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Children with co-occurring Developmental Diagnoses and Mental Health Disorders

Children with co-occurring Developmental Diagnoses and Mental Health Disorders. EMHI 1/26/2011 Penny Knapp MD Penny.knapp@dmh.ca.gov. Outline. ETIOLOGIES OF DD/DI OVERLAP of DD/DI WITH SED SCREENING DIAGNOSIS TREATMENT CA SERVICES. I - ETIOLOGIES OF DD/DI. Genetic

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Children with co-occurring Developmental Diagnoses and Mental Health Disorders

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  1. Children with co-occurring Developmental Diagnoses and Mental Health Disorders EMHI1/26/2011 Penny Knapp MD Penny.knapp@dmh.ca.gov

  2. Outline • ETIOLOGIES OF DD/DI • OVERLAP of DD/DI WITH SED • SCREENING • DIAGNOSIS • TREATMENT • CA SERVICES

  3. I - ETIOLOGIES OF DD/DI • Genetic • Intra-uterine toxins: alcohol, nicotine, cannabis • Acquired Childhood Diseases --infection (HIV, meningitis, encephalitis) --cranial trauma (automobileaccident, shaken baby syndrome) • Other (asphyxia, near drowning,intoxications)

  4. Fetal Alcohol Syndrome: FAS • FAS is the most frequent preventable cause of MR • But, most individuals with FAS are not retarded; only 25% have IQ < 70 • Children with more dysmorphic features tend to have lower IQ scores.

  5. Cognitive and behavioral features in FASD • Impairment of both verbal and nonverbal learning & memory. • Language: marked deficits in word comprehension & naming ability. • Attention (often meet criteria for ADHD), visuo-spatial and executive function impairment • Motor: fine and gross motor • Adaptive functioning: social, aggression, beyond what can be explained by low IQ

  6. Mental Health problems in FAS (90%) • Conduct problems in school >60% • Trouble with the law or incarceration 45-60% • Alcohol or drug dependence 30-45% • Dependent living >80%

  7. II - OVERLAP of DD/DI WITH SED • Mental disorders more common in persons with DD/ID than general population. • The disorders themselves are essentially the same - hence use DSM IV-TR (or after 2012, DSM-V. • Clinical presentations may be modified by poor language skills & life circumstances, so DX might derive more from report & observable behavioral symptoms.

  8. III - SCREENING • Standardized tools should be used • (e.g. ASQ, ASQ-SE, PEDs, PEDS DM, MCHAT) • AAP has published algorithms for screening/treating developmental disorders (PEDIATRICS 2001,2006) and mental health disorders (2010) • http://pediatrics.aappublications.org/content/vol125/Supplement_3 plus toolkit - see AAP.org • California First 5 Special Needs project has developed a protocol:

  9. Statewide Screening Collaborative • The CSSC is supported via facilitation & TA provided by First 5 California, CDPH, MCAH, and the WestEd Center for Prevention and Early Intervention (CPEI). • Participating agencies and organizations include state &local public and private entities concerned with early childhood health, mental health, child development, developmental disabilities, and social services. • http://www.cdph.ca.gov/programs/ECCS/Pages/StatewideScreeningCollaborative.aspx

  10. Comorbidity of MR and mental illness • PDD, ADHD, CD, Tic disorders, stereotypic movement disorders, Schizophrenia, Mood disorders, Anxiety disorders, PTSD, OCD, Eating disorders, Personality disorders Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults With Mental Retardation and Comorbid Mental Disorders. J. Am. Acad. Child Adolesc. Psychiatry, 1999, 38 (12 Supplement):5S-31S.

  11. Virtual DD/ID? Environmental Problems and Behavioral Syndromes can interfere with normal development • Psychosocial deprivation • Neglect & attachment disorders • Maltreatment • Emotional and behavioraldisorders Evaluation should include both development and social-emotional development

  12. Developmental Disorders that may not have developmental delay Autistic spectrum • Aspergers syndrome, high-functioning PDD • Multisystem Developmental Disorder (MSDD) - sensorimotor, attention & organization, regulatory, communication development problems with autistic features • http://www.dbpeds.org/articles/detail.cfm?TextID=96).  

  13. IV - DIAGNOSIS • Dx assessment synthesizes biological, psychological and psychosocial context of mental disorders for…. • ….comprehensive Tx planning integrating family counseling, pharmacological, educational, habilitative, and milieu interventions AACAP (1999) Practice Parameters

  14. Rating scales Standardized scales should be used: examples: • Reiss Screen for Maladaptive Behavior 8 psychopathology scales, 6 maladaptive behavior scales. Total core helps discriminate if a psych. DX. • Aberrant Behavior Checklist (ABC) 58 items rating behaviors --> 5 subscales, informant-based (useful w non-verbal pts)

  15. DM-ID • The Diagnostic Manual – Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability, developed by the National Association for the Dually Diagnosed (NADD) with (APA), is a diagnostic manual designed to be an adaptation of the DSM-IV-TR. • Diagnostic Manual – Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability, has been abridged for clinical usefulness.

  16. DM-ID (2) Derived from literature review, evidence base, and expert consensus. Response to these problems: • Individuals with ID are 2-4x likelier to have psychiatric disorders • Self report (per DSM) is compromised by verbal limitations, “cloak of competence,” “acquiescence bias”, intellectual distortion, psychosocial masking & cognitive disintegration.

