Download MRDD Welcome to My World - Weiss

“MR/DD: Welcome To My World”
Dr. Robb Weiss, Psy. D., BCBA-D
Chief Psychologist
Director Behavioral Health Services
San Angelo State Supported Living Center
[email protected]
Texas Psychological Association
2015 Annual Convention
The Future of Psychology Practice in the Era of
Health Care Reform
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2015
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Saturday 1:00PM-4:00PM 3 hours PD Workshop El
Rincon MR/DD: Welcome To My World (W21)
This presentation will provide an overview of many aspects of service delivery
to individuals diagnosed with intellectual/developmental disabilities. It is an
overview of practical psychological/behavioral core concepts, definitions,
terms, and resources in the field of ID/DD. It reviews historical information,
legal precedent, legislative issues, conceptual information, clinical aspects of
assessment, diagnosis, treatment, standards and guidelines, continuum of
care, dual diagnosis, relevant organizations, evolution of necessary
credentials and knowledge base for working in the field, quality
assurance/data collection, policy/regulatory standards, and competencies.
Attendees will:
Learn fundamental theory and practice in the field of ID/DD
Learn to apply concepts in the field of ID/DD
Develop specific skills, competencies, and points of view needed by
professionals in the field of ID/DD
Presenter(s): Robb Weiss, Psy.D., BCBA-D
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Bio
Dr. Robb Weiss, Psy. D., BCBA-D is currently the Chief Psychologist and Director Behavioral Health Services at the San
Angelo State Supported Living Center in Carlsbad, Texas. He was previously the Chief of Psychology at Central State
Hospital (CSH) in Milledgeville, Georgia. It was the largest mental health facility in the state system. In addition, he was
the Coordinator of Psychology of the Developmental Disabilities Division and Coordinator of Psychology of Psychiatric
Treatment at CSH. He began employment at CSH 07/01/03. He has an extensive curriculum vitae dating back to 1977.
He is licensed to practice in Tennessee, Kentucky, Mississippi, Florida, Georgia, and Texas. He is a Board Certified
Behavior Analyst-Doctoral Designation (BCBA-D). He graduated from Nova Southeastern University (then called Nova
University) with his Doctor of Psychology degree 02/23/87. He bypassed the M.S. in Clinical Psychology degree at
Mississippi State University. He has a triple major in his undergraduate studies at the University of South Florida e.g.
microbiology, chemistry, and psychology. He obtained an Associate of Arts degree in pre-medical science from Miami
Dade Community College (then called Miami Dade Junior College). He is a member of the American Psychological
Association, the Texas Psychological Association, and the Psychological Association of Greater West Texas. He is a past
member of the following High IQ organizations: ISPE (International Society of Philosophical Enquiry) 99th Percentile,
Intertel 99th Percentile, and is a current member of the TNS (Triple Nine Society) 99.9th Percentile. His areas of interest
are in Geropsychology and he is credited in a nationwide video and accompanying textbook on providing group therapy
in Nursing Homes; and in the field of Intellectual Disabilities/Developmental Disabilities (ID/DD) previously referred to
as MR/DD. He is a certified suicide risk assessor with the national QPR organization. He has presented at both the local
chapter of the Psychological Association of Greater West Texas, and at the Texas Psychological Association annual
convention on “MR/DD: Welcome To My World”. In addition, he has presented at the national level at the Association
of Professional Developmental Disabilities Administrators (APDDA) on “Issues Affecting Behavioral Interventions”, and is
its’ Approved Continuing Education Coordinator (ACE) for the Behavior Analyst Certification Board (BACB). He is an
adjunct professor of psychology at Angelo State University. Finally, he is certified to perform Forensic Competency
Evaluations.
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Purpose
The purpose of the presentation is to provide an “overview” of many aspects
of service delivery to individuals diagnosed with intellectual/developmental
disabilities. It is an “overview” of practical psychological/behavioral core
concepts, definitions, terms, and resources in the field of ID/DD. It is
intended for an audience of professionals already in the field of ID/DD and/or
those who desire increased competence. It constitutes specialized
knowledge for professionals and students and/or refresher for those already
in the field. The presentation is a work in progress constantly being
updated/revised with new information. It reviews historical information, legal
precedent, legislative issues, policy, standards, regulations, conceptual
information, clinical aspects of assessment, diagnosis, treatment, standards
and guidelines, continuum of care, dual diagnosis, relevant organizations,
evolution of necessary credentials and knowledge base for working in the
field, quality assurance/data collection, policy/regulatory standards, and
competencies.
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An Overview of Practical Psychological/Behavioral
Core Concepts, Definitions, Terms, and Resources in
the field of ID/DD
Audience: professionals/students currently in the
field of ID/DD who desire a refresher
Audience: professionals/students who desire
increased competence/specialized knowledge in
the field of ID/DD
Presentation is a work in progress
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Anachronism
Mental Retardation no longer exists
Intellectual Disability is the current terminology
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MR Versus ID
The construct of intellectual disability (ID) belongs within
the general construct of disability that has evolved over
the last 2 decades to emphasize an ecological perspective
that focuses on the interaction of the person with his or
her environment and the recognition that the systematic
application of individualized supports can enhance
human functioning.
The importance of this evolutionary change is that ID is
no longer considered entirely an absolute, invariant trait
of the person e.g. Mental Retardation, but is a state of
functioning.
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“You know that you know”
“You know that you don’t know”
“You don’t know that you know”
“You don’t know that you don’t know”
-- Albert Einstein
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Insanity
“There is nothing that is a more certain sign of
insanity than to do the same thing over and over
and expect the results to be different.”
Albert Einstein
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Faking “Stupid”
You can fake “stupid” but you can’t fake “smart”
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Communication
“Cannot not communicate”-double negative
“Nobody doesn’t like Sara Lee”
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Happy to Welcome……………………...
The San Angelo Odyssey
By Dr. Robb Weiss, Chief Psychologist
10/10/2012
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Enlightener Article
The largest state mental hospital in Georgia, at one time the largest in the United States, is in the process of
closing down after 200 years of existence. I was employed there for the past 7 years as the Coordinator of
Developmental Disabilities, Coordinator of Psychiatric Services, and the Chief of Psychology. And so, I found
myself in the unsavory position of needing to find new employment. So I buy a 40’ motorhome and hook my car
to the back of it. Both my wife and son are each driving a huge U Haul with a car on the back. So the caravan cuts
across 5 states in a never-ending nightmare of scenarios, beginning with the motorhome breaking down before
we ever leave the state of Georgia, followed by unbelievable scenarios involving having to turn around 58 feet of
motorhome-car “train” in the most unbelievable places, and ending with another nightmare scenario even as we
enter San Angelo itself.
