Dual diagnosis: When there is a psychiatric disorder on top of a developmental or learning disorder IEP Day April 11, 2008 Joshua D. Feder, MD Faculty, Interdisciplinary Council on Developmental and Learning Disorders Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego School of Medicine
There are no ‘clean’ patients in child and adolescent psychiatry • Dual Diagnosis in education = Intellectual Disability + MH disorder • Dual Diagnosis in Mental Health = Psychiatric + Substance Problem • Lumpers: ‘It isall TS’, or ‘It isallAutism’ • Splitters: The person qualifies for multiple diagnoses
Practicalities: • List and prioritize target symptoms • Find the ‘lynchpins’ – e.g. alcohol, inattention, depression – it’s different for each individual
What are the diagnoses?
• • • •
And Depression And Substance Abuse And OCD And Psychosis
SOAPED Mnemonic: • Substance – drugs, medicines, poisons, supplements, etc. • Organic – brain trauma, seizures, tuberous sclerosis, etc. • Affective/anxiety/abuse – includes bipolar, depression, OCD, simple phobias, PTSD, attachment problems • Psychosis – that has its own mnemonic too…so many types and causes, with schizophrenias the big family here • Eating/elimination – anorexia, bulemia, enuresis, encopresis, etc. • Disruptive – including ADHD (inattentive, hyperactive, combined), oppositional defiant disorder, conduct disorders
Why does Diagnosis Matter? • Maybe a specific treatment (‘true’ bipolar disorder, seizures, ADHD, OCD, depression) • Maybe acceptance (genetic, PANDAS)
Screening overall Function (HEADS) • • • • •
Home/ discipline Education/ occupation Activities/ friends Drugs/ medications Sex/ close relationships
Assessment Ia: History of the Present Condition • “Chief complaint” – Why now? • History of ‘present illness’ – often chronic • The who, what, where, when, how, and why of the problem • List of target symptoms • Prior treatment (medical, therapies, etc.)
Assessment Ib: Developmental History • • • • • •
Pregnancy, labor & delivery – illnesses, toxins, APGAR scores, length & weight, complications, e.g., fetal distress, meconium staining, jaundice Infancy & early childhood – early regulation, attachment, and relationships; simple baby games Milestones: e.g., walking, talking & toilet training Common childhood illnesses – ear infections, strep, asthma Schools and educational function Friends and social function
Assessment Ic: Individual Differences in Regulation and Processing • Sensory processing and integration disorders • Motor tone, function and planning disorders • Central auditory processing disorders; receptive and expressive language disorders • Visual-spatial processing disorders • Praxis –executive functioning: ideas to plans to sequences to execution, adaptation
Assessment Id: Social-Emotional Growth • • • • • • •
Regulation and calm attention Capacity for warm engagement Beginning circles of interaction Beginning themes and symbols Complex symbols, communication, and play Logical thinking, cause and effect in social problem solving Higher levels – grey area thinking
Assessment 1e: More History… • • • • •
Family History – medical, psychiatric and developmental Growth - height, weight, head circumference, level of physical/ sexual development Medical review of systems – hearing, vision, allergies, cardiac, neurologic, surgery & anesthesia, serious medical illness, hospitalizations Psychiatric review of systems – covering the SOAPED areas, but also violence, aggression, suicidality, mistreatment, discipline, legal problems, moves, etc. Safety check: seatbelts & driving habits; sunscreen; securing meds, alcohol & toxins; hot water; helmets; hydration; guns & weapons; gates, pools, stairs, sockets, and trampolines
Assessment II: TIME WITH THE PERSON • Twice, minimally? Recommendations by professional organizations vs. realities of medical practice • The second time is almost always different, and gives the opportunity to check out ideas • See with family? Alone? • School visits? • Home visits? • Video?
Assessment III: Collateral Information • People – teachers, therapists, doctors, other caregivers, relatives, job coaches, etc. • Records – medical (labs, consults, growth charts, etc.); I.E.P.’s and school assessments; outside assessments, e.g. psychoeducational testing; OT, Speech, other reports
Variable presentation of psychiatric conditions • Colored by developmental level • Colored by individual differences (cognition, language, sensory processing – tactile, auditory, visual/spatial - also visual motor integration and motor planning, etc.) • Colored by quality of relationships with those nearby
Variable presentation of psychiatric conditions example: Depression in Early Childhood with Intellectual Disability • • • •
Developmental – may be active or aggressive, appear depressed Individual differences – might not have the words to express sadness, might instead be bothered more by sensory stimuli Relationships – might be helped a lot by a parent, but inconsolable at preschool, and acting out Might present as a child who is biting and seems to need sensory input, but after assessment you find a strong family history of depression, ability of one parent to soothe the child appropriately, etc., and depression become one of many possibilities to consider
Differential Diagnosis and Target Symptoms • Usually, going from chief complaint to diagnosis is not easy, and the best we can do is come up with a list of target symptoms and a list of possible diagnoses
Treatment:
• Targets • Priorities
GRIDDING OUT TARGET SYMPTOMS VS. TREATMENTS
Priorities: • • • •
SAFETY 1st Lynchpins ‘thorns’ And maybe a few things that are just as well left alone….
George Engel: Biopsychosocial model
• Biological: exercise, diet, sleep, nutrition, medication… • Psychological: all kinds of therapies, mind over illness • Social: family, school, etc. (WRAPAROUND concept)
YOUR EXAMPLES HERE:
Resources: • www.circlestretch.blogspot.com • Professional groups: e.g. AACAP, Your Child and Your Adolescent • Diagnosis support groups: e.g. ASA, TSA, CHADD, etc. • Looking for ‘Kevin’