  17. Adapted criteria – example Major Depressive Episode DSM-TR: 4 or more of the following symptoms 1 depressed mood, loss of interest • Adapted criteria : observable signs, e.g. sad facial expression, flat affect,, appearing angry, agitated 2 diminished interest in activities (no adaptation) • significant (5%) weight loss (in children, failure of expected weight gain) (no adaptation or possibly agitation or obsession about food) • Insomnia etc (no adaptation)

  18. DM-ID, Major Depression, continued • Psychomotor agitation (no adaptation, but add reported behavior) • Fatigue, loss of energy (no adaptation) • Feelings of worthlessness or excessive guilt (no adaptation, but observers may note negative self-statements etc)

  19. Behavioral Phenotypes of genetic disorders • Specific and characteristic behavior repertoire exhibited by patients with a genetic or chromosomal disorder. • Consistently associated with the condition

  20. Donna (2 years) • “Stubborn” • Attention problems • Non-compliant • Repeats certain actions, has to arrange things in certain ways • Delayed language

  21. Trisomy 21 • Developmental language delay • Expressive language more affected than receptive • Good language pragmatics • Visual processing better than auditory

  22. Trisomy 21 • SIB, injury of others • Difficulty acquiring new skills • Challenging behavior that causes social isolation • Anxiety, depression, withdrawal

  23. Trisomy 21 - Medical • Congenital Heart disease (up to 50%): AV septal defects, VSD, PDA, other) • GI - duodenal atresia (2%), Hirschsprung disease • Hearing loss (40-75%) • Eye disorders (60%) • Leukemia 1:150 • Thyroid disorders (occasional) Medical Checklist www.ndsccenter.org/resources/healthcare.pdf

  24. Why study behavioral phenotypes? • Helps DBPs and CHPs to identify conditions, make referrals for genetic diagnosis and counseling • treatment planning • contribute to research and syndrome delineation. Moldavsky - J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(7):749-761.

  25. Understanding genetic underpinning of behavior • Altered genetics --> metabolism of neurotransmitters or their receptors (e.g. influence of MAO-A/B on aggression) • Genetic influence on brain development (e.g. altered temporal lobe, decreased vermis in Fragile X) • Abnormal hormonal influence on brain development (e.g. Turners)

  26. V - TREATMENT • Treatment planning • Behavioral emergencies • Psychosocial interventions • Pharmacotherapy

  27. Treatment Planning Children 0-3 years: • Develop individual family service plan (IFSP) • Early Intervention (EI) through local RC • Provide supportive services: physical therapy (PT), occupational therapy (OT), speech and language (S/L) as needed Children 3 years and older: • transition from IFSP to school-based services -provide an individualized education plan (IEP) • continue PT, OT, S/L as needed

  28. Behavioral Emergencies • Ensure safety first • Evaluate medical causes (e.g. constipation, infection --> irritability --> crisis) • Evaluate if adverse effects of existing medications • Consider Rx medications that worked in past. • Evaluate/re-evaluate environmental triggers • Plan to prevent recurrence of crises

  29. Psychosocial interventions Tailor the modality to the patient e.g. psychotherapy (if verbal), group therapy, milieu interventions, behavioral (e.g. ABA, PBS) Parent support & parent-to-parent networking

  30. Parents • Confusion - alleviate with solid information • Stigma, guilt, apprehension • Isolation - alleviate with parent networking • Difficulty finding services - assist, advocate • Extra challenges navigating adolescence

  31. Psychopharmacology • Review nonpsychiatric drugs that may --> behavioral or emotional symptoms, e.g. beta blockers, which may --> depressive symptoms, and phenobarbital (epilepsy) --> may result in impulsive, aggressive behavior. • “The medication evaluation:” avoid “affectionless control” that interferes with capacity; incorporate review with team of the whole patient.

  32. Medication for DD/ID • Before RX: rule out non-psych causes of behavior, collect behavioral data, consider least intrusive intervention (may be medication). • When prescribing: • Integrate with overall treatment • Do not diminish functional status • Use lowest effective dose • Monitor outcomes

  33. IV Services in CA public system • Eligibility for RS services: disability that begins before 18th birthday, expected to continue indefinitely and --> substantial disability as defined in Section 4512 of the California Welfare and Institutions Code. • Early Start: children 0-36 months: per Section 95014 of the California Government Code. • Prevention Program: www.php.com/services/early-intervention-infants-toddlers-0-3

  34. Modification of Early Start service eligibility 7/09 • For children aged 0-23 months, a significant delay is a 33% delay in one or more areas. • For children aged 24-36 months, a significant delay is 50% in one area or 33% in two or more areas. • The areas of delay are unchanged and are: cognitive development, physical and motor development, communication development, social or emotional development, or adaptive development.

  35. Mental Health Services • Regardless of whether the individual has a Dx of DD/ID and/or is a Regional Center client, they are eligible for mental health services if they are a Medical beneficiary and meet “medical necessity” ie Axis 1 diagnosis (DSM TR) + functional impairment + care required is beyond scope of PPCP.

  36. Other References http://www.nlm.nih.gov/medlineplus/developmentaldisabilities.html Crosswalk  of DSM codes to ICD-9 codes: http://www.qualitycareforme.com/documents/provider_careconnection_icd_9crosswalk.pdf DSM-V (due out in 2012) http://www.psych.org/MainMenu/Research/DSMIV/DSMIVTR/CodingUpdates.aspx overview article on developmental disabilities: • http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=10322&cn=208

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