I had only heard of Texas through the TV show Dallas, so I knew for certain that I would meet J.R. Ewing, see the
South Fork ranch, and see the glimmering skyscrapers. Well, traveling through Dallas, I thought we would all die
on the highway and never quite did see JR or the skyscrapers.
From Abilene to San Angelo, I was absolutely dumbstruck by the epic and panoramic view of land like I have never
seen before, having grown up in New York and Miami Beach. Suddenly I see the perimeter of a city not unlike the
Emerald City in the Land of Oz, in the middle of nowhere. So here we land in San Angelo, Texas, aka “nirvana” to
buy the home of our dreams that we first saw on the Internet when we were learning about this place called San
Angelo.
I’ve found the most incredible bunch of people at this new (to me!) San Angelo State Supported Living Center that
I have ever known in my life. Now I’ve gotten my 6th state license that enables me to practice in Texas! I’m truly
home now! How’s that for an introduction to your new Chief Psychologist!
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A Little History
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SANATORIUM, TEXAS. Sanatorium is in Tom Green County sixteen miles northwest of San Angelo on U.S. Highway 87. It was never an incorporated town, instead, it was a relatively selfsufficient tuberculosis sanatorium. The postmark "Sanatorium, Texas" began with the opening of a post office on the campus in 1919 and disappeared on October 7, 1965, when the post
office closed. During the first decade of the twentieth century more than 4,000 deaths a year in Texas were attributed to pulmonary tuberculosis. In 1909 the Texas Senate passed a bill
creating a TB colony, but it was defeated in the House. In 1911 both houses passed a bill creating two colonies-one for advanced and one for early cases-dedicated to the treatment and
education of people infected with TB. Although plans for the former were abandoned, 330 acres was purchased near Carlsbad for the location of the Anti-Tuberculosis Colony No. 1. The
first institution of its kind in Texas, the colony provided the isolation to calm the fears of the public, as well as rest and clean air, the only known cure for TB sufferers. Admission was
restricted to patients between the ages of six and sixty for a period not to exceed six months. The fifty-seven-bed facility opened with a barbecue and celebration on July 4, 1912. Bascom
Lynn, who commuted from San Angelo, was the first superintendent. In 1913 the facility was renamed the State Tuberculosis Sanatorium, and on January 1, 1914, Governor Oscar B.
Colquitt appointed Joseph B. McKnight resident superintendent. Under McKnight's leadership the sanatorium expanded for the next thirty-five years. Attracting employees was difficult
because of the fear of TB, low wages, and geographic isolation, therefore, the Sanatorium School for Nurses in Texas was organized in 1915 to train the needed staff. The two-year
training focused on TB treatment, and nearly all the students were recovering TB patients. The first class of four graduated in 1917 with a R.T.N. degree (registered tuberculosis nurse). In
1920 administration of the sanatorium passed from the Anti-Tuberculosis Commission to the Board of Control.
By the 1930s the facility had treated more than 13,000 patients. From the original four buildings constructed at a cost of $10,000, the facility had grown to thirty-five buildings valued at
$1.5 million. In 1930 there were thirteen buildings with 662 patient beds, including 162 beds in the children's Preventorium. The grounds had been expanded to nearly 1,000 acres and
included a post office, library, barber shop, dairy, hog farm, butcher shop, bakery, power plant, laundry, printing press with its own newspaper (the Chaser), four water wells, and a
school for the children. There were also church services and organized meetings for the Masons, Order of the Eastern Star, bridge club, sewing club, and stamp collectors' club. The
complex had grown into a virtually independent community known as Sanatorium. By 1949 Sanatorium had grown to 970 beds with 300 patients on the waiting list. McKnight continued
to propose expansions, including a new seventy-five bed dormitory, more employee living quarters, and a twenty-five bed surgery unit to supplement the existing surgical building
constructed in 1947–48. Raymond F. Corpe, who was on loan from the United States Public Health Service, had begun to perform thoraco-plastic operations.
The 1950s brought dramatic change to the institution. McKnight, who had become synonymous with the battle against TB, retired in 1950. On June 2, 1951, the Texas legislature renamed
the institution the McKnight State Sanatorium. The ancillary operations such as the dairy, hog farm, and the Preventorium were systematically closed during the decade. The new
superintendent, Dr. Allison, successfully removed the age-limit restrictions and the ban on readmission. But the biggest change was a result of the changing TB treatment. The old
treatments, including bed rest and phrenic nerve paralysis, were increasingly replaced by the thoracic surgery program and such drugs as streptomycin and capreomycin. As a result the
institution was renamed the McKnight State Tuberculosis Hospital in 1955.
The length of stay was reduced from 372 days in 1960 to 311 days in 1961, 254 days in 1962, and 204 days in 1963. In the 1963–64 fiscal year the operating expenses of the hospital
totaled $1,417,000. The 290 employees cared for a average of 388 patients at an average patient-per-day cost of $9.98. Changes continued in the 1960s. The nursing school, renamed the
State Tuberculosis School of Nursing in 1938, closed in 1961 after graduating 501 nurses. The number of TB beds was reduced to 550 and the length of treatment continued to decline due
to new drugs and surgery techniques. Staff now numbered around 100, including a chief thoracic surgeon, five resident physicians, and administrative personnel. After treating
approximately 50,000 adult and 5,000 juvenile patients, the McKnight State Tuberculosis Hospital was converted to the San Angelo State School in September 1969. Medical techniques
and drugs were now successful in more than 90 percent of TB cases, making Sanatorium and other TB institutions superfluous. The mission of the new institution was to serve the needs
of mentally retarded men and women.
BIBLIOGRAPHY:
San Angelo Standard Times, October 7, 1965.
John C. Henderson
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Values
The field of ID/DD is laden with values, both
individual and cultural.
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Human Needs
Quality of Life/Happiness
Addressing each individual’s needs may result in a reduction of challenging behaviors
Acceptance, the need for approval
Curiosity, the need to learn
Eating, the need for food
Family, the need for family bonding
Honor, the need to behave according to a moral code
Idealism, the need to improve society
Independence, the need for self-reliance
Order, the need for orderliness
Physical activity, the need for muscle exercise
Power, the need for influence
Romance, the need for sex
Saving, the need to collect
Social Contact, the need for peer companionship
Status, the need be an important person
Tranquility, the need for safety
Vengeance, the need to get even with those who frustrate or offend
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Value-Based Happiness
Pay less attention to people’s deficiencies and
greater attention to their happiness.
