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Current trends in mental health care for persons with mental retardation.

Mental health needs of people with mental retardation have become increasingly recognized in recent years, both in the United States and other parts of the world, as demonstrated by a proliferation of professional journal articles, books, conferences and newsletters reporting both relevant practical studies and conceptual issues (MacLean, 1993). These persons are often referred to as being "dually diagnosed."

This current interest in the diagnosis and treatment of mental illness in people with mental retardation is spearheaded by the National Association for the Dually Diagnosed (N.A.D.D.), founded in 1982 as a multidisciplinary and parent association specifically concerned with these issues. Most N.A.D.D. members reside in the United States or Canada. N.A.D.D. has been instrumental in directing national and international attention to clinical, programmatic, and policy issues concerning persons who have mental illness and mental retardation. Other organizations with similar interests include the American Association on Mental Retardation, which has organized a special interest group on mental health services, the American Psychiatric Association, which has a committee on developmental disabilities, and the European Association for Mental Health in Mental Retardation.

Prevalence

Results of recent studies (Benson, 1985; Jacobson, 1990; Reiss, 1994) have shown that twenty to sixty percent of persons with mental retardation have symptoms which appear to meet criteria for a psychiatric diagnosis as outlined in Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (American Psychiatric Press, 1987). Since each of these studies surveyed a particular group of persons with mental retardation, living in a particular setting, at least some of the variance in prevalence rates probably reflects particular demographic differences in the groups (King, et al. 1994), as well as significant differences in the research methodology employed. No general prevalence study has yet been reported for persons with mental retardation comparable to the widely cited National Institute of Mental Health Epidemiologic Catchment Area program, which assesses prevalence rates in the general population (Burke & Regier, 1988). While many experts feel that psychiatric disorders are more prevalent in people with mental retardation as compared with a nonretarded population (Menolascino & Fleisher, 1993), Reiss noted in 1994 that no research had at that time been reported directly comparing the rates of mental disorders in people with mental retardation versus the general population.

Diagnostic Challenges

Although most experts feel that the types of psychiatric disorders experienced by persons with mental retardation generally represent the full range of diagnostic classifications (Popper, 1988; Sovner & Hurley, 1989), the assessment of psychopathology in this population is clinically challenging. Mental disorders in individuals with mental retardation are often unrecognized, undiagnosed, and untreated. Some of the underestimation probably results from a phenomenon called "diagnostic overshadowing," where the presence of mental retardation decreases the diagnostic significance of an accompanying mental health disorder (Reiss et al. 1982). Sovner listed in 1986 four non-specific factors associated with mental retardation that influence the diagnostic process: intellectual distortion, the effects of the mentally retarded person's diminished ability to think abstractly and communicate independently; psychosocial masking, the effect of disabilities on the content of psychiatric symptoms; cognitive disintegration, the tendency of mentally retarded people to become disorganized under emotional stress; and baseline exaggeration, the fact that during a period of emotional stress, deficits in maladaptive behavior may significantly increase in severity.

Although the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders series was designed primarily to assess psychopathology in persons with relatively normal intelligence and psychosocial functioning, earlier versions (Third Edition, Revised, 1987) listed an advisory subcommittee on mental retardation. No such listing appears in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), 1994. Effects of mental retardation on the diagnostic process are not described. For a number of years many experts have felt that the DSM series can be used with people with mild or moderate mental retardation (Sovner, 1986; Menolascino & Fleisher, 1993; Torrey, 1993). More recently (King et al. 1994) demonstrated that by utilizing simultaneous clinical examination, staff interview, and medical review, it is possible to make psychiatric diagnoses in a population of institutionalized individuals with severe to profound mental retardation. (They also point out that the cohort they studied is by no means representative of the population with mental retardation as a whole.)

Clinicians can also utilize standardized diagnostic instruments specifically designed to assess behavioral disorders in people with mental retardation. Reiss in 1994 discussed ways of evaluating psychometric instruments including various features of psychometric evaluation criteria and self-report versus informant measures. A list of general psychopathology instruments, with a brief discussion of their general utility is also included. A variety of testing instruments were reviewed by Aman for the National Institute of Mental Health in 1991.

Treatment

Several treatment approaches have been demonstrated to be effective for persons with mental health disorders and mental retardation. While psychopharmacologic (drug) treatments are widely used, they are by no means the only form of treatment presently available. Psychotropic drugs, particularly neuroleptics, were often used in the past for this population in attempts to control behavior primarily by sedation, but recent emphasis on precision of diagnosis has encouraged treatment with the same wide range of medications, for the same purposes, as for individuals in the general population with mental health disorders. An international psychopharmacology consensus conference specifically concerned with drug use in persons with mental retardation was held at Ohio State University in June 1995. A book, scheduled for release in 1996, outlining the results of this consensus process is presently being developed by conference participants.

