contributions of the biochemical and psychosocial aspects of the originating and maintaining conditions of self-injury in people with developmental disabilities.
The foundations of behavior analysis assert that behavior is lawful, rational to the individual, and understandable (Skinner, 1981). The functional assessment process seeks to establish these relationships and make clear the logic and sense of behavior. Mental illness often makes these relations difficult to ascertain, as private events are a part of the internal logic and play a critical role in the establishment of patterns. Care providers for persons with DD/MI often describe problem behaviors as making no sense and coming like a bolt out of the blue. In a functional assessment, the events and situations that control and maintain a behavior are noted and examined, thus creating sense out of the behavior (Horner, 1994). Private events related to the mental illness may create patterns of behavior reinforced by escape (e.g., from stressful situations) or the opportunity to obtain certain events, people, or activities (e.g., the change to engage in obsessive compulsive behavior). Understanding that these behaviors serve a function for the individual, no matter how difficult it is to understand, provides a method for linking services for individuals utilizing the best of both psychiatric and behavioral intervention. Combining information related to psychiatric symptoms into a behavioral model also eliminates the frequently asked dichotomous question, "is it behavior or is it mental illness?" The most accurate answer to this question is often "both," and without an understanding of how the two interact, a real understanding of the question is impossible (Baker, Blumberg, & Freeman, 2002). Sharing information among the professionals and care providers from various areas of service and theoretical orientation can assist in explaining the behaviors of a population whose complex needs have challenged existing service systems. Developing models of behavior that consider includes mental illness and applied behavior analysis will make a difficult job easier.
Recommendations in the Design of Proper Supports For Persons With The Dual Diagnoses Of Developmental Disabilities And Mental Illness
As noted throughout this article, there are numerous challenges in supporting this population. The authors wish to conclude this article with a set of recommendations that professionals and care-givers can use as they create effective supports for persons with DD/MI.
Interdisciplinary teaming. Create an interdisciplinary team with representation from both behavioral and mental health fields of inquiry. While this often is done for many types of persons, effective team collaboration is of primary importance for this population. In the absence of this sharing, support will be difficult if not impossible.
Psychiatric Diagnosis. Obtain a psychiatric diagnosis prior to completion of a functional assessment. It is best to obtain this from a psychiatrist familiar with developmental disabilities. If the individual is not a competent historian, or has difficulty communicating, others who know the person well should accompany the individual to the appointment in order to provide the relevant information. Prior to the visit, it is useful to contact the psychiatrist and ascertain what types of information the psychiatrist would like to see or find useful.
Functional Assessment. The interdisciplinary team should perform a functional assessment considering how any relevant psychiatric disorder might operate as a potential establishing operation. Mental health professionals should participate in the functional assessment completion. It is important as well to consider as well how the psychiatric disorder might increase the salience of environmental events. Information concerning these should inform hypothesis development and subsequent interventions
Plan of Treatment. Care-providers should complete a plan of treatment and intervention that addresses both psychiatric and behavior analytic components of the problem behavior (Baker, Blumberg, & Freeman, 2002). It is of critical importance that lifestyle and wellness are seen as valid intervention components. The functional assessment process will note situations associated with problem. Intervention approaches that involve changing the time of day an activity occurs or teaching an individual to identify signs of increasing arousal and engage in a relaxation routine should be considered (Baker, Blumberg, & Freeman, 2002).
Multiple Causes. Behavior initially maintained by physiological or psychiatric influences over time can acquire secondary social motivations. A person with whom an author worked began to emit self-injurious behavior with a psychiatric causation, and noted that sympathy from family members happened following the behavior. Over time, a second motivating factor, social attention, became an additional complicating motivator. Another individual, for example, learned that episodes of unusual speech typically resulted in excuse from work-related tasks. That individual learned to produce such comments when asked to do chores, regardless of whether she was experiencing delusions (Baker, Blumberg, & Freeman, 2002). The problem behavior may continue after the illness has abated because the individual is reinforced by extra attention from caregivers.
In conclusion, persons with the dual diagnoses of developmental disabilities and mental illness will require support from both behavioral and psychiatric perspectives. While these supports are managed separately in most cases, cross discipline design of support will be more effective. A functional assessment including the mental illness as an establishing operation will serve to bring these perspectives together. This functional assessment can integrate physiological, psychological, and behavioral points of view, both in terms of understanding the behavior and wisely designing comprehensive and effective interventions. The ultimate goal of supports here is reduce barriers created by problem behaviors and provide a reasonable and person-directed quality of life.
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