Help people with ID experience the activities
they most value.
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DOJ Settlement Agreement
The living centers came under fire in 2008 after
reports of a "fight club" at the Corpus Christi facility.
Since then, independent monitors under the
supervision of a federal judge have visited the Texas
centers twice a year. They evaluated the operations
against 171 standards of care.
Texas has not closed any of its large state-run
facilities for people with disabilities since 1995.
Texas has more living centers and more residents
living in them than any other state.
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Sunset Advisory Committee
• Call to close 5 SSLCs and Austin State
Supported Living Center
• Implications
• Legislation is dead
• Possible implications with DOJ as we are not
closing institutions that have been judged to
be inadequate for providing services
• Not under CRIPA
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Transformation to Recovery
• “Patients, consumers, and clients….oh my!”
• New Civil Rights Movement
• Yale University model
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There is no excuse
• There is no excuse………
• Vulnerable population
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Professional Background
Active 6 state licenses-TN/KY/MS/FL/GA/TX
Former member-Intertel-90th percentile IQ
Former member-International Society for Philosophic Enquiry (ISPE)-90th percentile IQ
Current member-Triple Nine Society (999)-99.9th percentile IQ
Professional background-Mental Health & ID/DD
Areas of interest-Geropsychology and ID/DD
Doctor of Psychology-Psy. D.
Board Certified Behavior Analyst-Doctoral Designation (BCBA-D)
Behavior Analyst Certification Board (BACB) Approved Continuing Education (ACE) Coordinator for the Association of Professional Developmental
Disabilities Administrators (APDDA) 2013
Certified Risk Assessor-QPR Institute-Eastern Washington University
Member American Psychological Association (APA)
Member Texas Psychological Association (TPA)
Member Psychological Association Greater West Texas (PAGWT)
Presentations: “MR/DD: Welcome To My World”-PAGWT (2012)
“MR/DD: Welcome To My World”-TPA (2013)
“MR/DD: Welcome To My World”-TPA (2015)
“Issues Affecting Behavioral Interventions”-Annual Habilitation Therapies Conference (2015)
“Issues Affecting Behavioral Interventions”-APDDA (2014)
“Cultural Diversity: Judaism”-PAGWT (2014)
Adjunct Professor-Angelo State University- Specialty Course-M.S. Counseling Program- “ID/DD: Theory and Practice” (Fall Semester 2014)
Adjunct Professor-Angelo State University- Specialty Course-M.S. Counseling Program- “Applied Behavioral Analysis” (Fall Semester 2015)
Credentialed to perform Forensic Competency Evaluations
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Resume
• College 1970-1987
• Doctor of Psychology-Psy. D. granted
02/23/1987
• South Florida School of Professional
Psychology
• Florida School of Professional Psychology
• Nova University (Nova Southeastern
University)-37th largest private university-APA
approved
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Nova Atlanta Alumni Association
“Spotlight”
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Autobiographical profile
http://novaatlantaalumni.blogspot.com/search?updated-max=2007-06-19T16%3A43%3A0005%3A00&max-results=7
NOVA ATLANTA ALUMNI SPOTLIGHT
Dr. Robb Weiss, Psy. D. is the Chief of Psychology at Central State Hospital (CSH) in Milledgeville,
Georgia. It is the largest mental health facility in the state system. He is also the Coordinator of
Psychology of the Developmental Disabilities Division and Coordinator of Psychology of Psychiatric
Treatment at CSH. He began employment at CSH 07/01/03. He has an extensive curriculum vitae dating
back to 1977. He is licensed to practice in Tennessee, Kentucky, Mississippi, Florida, and Georgia. He
graduated from Nova Southeastern University (then called Nova University) with his Doctor of
Psychology degree on 02/23/87. He bypassed the M.S. in Clinical Psychology degree at Mississippi State
University. He has a triple major in his undergraduate studies at the University of South Florida e.g.
microbiology, chemistry, and psychology. He obtained an Associate of Arts degree in pre-medical
science from Miami Dade Community College (then called Miami Dade Junior College). He is a member
of the American Psychological Association and the Georgia Psychological Association. He is a member of
the following High IQ organizations: ISPE (International Society of Philosophical Enquiry) 99th Percentile,
Intertel 99th Percentile, and the TNS (Triple Nine Society) 99.9th Percentile.
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Definitions
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ICF/ID
Intermediate Care Facility for people with Intellectual Disabilities. These facilities are governed by Federal and State "tags" and monitored by
various surveying organizations. For example, in Texas, DADS or The Department of Aging and Disability Services governs the ICF/ID settings.
QIDP
A person holding at least a Bachelor's Degree in the Human Service Field. The QIDP stands for Qualified Intellectual Disabilities Professional
and must have a minimum of one years experience directly working with people who have developmental disabilities.
LVN
LVN is a Licensed Vocational Nurse. ICF's require many task to be completed by an LVN. For example, an LVN is required to initial dose new
medications or take physician orders. Note: There is an alternative to the LVN known as an LPN in some states. This stands for Licensed
Practical Nurse and he or she may complete all the task of an LVN. Some states such as Texas have implemented requirements that an R.N.
(Registered Nurse) now function in the capacity of the nurse for the ICF/ID.
Immediate and Serious Threats
Still known among providers as "IJ" or "Immediate Jeopardy" an Immediate and Serious Threat requires prompt action by the facility in
question. This is serious problem within an ICF that could result in the ICF's license being revoked. These are initiated in most states by State
Surveyors and generally surveyors will not leave the ICF during an Immediate and Serious Threat without a plan and correction in place. If the
surveyor does leave the facility before the Immediate and Serious Threat has been resolved, or at least on its way to being resolved, then
surveyors generally recommend a 23 Day Termination.
23 Day Termination
In many views a 23 Day Termination is as dangerous as an Immediate and Serious Threat. The facility is placed on a time period of 23 days to
correct a problem viewed by the state as highly significant and the facility must show progress toward correcting the problem. Because most
facilities take action once they have been notified of an Immediate and Serious Threat, the 23 Day Terminations are not usually issued,
instead the 90 Day Termination is issued.
90 Day Termination (2567)
Most of the time the facility has had a serious issue or Immediate and Serious Threat that has been temporarily fixed or a suitable plan has
been put in place while surveyors are on-site. However, the facility still must show significant progress within the time period allowed or there
could be a termination of a license just as is found with the 23 Day Termination.