A number of studies have shown that psychotherapy with individuals with mental retardation is often effective in improving coping abilities or relieving symptoms of psychopathology (Fletcher, 1993). The principles of individual psychotherapy are essentially the same as with the general population (Levitas & Gilson, 1989; Rubin, 1982), but techniques must be adapted to the developmental skills of the individual being treated (Szymanski, 1980; Monfils & Menolascino, 1984; Blotzer & Ruth, 1995). Psychotherapy should enable the individual to identify needs, communicate feelings, and cope with internal conflicts or external stress. Therapy for this population is adapted to the individual's level of understanding, with clear, understandable language. Abstractions are translated by the therapist into concrete language, and reference is made to life events that the treated individual can understand.

Group therapy is an effective, often underestimated, treatment modality for people with mental retardation and mental illness (Fletcher & Duffy, 1993). Only a few references are found in recent professional literature regarding group therapy with persons with mental retardation (Pfadt, 1991; Nezu et al. 1991), but these authors do feel this treatment is effective. The few earlier published studies also document the efficacy of using this approach (Wilcox & Guthrie, 1957; Garlow et al. 1963; Rosen & Rosen, 1969, Richards & Lee, 1972). Group therapy offers several advantages. Group members have an opportunity to discuss common issues and interact with others with similar circumstances, feelings and goals. This commonality fosters group cohesion and peer support, which can help reduce feelings of isolation, defeat, and anxiety (Fletcher, 1984). Also, peer interaction provides a forum for problem solving, where individuals can develop effective coping strategies and improve interpersonal relationship skills.

Another treatment approach, anger management training, was described by Benson in 1990. This program, primarily designed for persons with mild to moderate retardation, includes identification of emotions, relaxation training, self-instructional training, and problem-solving skills.

Behavior management programs are widely used to modify inappropriate behavior and teach adaptive skills. Effective behavior management programs include a careful individual assessment and analysis of the function of the behavior (Gardner, 1988), utilizing a multi-modal behavioral treatment model (Gardner & Graeber, 1993).

In a somewhat different approach, McGee described in 1993 a combined psychotherapeutic and behavior modification program called gentle teaching, which involves development of a therapeutic relationship between therapist and individual he refers to as bonding. This technique attempts to redirect maladaptive behavior toward meaningful human engagement.

Recent Issues

Many individuals with both mental illness and mental retardation have been or are being deinstitutionalized, often without adequate community supports. This group comprises a complex population whose needs are often poorly identified, and who are often referred from one agency to another in frequently futile efforts to obtain adequate mental health services (Menolascino, 1988). While people of normal intelligence who experience emotional problems can usually avail themselves of clinical services within the mental health delivery system, persons with mental retardation who experience similar problems often do not have easy access to mental health services (Fletcher, 1988). These persons characteristically "fall through the cracks" in the delivery system because neither the mental health system nor the mental retardation system will accept responsibility for their care and treatment (Fletcher & Menolascino, 1989; Stark et al. 1988). Services have often been inaccessible to dually diagnosed persons because of bureaucratic system boundaries (Fletcher et al. 1989). Agencies usually are licensed and regulated either by a state department of mental health or a state department of mental retardation. Access to either service delivery system is often based on a diagnosis of exclusion (Fletcher, 1988), where persons with mental retardation are excluded from mental health services and persons with mental health diagnoses are excluded from mental retardation services.

To solve all these problems of access to services, both the mental health and mental retardation service structures must be willing to cross boundaries and transcend the issues of primary diagnosis and territorialism which have long impeded the effective delivery of services (Reiss, 1993). A coherent policy is vital to meet both the developmental and psychiatric needs of those with a dual diagnosis. Effective service models utilize both existing mental health and mental retardation systems. A best approach usually is to treat the acute mental health needs of persons with mental retardation in community-based psychiatric settings, and to meet their long-term needs in community programs specifically designed for persons with mental retardation, with secondary support provided by the mental health system (Fletcher & Menolascino, 1989; Menolascino, 1989; Davidson et al. 1995).