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Definitions
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IDR
An IDR is an Informal Dispute Resolution. An IDR is completed when the facility disagrees strongly with a cited deficient
practice or a set of cited deficient practice tags. In Texas the surveyor on-site should give the provider information about the
IDR process at the exit.
POC
POC stands for Plan of Correction. Once a survey or state complaint visit is complete, it is not unusual for deficient practices
to be cited. Once those cited tags are received by the facility, the facility is required to submit a Plan of Correction and
complete that plan of correction within an allotted time frame.
LON
LON means Level of Need. A LON determines how much money a facility receives to care for an individual. LON changes for
less money are typically easier and require less paperwork than an LON for an increase. A facility is required to provide all
proof that a person now requires more care and therefore needs a LON change to the state.
Annual Staffing
An Annual Staffing meeting is required at least once a year for individuals served in an ICF/ID setting. The meeting generally
reviews past IPPs, sets up an IPP for the next year, reviews medical conditions, Living Options, and other requirements as
outlined by the state and federal regulations.
IPP
Individual Program Plans are the results of Annual Staffings and other Interim Staffing meetings. An IPP outlines how in the
coming year, generally, a facility proposes to assist an individual served in gaining the most independence that he or she can.
An IPP is a federal requirements and is done in all states with ICF/ID settings.
Data implementation
Data or goals are terms used sometimes interchangeable for the documentation taken to prove that an IPP has been
implemented. Different facilities use different programs, forms, or word processor programs to ensure they have proof that
data has been implemented for individuals served in the facility.
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2015
The Olmstead Act
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Originated in Georgia
Central State Hospital
Milledgeville, Georgia-”Pretty Woman”
“Here Comes Honey Boo Boo”-McIntyre, GA
Under Title II of the Americans with
Disabilities Act, “unnecessary institutional
segregation of the disabled constitutes
discrimination per se, which cannot be
justified by a lack of funding.”
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The Olmstead Act
1. What Olmstead is Not
2. How Olmstead is misused
3. The Olmstead decision supports facility-based (institutional
care) for those individuals whose severe impairments require
the close care found in such settings
4. Olmstead encourages a continuum of service options for
disabled persons-home, community and institutional
5. People with mental retardation, especially individuals with
severe and profound mental retardation, and their families
have vastly different support requirements than those with
physical disabilities. As families age, their abilities to be the
primary care givers (and fiscal intermediaries) will also
change.
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“intentional communities” for DD
population vs. CMS definitions and rules
In an era when 50 percent of Americans don’t even know their own neighbors, living in
a small home can be especially isolating for a person with I/DD. Micki Edelsohn, the
founder of the Delaware non-profit Homes For Life, built her first group home in 1989
for four men, including her son Robert, 42, who has an intellectual disability due to a
birth injury. Since then, she has established 25 similar homes all over the state, as well
as several completely integrated apartments that meet the most stringent
interpretation of the CMS final rule. Her verdict?
“Community integration is a myth,” she told me. “My homes are in nice
neighborhoods—do you think the neighbors are asking the residents over for barbecues
or to go to the movies? Of course not. There has been no real interaction between the
neighbors and the people living in the homes besides the occasional wave.” After
building group homes for a quarter of a century, Edelsohn told me, “Before I die, my
son will be in an intentional community.”
Many parents and providers I spoke to at congregate settings across the country prefer the
term intentional community, which likens a place like Misericordia to any planned residential
development in which people choose to live together because of certain shared
characteristics. That sense of common ground is what’s often lacking when individuals with
I/DD live in integrated housing, surrounded by neighbors who don’t understand them.
http://www.theatlantic.com/health/archive/2015/05/who-decides-where-autistic-adults-live/393455/
Public/Community antipathy against MR
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Less Restrictive Setting
Perhaps it was this population that Supreme Court Justice Ruth Bader
Ginsburg was worried about when she carefully crafted her opinion in the
1999 Olmstead case to make it clear that community inclusion might not be
right for everyone. Such integrated settings, she wrote, should only be
required “when the State’s treatment professionals have determined that
community placement is appropriate” and “the transfer from institutional
care to a less restrictive setting is not opposed by the affected individual.” In
other words, forcing developmentally disabled individuals into dispersed
community settings that don’t meet their needs is as much a violation of
Olmstead as forcing them into institutions.
“Even when living in their own apartments, people can be dehumanized
through words or actions and involuntarily segregated by support staff.
Physical locations don’t do this, people do.”
It would appear that living in “the community” is more restrictive than living
in the institutional setting.
http://www.theatlantic.com/health/archive/2015/05/who-decides-whereautistic-adults-live/393455/
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Intentional Community
• Planned residential development in which
people choose to live together because of
certain shared characteristics.
• That sense of common ground is what is often
lacking when individuals with I/DD live in
integrated housing, surrounded by neighbors
who don’t understand them.
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Choice-Making Among Medicaid HCBS
and ICF/MR Recipients in Six States
K. Charlie Lakin, Robert Doljanac, Soo-Yong Byun, Roger Stancliffe, Sarah Taub,
Giuseppina Chiri, and David Felce (2008) Choice-Making Among Medicaid HCBS and
ICF/MR Recipients in Six States. American Journal on Mental Retardation: September
2008, Vol. 113, No. 5, pp. 325-342.
Choice in everyday decisions and in support-related decisions was addressed among
2,398 adults with intellectual and developmental disabilities receiving Medicaid Home
and Community Based Services (HCBS) and Intermediate Care Facility (ICF/MR)
services and living in nonfamily settings in six states. Everyday choice in daily life and
in support-related choice was considerably higher on average for HCBS than for
ICF/MR recipients, but after controlling for level of intellectual disability, medical care
needs, mobility, behavioral and psychiatric conditions, and self-reporting, we found
that choice was more strongly associated with living in a congregate setting than
whether that setting was HCBS- or ICF/MR-financed. Marked differences in choice
were also evident between states.
The issue of increased choice, whether in a congregate setting or in a smaller,
integrated setting may be one benefit of a cost-benefit analysis-not a reason to rule
out congregate settings all together.
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Evolution of concept of “disability”
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Historically: Medical model e.g. individual is damaged
Currently: Socioecological model e.g. interface between the individual and the
supports in the environment
Implications are far reaching for transforming psychological practice (from
decelerating undesirable target behaviors to modifying environments that fail to
foster growth and development and providing a system of supports to ensure
success for the individual), policy, society, research, funding, collaboration
amongst disciplines, etc.
Disabilities have been far too long “marginalized” e.g. “redheaded stepchild”
The clinical definition of intellectual disability is predominantly a social construct
and does not represent a qualitative distinction between those people who meet
the diagnostic criteria and those who do not (many people with IQs below 70 will
not warrant a formal diagnosis of intellectual disability because their adaptive
behavior is sufficient for them to cope with day-today demands of life (there is
very little functional difference between someone with an IQ score of 70 and
someone with an IQ score of 75)
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2015
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Intellectual Disabilities
What are intellectual disabilities?
According to the American Association on
Intellectual and Developmental Disabilities,
intellectual disabilities are characterized by
significant limitations in both intellectual
functioning (reasoning, learning, problem solving)
and in adaptive behavior, which covers a range of
everyday social and practical skills. This type of
disability originates before the age of 18.
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2015
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Intellectual Disabilities
What are the effects of intellectual disabilities?
While the effects and severity of these conditions can vary widely,
people with developmental disabilities have problems with major life
activities such as language, mobility, learning, self-help, and
independent living. Intellectual disabilities in these individuals are
often not identified until they enter school. Many people with
intellectual disabilities grow up to lead independent lives. The
remaining minority of people with intellectual disabilities, those with
IQs under 50, have significant limitations in functioning. With early
intervention, a functional education, and appropriate supports as an
adult, individuals with intellectual disabilities can lead satisfying lives.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Intellectual Disabilities
What are the causes of intellectual disabilities?
Intellectual disabilities can be caused by any condition that
impairs development of the brain before birth, during birth, or
in the childhood years. Hundreds of causes of intellectual
disabilities have been identified. However, for approximately
one-third of those affected, the cause of their disability
remains unknown. Causes of intellectual disabilities include:
• Pregnancy/delivery problems (drugs, malnutrition, illness,
prematurity)
• Early childhood diseases and accidents
• Exposure to toxins and other environmental health hazards
• Genetic anomalies and disorders
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2015
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Intellectual Disabilities
Can intellectual disabilities
be prevented?
Significant advances in research over the past 35
years have prevented many intellectual disabilities.
For example, every year in the United States, more
than 10,000 cases of intellectual disabilities are
prevented through newborn screening and dietary
treatment, thyroid hormone replacement therapy,
use of anti-Rh immune globulin to prevent Rh
disease and severe jaundice in newborn infants,
and Hib and measles vaccines.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Mental Retardation: What it is not!!
• -not something you have or are (blue eyes,
short, etc.)
• -not a medical or mental disorder
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Mental Retardation
• -refers to a particular state of functioning
(not an inherent quality) that begins in
childhood and in which limitations in
intelligence coexist with related limitations in
adaptive skills
• -describes the “fit” between the capabilities of
the individual and the structure and
expectations of the individual’s personal and
social environment
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2015
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Mental Retardation
• A condition that affects a person’s ability to
learn and function independently
• Individuals with mental retardation learn
more slowly and with greater difficulty
• Individuals with mental retardation can learn,
but the rate at which they learn is slower
• It is possible there are some things a person
with mental retardation may not be able to
learn, such as complex problem-solving skills
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2015
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Mental Retardation
Diagnosed by assessing:
person’s ability to learn, think, solve problems, and
make sense of the world e.g. intellectual
functioning (IQ)
Whether the person has the skills needed to take
care of him or herself to live independently e.g.
adaptive functioning (rating scales comparing what
an individual can do with what other individuals of
his or her age can typically do
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2015
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Mental Retardation: A Clinical
Overview
Background
Historical context
Current practices
Phenomenology
IQ & adaptive behavior
Developmental level
Aberrant behaviors
Pathophysiology
Gene X Environment etiologies
Abnormal CNS development
Learning & environment
Neuropsychiatric impairment
Treatment
Psychosocial/Behavioral
Pharmacologic
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Diagnostic criteria for Mental
Retardation
• Psychometric-Psychological testing before age 18
• Anecdotal-Information that supports deficits
before age 18
• DSM-IV-TR
• Diagnosis “typically” does not change after age
18 unless based on erroneous diagnosis prior to
age 18, however, the diagnosis is fluid.
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2015
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Diagnosing MR
The diagnosis of Mental Retardation requires that the “onset” of the disorder be before age 18
years (DSM-IV-TR). It is not required that the “diagnosis” be made prior to age 18 years. The
diagnosis can be made in adulthood if the clinical presentation meets relevant diagnostic criteria.
The level of severity may be altered after age 18 though the original level of severity was
provided based on information obtained about functioning levels before age 18. If there is
sufficient documentation indicating that the onset of significantly sub-average general intellectual
functioning was accompanied by significant limitations in adaptive functioning in at least two skill
areas prior to age 18 years, then the diagnosis of Mental Retardation can be made (even later in
adulthood). This is not a new concept. We can give a MR diagnosis to an adult if there is solid
historical evidence of onset of mental retardation prior to age 18, even if the diagnosis was not
made prior to age 18. The fact that an MR diagnosis was not made prior to age 18, does not
mean that we have missed our opportunity to diagnose that condition and thus facilitate delivery
of appropriate services/supports. Any further argument would center around what constitutes
“strong historical evidence and sufficient documentation” that would enable us to give a MR
diagnosis in adulthood. In the absence of good records review developmental milestones, grades
in school, performance at work, anecdotal information provided by third parties and the person
him/herself, clinical judgment about IQ/development/ID (IQ scores are quite stable and have
predictive validity, interventions can make a difference.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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AAIDD
The American Association on Intellectual and
Developmental Disabilities
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2015
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Comparing the APA and the AAIDD
Diagnostic Criteria for ID
• The APA diagnostic criteria is commonly used to diagnose intellectual
disability (ID, formerly mental retardation). As such, the focus leans
toward identifying limitations. The AAIDD definition is more often used to
develop a rehabilitation plan. It leans toward identifying abilities that
facilitate rehabilitation. Diagnosis and rehabilitation are two different but
related agendas. The APA definition serves to identify limitations that
facilitate diagnosis. In contrast, the AAIDD definition highlights abilities
that facilitate rehabilitation.
• The APA diagnostic criteria are usually relied upon for that purpose; i.e.,
diagnosis. In contrast, the AAIDD is relied upon to develop a rehabilitation
plan. This plan is called an individualized support plan, or ISP. The ISP
identifies the optimal level of support for the person with an ID. This is
accomplished by the identifying strengths and functional abilities that can
offset deficits. Although limited intellectual and adaptive functioning
identify an ID, it is equally important to identify strengths and abilities.