In the past the lifestyles of persons with mental health problems, mental retardation, or both were regulated by the program models that were developed for them; today the trend is toward a service system that is individualized, based on personal choice and satisfaction. Thus the role of the human service system now is to supply whatever support may be necessary to enable affected individuals to improve functioning, leading to personal success and satisfaction in the environment of their choice.

References

Aman, M. (1991). Assessing psychopathology and behavioral problems in persons with mental retardation: A review of available instruments. Washington, DC: U.S. Department of Health and Human Services.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Benson, B. A. (1985). Behavior disorders and mental retardation: Associations with age, sex and levels of functioning in an outpatient clinic sample. Applied Research in Mental Retardation, 21, 79-85.

Benson, B. A. (1990). Anger management training. In A. Dosen, A. van Gennep & G. J. Zwanikken (Eds.), Treatment of mental illness and behavioral disorder in the mentally retarded: Proceedings of the International Congress. Leiden, Netherlands: Logon.

Blotzer, M. A. & Ruth, R. (1995). Sometimes you just want to feel like a human being: Case studies of empowering psychotherapy with people with disabilities. Baltimore, MD: Brookes.

Burke, J. D. & Regier, D. A. (1988). Epidemiology of mental disorders. In J. A. Talbot, R. E. Hales, & S. C. Yudofsky (Eds.), Textbook of Psychiatry (pp. 76-89). Washington, DC: American Psychiatric Press.

Davidson, P. W., Cain, N., Sloane-Reeves, J. E., Giesor, V. E. Quijano, L. E., Van Heyningen, J., & Shoham, I. (1995). Crisis intervention for community-based individuals with developmental disabilities and behavioral and psychiatric disorders. Mental Retardation, 33, 21-30.

Fletcher, R. (1984). A model day treatment service for the mentally retarded-mentally ill population. In F. J. Menolascino & J. Stark (Eds.), Handbook of mental illness in the mentally retarded. New York: Plenum Press.

Fletcher, R. (1988). County systems model: Comprehensive services for the dually diagnosed. In J. A. Stark, F. J. Menolascino, M. H. Albarelli, & V. C. Gray (Eds.), Mental retardation and mental health: Classification, diagnosis, treatment, services. Berlin: Springer-Verlag.

Fletcher, R. J. (1993). Mental illness-mental retardation in the United States: Policy and treatment challenges. Journal of Intellectual Disability Research, 37, (Suppl. 1), 25-33.

Fletcher, R. & Duffy, T. (1993). Group therapy with mentally ill-mentally retarded persons. In R. Fletcher & A. Dosen (Eds.), Mental health aspects of mental retardation: Progress in assessment and treatment. Lexington, MA: Lexington Books.

Fletcher, R., Holmes, P., Keyes, C., & Schloss, P. (1989). Linking research and practice: An integrated approach to dual diagnosis. In R. Fletcher & F. Menolascino (Eds.), Mental retardation and mental illness: Assessment, treatment and services for the dually diagnosed. Lexington, MA: Lexington Books.

Fletcher, R. & Menolascino, F. (Eds.). (1989). Mental retardation and mental illness: Assessment, treatment and services for the dually diagnosed. Lexington, MA: Lexington Books.

Gardner, W. I. (1988). Behavioral therapies: Past, present, and future. In J. A. Stark, F. J. Menolascino, M. H. Albarelli, & V. C. Gray (Eds.), Mental retardation and mental health: Classification, diagnosis, treatment, services. Berlin: Springer-Verlag.

Gardner, W. I. & Graeber, J. L. (1993). Treatment of severe behavioral disorders in persons with mental retardation: A multimodal behavioral treatment model. In R. Fletcher & A. Dosen (Eds.) Mental health aspects of mental retardation. New York: Lexington Books.

Garlow, L., Butler, A., Einig, K. & Smith, J. (1963). An approach of self-attitudes and behavior following group psychotherapy with retarded young adults. American Journal of Mental Deficiency, 67, 892-898.

Jacobson, J. W. (1990). Do some mental disorders occur less frequently among persons with mental retardation: American Journal on Mental Retardation, 94, 596-602.

King, B. H., DeAntonio, C., McCracken, J. T., Forness, S. R., & Ackerland, V. (1994). Psychiatric consultation in severe and profound mental retardation. American Journal of Psychiatry, 151, 1802-1808.

Levitas, A. & Gilson, S. (1989). Psychodynamic psychotherapy with mildly and moderately retarded patients. In R. Fletcher & F. Menolascino (Eds.), Mental retardation and mental illness: Assessment, treatment and services for the dually diagnosed. Lexington, MA: Lexington Books.