Knowledge of these abilities helps to develop the ISP to maximize
independent functioning.
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2015
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AAIDD Diagnostic Criteria for
intellectual Disability
The AAIDD has refined and modified ID diagnostic criteria since 1921. The criteria are updated based on new
research and changes in clinical practices.
The AAIDD definition and APA definition are quite similar. The three primary criteria remain the same although
the labels are slightly different:
1. AAIDD also uses limitations in intellectual functioning. Like the APA criteria, this refers to mental abilities.
Some examples are learning, reasoning, and problem solving. One criterion to measure intellectual functioning
is an IQ test. Generally, an IQ test score of around 70 or as high as 75 indicates a limitation in intellectual
functioning. These scores would occur about 2.5% of the population. Or stated differently, 97.5% of people of
the same age and culture would score higher. The tests used to measure IQ must be standardized and culturally
appropriate.
2. AAIDD labels adaptive functioning as adaptive behavior. Standardized tests also determine limitations.
Adaptive behavior comprises three skill types.
Conceptual skills: This includes language and literacy; mathematics; time and number concepts; and selfdirection.
Social skills: This includes interpersonal skills; social responsibility; self-esteem; gullibility; social problem
solving; and the ability to follow rules/obey laws. It also includes naïveté. This lack of wariness leads to
victimization.
Practical skills: This includes activities of daily living (personal care). It also includes occupational skills,
healthcare, travel/transportation, schedules/routines, safety, use of money, use of the telephone.
Limitations in adaptive behavior are indicated in one of two ways. One possibility is a score approximately two
standard deviations below average in any one of the three areas. The second possibility is an overall score in all
three areas is approximately two standard deviations below the average score for that age group.
3. This disability originates before the age of 18.
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2015
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Significant Intellectual Disability
A significant intellectual disability has been and
continues to be defined as a finding of sub-average
intellectual functioning based on a score two
standard deviations or more below the mean
(IQ<70) on an accepted standardized intelligence
test (Wechsler, Stanford-Binet, etc.). “Significant” is
two standard deviations from the mean, so that is a
consistent standard that will not vary from person
to person. The Stanford-Binet provides a lower
basal for diagnosing greater severity levels of ID.
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2015
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Severity of Mental Retardation
Prior to DSM 5 based on IQ level
As of DSM 5 based on level of adaptive supports
Mild-(50-55)-70
Moderate-(35-40)-(50-55)
Severe-(20-25)-(35-40)
Profound-below 20 or 25
Don’t confuse this with V62.89 Borderline
Intellectual Functioning-IQ in the 71-84 range
[coded on Axis II]
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2015
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Developmental Disabilities
What are developmental disabilities?
Developmental disabilities encompass a broad
range of conditions that result from cognitive
and/or physical impairments. They are identified
before the age of 22, and usually last throughout a
person’s lifetime. These disabilities include
intellectual disabilities, autism spectrum disorders,
Down syndrome, language and learning disorders,
cerebral palsy, vision impairment, and hearing loss.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Developmental Disabilities
How prevalent are developmental disabilities?
Developmental disabilities occur in people of all
racial, ethnic, educational, and socioeconomic
backgrounds. According to the National Association
of Councils on Developmental Disabilities, 5.4
million Americans have developmental disabilities.
Approximately 17 percent of children under the age
of 18 are affected. The most common
developmental disorder is intellectual disability.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Developmental Disabilities
What are the most common developmental disabilities?
The most common developmental disorder is intellectual disability. According to the Centers for Disease Control and Prevention, more than one
out of every 100 school children in the United States has some form of intellectual disability. Cerebral palsy is the second most common
developmental disorder, followed by autism spectrum disorders. According to First Signs, Inc., other developmental disorders include:
Attention-Deficit/ Hyperactivity Disorder (ADHD)
Angelman Syndrome
Bipolar Disorder
Central Auditory Processing Disorder (CAPD)
Down Syndrome
Expressive Language Disorder
Fragile X Syndrome
IsoDicentric 15
Landau-Kleffner Syndrome
Learning Disabilities (LD)
Neural Tube Defects
Phenylketonuria (PKU)
Prader-Willi Syndrome
•Seizure Disorders
•Tourette Syndrome
Traumatic Brain Injury (TBI)
Williams Syndrome
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Developmental Disabilities
How are developmental disabilities diagnosed?
If you are concerned that a member of your family may have a
developmental disability — whether physical or
intellectual— contact a respected behavioral healthcare
organization and/or healthcare professional. First, the
organization should have a qualified professional give your
family member standardized intelligence and skills tests.
Second, the professional should determine your family
member’s strengths and weaknesses in the areas of
intellectual and adaptive behavior skills, psychological and
emotional considerations, physical health, and environmental
factors. Finally, a trained interdisciplinary group of
professionals should meet to determine what supports are
needed to address each of the areas stated above.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Developmental Disability
Developmental Disability means a severe , chronic disability of an individual that:
(A) Is attributable to a significant intellectual disability, or any combination of a significant
intellectual disability and physical impairments;
(B) Is manifested before the individual attains age 22;
(C) Is likely to continue indefinitely;
(D) Results in substantial functional limitations in three or more of the following areas of major
life activities:
(i) Self-care;
(ii) Receptive and expressive language;
(iii) Learning;
(iv) Mobility;
(v) Self-direction; and
(vi) Capacity for independent living; and
(E) Reflects the person’s need for a combination and sequence of special, interdisciplinary, or
generic services, individualized supports, or other forms of assistance which are of lifelong or
extended duration and are individually planned and coordinated.
Not a mental disorder
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Autism
• CDC estimates half a million children in the US
• A brain-based neurobiological disorder caused by abnormalities in
the brain that may come with many challenges, but also imparts
great gifts
• More to do with biology than psychology
• Not a mental illness, a result of bad parenting, or a death sentence
for fulfilling and productive lives
• Most common member of autism spectrum disorders
(ASDs)/Pervasive Developmental Disorders (PDD)
• Usually diagnosed by age of 3
• Found in every country, every ethnic group, and every
socioeconomic class
• Diagnosed four times as often in boys than in girls
• Early intervention is needed
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Autism
WHAT IS AUTISM?
Autism is a Spectrum Disorder
Autism is a Developmental Diagnosis
Characteristics Will Change as the Person
Grows Older
• Previously coded on Axis I
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2015
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Post Traumatic Stress Disorder (PTSD)
in People with Autism
• Role of aversives and restraints
• May explain newly emerging symptoms
• Despite fairly abundant anecdotal evidence,
knowledge of the nature, prevalence, and
treatment of psychological trauma in the lives
of people with severe disabilities is lacking
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Prevalence of Autism Spectrum
Disorders
• Centers for Disease Control and Prevention
• Morbidity and Mortality Weekly Report
(MMWR)
• Autism and Developmental Disabilities
Monitoring (AADM) Network
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Discrete Trial Training (DTT)
• Skill Acquisition-Tight stimulus control
• Method of providing intervention for individuals
diagnosed with Autism
• According to Anderson et al. (1996), the discrete
trial method has four distinct parts:
• (1) the trainer's presentation
• (2) the child's response
• (3) the consequence
• (4) a short pause between the consequence and
the next instruction (between interval trials)
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Autism Speaks
Autism Speaks funded the largest-ever multinational
study of parental age and autism risk. It was found that
there was an increased autism risk for children of teen
mothers and children whose parents have relatively
large gaps between their ages. Additionally, older
parents were found to be at a higher risk of having
children with autism. While parental age is a risk factor
for autism, the study states that it is important to
remember that overall, the majority of children born to
older or younger parents develop without the illness.
Autism Speaks, Science Daily 06/09/2015
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Debunking myths about autism
• ASD is the name for a specific group of
behavioural and developmental challenges
that affect a child's social behaviour,
communication and play. It is caused by rare
genetic variants that influence how the brain
grows and develops. Since autism is a
spectrum disorder, each person's symptoms
differ in variety and severity.
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2015
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Debunking myths about autism
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MYTH: There is an autism epidemic.
FACT: The prevalence of those diagnosed with ASD has gone up about tenfold since the mid-1980s, but it is
important to note the increase is largely associated with changes in the diagnostic criteria and a greater
awareness in the medical community of how autism presents at different ages. There is no evidence that there is
any environmental factor that might account for the increase in prevalence.
MYTH: Vaccines cause ASD.
FACT: It is very clear that autism is not caused by vaccines. The initial paper published on this topic has been
disproved. This claim has now been recognized as fraudulent and biased by the pursuit of class action lawsuits. In
fact, there are several communities where the ingredients that were reported to cause autism have been removed
from the vaccine and yet within those communities the diagnosis of autism continues to rise.
MYTH: ASD is caused by poor parenting.
FACT: This myth comes out of very poor research from the 1950s, which was already being widely refuted by the
1960s. There is absolutely no evidence that poor parenting or poor parent-child relationships cause autism. ASD is
caused by genetic factors, possibly combined with environmental factors in utero.
MYTH: Only boys can have autism.
FACT: The sex ratio in ASD is roughly four boys to every girl. So it is certainly true that girls can have ASD, but they
tend to be more severely affected than boys. However, this may be because girls with ASD are not as readily
recognized. In fact, some evidence suggests we should be using different diagnostic criteria for girls than for boys
to take account of these variations.
MYTH: ASD can be cured with diet or other alternative treatments.
FACT: We have to be careful here. Whether autism can be "cured" or not is contentious, but there is no question
that children with ASD improve the earlier they get the intervention and the more intense that intervention might
be.
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2015
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Debunking myths about autism
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MYTH: People with ASD do not feel or like to socialize.
FACT: Children with ASD do socialize and feel emotions, but the communication and the expression of those emotions is atypical. Their
desire to socialize with people might not be as intense as it is in typically developing children. Nevertheless older children, adolescents
and young adults with ASD do enjoy interacting with other children and adolescents and do seek them out.
MYTH: ASD gives people savant or genius abilities.
FACT: The use of the word "savant" comes from older research suggesting that although there are some people with autism who are
non-verbal or have severe cognitive disability, they nevertheless have a fantastic memory, a capacity for drawing, an ability to do
elaborate calculations and can read much better than expected. That is certainly true for a tiny minority of people with ASD, but it is
better to refer to these as splinter skills rather than "savant" or "genius." The definition of a genius is having an IQ above 120 and, while
this is certainly possible for people with ASD, it is much less likely than in the general population
MYTH: Autistic children should only attend separate special needs programs.
FACT: Children with ASD benefit from interactions with typical children because it improves their social and communication skills and
decreases their repetitive play. So the treatment recommendation now is to keep children in the educational mainstream and only
withdraw them under exceptional circumstances, for short periods of time. All children with ASD require a special education plan that
takes their disability into account.
MYTH: You should try to stop an autistic child's repetitive behaviour.
FACT: The important issue here is to understand the function of that repetitive behaviour. Sometimes children engage in repetitive
behaviour because they are bored, stressed or playing. The key treatment here is to try and modify that repetitive behaviour so that it
becomes more developmentally appropriate and more like typical play. In other words, we need to understand why a child engages in
repetitive play and then deal with the underlying cause instead of focusing on the behaviour itself.
MYTH: Children with autism cannot become independent adults.
FACT: The range of outcome possibilities for children with ASD is quite remarkable. Many children with ASD grow up to be adults who
live independently, who work, who develop close friendships, even romantic relationships. It is likely that most adults with ASD will
always require some kind of support, but this can sometimes be done at a distance. It is also true that there are many individuals with
ASD who require full-time, specialized services as adults and those appropriate supports are available through community services.
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2015
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Discharge versus Transition
• Discharge-behavioral criteria
• Transition-interface between needs and
supports
• Continuum of care
• Transition planning occurs upon admission
• Least restrictive environment [institution may
be less restrictive than the group home]
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2015
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Intermediate Care Facility for the
Mentally Retarded (ICF/MR)
ICF/MR Guidelines (Medicaid)
ICF/MRs-(incorrect)
ICFs/MR-(correct)
Think “Attorneys General” rather than
“Attorney Generals”
• ICF/IID: Intermediate Care Facility for
Individuals with Intellectual Disability
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Outreach
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Experiencing challenging behaviors at home, school, work site or community-not residential
treatment facility
Provides a complete set of recommendations to assist families and service providers in decreasing
unwanted behaviors and supporting positive behaviors
Examples include verbal and physical aggression, elopement, stealing, property destruction, selfinjurious and inappropriate sexual behaviors
Founded in best clinical practice and are considerate of personal choice, socially appropriate
behavior development, personal growth, and provided agency philosophy
Highly specialized teams with behavioral and psychological expertise
Observation and assessment in the natural environment
Interviews with the individual, teachers, families, service provider staff and other significant parties
A review of back and records and medication reviews
A treatment package that includes a development of a variety of interventions
Presentation of the treatment package to the community team in written and oral formats
Maintains regular contact with the team
Conducts an onsite follow-up visit
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Intensive Treatment Services
• Short-term inpatient treatment to individuals from community
settings
• Individuals who are experiencing severe behavior problems and are
in danger of losing community services
• Require adjustments to psychoactive medications in a highly
structured setting (not a behavioral holiday-think about the
contingencies operating in the residence of origin)
• Goal is to stabilize an individual’s behavior/medications and develop
treatment recommendations which can be transitioned back to the
community setting following the inpatient care
• Consider the philosophy, resources and limitations of the
community service provider who serves the individual
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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System Issues
Common System Issues
-Not enough funds
-Lack of available resources
-Staff turnover/shortages
-Communication difficulties
-Things don’t happen fast enough
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Future of Residential Services
• Wolf Wolfensberger
• Twenty predictions about the future of residential services in mental
retardation-changes imply 1. new model of residential services 2.