MacLean, W. E., Jr. (1993). Overview. In J. L. Matson & R. P. Barrett (Eds.), Psychopathology in the Mentally Retarded. Boston, MA: Allyn & Bacon.

McGee, J. (1993). Gentle teaching for persons with mental retardation: The expression of a psychology of interdependence. In R. J. Fletcher & A. Dosen (Eds.), Mental health aspects of mental retardation: Progress in assessment and treatment. Lexington, MA: Lexington Books.

Menolascino, F. (1988). Mental illness in the mentally retarded: Diagnostic and treatment issues. In J. A. Stark, F. J. Menolascino, F. Albarelli, H. Michael, & V. Gray (Eds.), Mental retardation and mental health: Classification, diagnosis, treatment, services. Berlin: Springer-Verlag.

Menolascino, F. (1989). Overview: Promising practices in caring for the mentally retarded-mentally ill. In R. Fletcher & F. Menolascino (Eds.), Mental retardation and mental illness: Assessment, treatment and services for the dually diagnosed. Lexington, MA: Lexington Books.

Menolascino, F. & Fleisher, M. (1993). Mental health care in the mentally retarded: Past, present, and future. In R. Fletcher & A. Dosen (Eds.), Mental Health Aspects of Mental Retardation: Progress in Assessment and Treatment (pp. 18-41). Lexington, MA: Lexington Books.

Monfils, M. & Menolascino, F. (1984). Modified individual and group treatment approaches. In F. J. Menolascino & J. Stark (Eds.), Handbook of mental illness in the mentally retarded. New York: Plenum Press.

Nezu, C. M., Nezu, A. M., & Arean, P. (1991). Assertiveness and problem-solving training for mildly mentally retarded persons with dual diagnoses. Research in Developmental Disabilities, 12, 371-386.

Pfadt, A. (1991). Group psychotherapy with mentally retarded adults: Issues related to design, implementation, and evaluation. Research in Developmental Disabilities, 12, 261-285.

Popper, C. W. (1988). Disorders usually first evident in infancy, childhood, or adolescence. In J. A. Talbot, R. E. Hales, & S. C. Yudofsky (Eds.), Textbook of Psychiatry (pp. 7689). Washington, DC: American Psychiatric Press.

Reiss, S. (1993). Assessment of psychopathology in persons with mental retardation. In J. L. Matson & R. P. Barrett (Eds.), Psychopathology in the mentally retarded. Boston, MA: Allyn & Bacon.

Reiss, S. (1994). Handbook of challenging behavior: Mental health aspects of mental retardation. Worthington, OH: IDS Publishing.

Reiss, S., Levitan, G. W., & Szyszko, J. (1982). Emotional disturbance and mental retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 87, 396-402.

Richards, L. D. & Lee, K. A. (1972). A group process in social rehabilitation of the retarded. Social Casework 1973, 53, 30-38.

Rosen, H. G. & Rosen, S. (1969). Group therapy as an instrument to develop a concept of self-worth in the adolescent and young adult mentally retarded. Mental Retardation, 18, 53-55.

Rubin, R. L. (1982). Bridging the gap through individual counseling and psychotherapy with mentally retarded people. In F. J. Menolascino & B. McCann (Eds.), Bridging the gap. Baltimore, MD: University Park Press.

Sovner, R. (1986). Limiting factors in the use of DSM-III with mentally ill-mentally retarded persons. Psychopharmacology Bulletin, 22, 1055.

Sovner, R. & Hurley, A. (1990). Assessment tools which facilitate psychiatric evaluations and treatment. Habilitative Mental Healthcare Newsletter, 9.

Stark, J., Menolascino, F., Albarelli, H., & Gray, V. (Eds.). (1988). Mental retardation and mental illness: Classification, diagnosis, treatment, services. Berlin: Springer-Verlag.

Szymanski, L. S. (1980). Individual psychotherapies with retarded persons. In L. Szymanski & P. Tanquay (Eds.), Emotional disorders of mentally retarded persons. Baltimore, MD: University Park Press.

Torrey, W. C. (1993). Psychiatric care of adults with developmental disabilities and mental illness in the community. Community Mental Health Journal, 29, 461-476.

Wilcox, G. T. & Guthrie, G. M. (1957). Changes in adjustment of institutionalized female defectives following group psychotherapy. Journal of Clinical Psychology, 13, 9-13.
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Author:Poindexter, Ann R.
Publication:The Journal of Rehabilitation
Date:Jan 1, 1996
Words:2899
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