increasing continuity between residential and non residential services 3.
cost-benefit rationales
• Will there always be an institution?-I: The impact of epidemiological
trends-1. development of nonresidential community services 2. new
conceptualizations of residential services 3. increased usage of individual
placements 4. provision of specialized group residences 5. decline in
incidence of severe and profound retardation
• Will there always be an institution?-II: The impact of new service modelsresidential alternatives to institutions- trends-1. development of
nonresidential community services 2. new conceptualizations of
residential services 3. increased usage of individual placements 4.
provision of specialized group residences 5. decline in incidence of severe
and profound retardation
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2015
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Developmental Disabilities
(DD)
• Originally not medical but legislative/legal
concept
• Now defined in functional terms
• Autism/Pervasive Developmental Disorder
(PDD)/Rett’s Disorder/Asperger’s Disorder
[no longer exists in DSM 5]
• Coded on Axis I (DSM-IV-TR)
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Axis II
Mental Retardation
Not a single entity
Heterogeneous behavioral syndrome
Individualized treatment planning
Does not cause….but is the cause of
“Normalization principle”-enable people to
live in as normal an environment as possible
• Not “make them normal”
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Psychiatric Issues
• Access to Psychiatric Services
-Service providers should have some experience
working with individuals with IDD
-Service providers should be willing to work with
team members on the individual’s behalf to obtain
enough information to make accurate diagnosis and
assess treatment results
-Crisis services are often unavailable due to a lack of
experience or understanding of the risks of the IDD
population
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Psychiatric Issues
• Internal Distress and Overt Behavior
-Increase in internal distress likely results in an
increase in the intensity and frequency, sometimes
duration, of observable challenging behaviors
-Regression in coping and impulse control skills
-Less inhibited, more difficult to manage
behavior
-May not understand the symptoms
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Psychiatric Issues
• Change in behavior must co-occur with significant
changes related to symptoms
-Disturbance in sleeping/eating patterns
-Report of depression, anxiety, fearfulness
-Report of hearing voices or being persecuted
-Behavior related to mood or affect (increase in anger,
rage, hostility); increase in intensity of the behavior
-Other symptoms related to specific diagnostic criteria
-The presence of challenging behavior alone is not
adequate for diagnosis
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2015
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Psychiatric Issues
• It is our responsibility to provide the individual
and their family with the alternatives and
information necessary to make an informed
decision on treatment and evaluations for
psychiatric issues. Psychiatric services,
counseling, and/or behavioral services should
be discussed with recommendations based on
an assessment by the appropriate treatment
provider.
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2015
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Psychiatric Issues
• Issues related to psychiatric services
-Ongoing assessment of internal distress (compare affect/mood before
and after treatment)
-For individuals who may have difficulties describing their experience,
ongoing assessment, including behavioral assessment, and
consultation with the psychiatrist is helpful to assure the most
effective overall treatment
-Secondary learning occurs when psychiatric symptoms result in
challenging behaviors that are rewarded by the consequences of the
behavior. Appropriate behavioral intervention is used to address these
challenging behaviors
-Increase positive behavior/skills that strengthen the individual’s ability
to manage their behavior when experiencing internal distress: coping
skills, relaxation skills, assertiveness skills; reporting to staff
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2015
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Psychiatric Impairments
• Psychiatric impairments rank second, after mobility impairment, in noted
secondary disabilities in persons with a developmental disability. The
reason behind this phenomenon, it seems, is that people with
developmental disabilities are at greater risk due to their physical and
cognitive impairments. And due to the nature of their disability, they are
more exposed to exploitive, degrading, physically and sexually abusive
situations.
• Research has shown that people with developmental disabilities are 4-10
times more likely to become victims of crime. Due to their impaired coping
and adaptation skills, it is extremely difficult for people with
developmental disabilities to effectively cope with trauma, much harder
than for the non disabled.
• The golden rule taught by the training instructors was “regardless of what
sector you are in, when you are working with someone with a
developmental disability, you should always consider the possibility that
they have a mental health disorder.” It is important to understand the
complexities surrounding dual diagnosis, namely:
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Dual Diagnosis/Mental Disorders: Subset
with Axis I Psychiatric Disorders
Difficulty in diagnosing psychiatric disorders in those with ID/DD (mild/moderate versus severe/profound)
[Accurate assessment/accurate diagnosis/accurate treatment]
Limited verbal communication, rely on nonverbal communication
obtained in natural setting
Difficulty correctly labeling emotions/internal states
Concrete language/lack of imagination leads clinician to miss significant symptoms
Usefulness of interview decreases
Recent stressors
Sleep/Appetite disturbance
Activity level
Functioning level
Family history of mental illness
Rating scales
Medical history and physical examination
Chart review
Direct observations in natural environment
Psychological testing
Medical evaluations
Functional behavioral assessment Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Dual Diagnosis/Mental Disorders:
Subset with Axis I Psychiatric Disorders
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Understanding that many people with developmental disabilities have mental health problems is important for
planning treatment, supports, and service provision and can help increase our knowledge about the etiology of
these conditions
Diagnosing mental health problems in people with developmental disabilities is a complex and challenging process
In many ways, the assessment of mental health problems in people with developmental disabilities follows the
same principles as the psychiatric assessment of people without developmental disabilities
The accuracy of such diagnosis depends on multiple factors intrinsic to both the patient and the assessor
Referral pathways are different e.g. very rare for people with developmental disabilities to initiate a mental health
referral themselves
Usually, they have to rely on family or residential staff to identify the problem, with most common reason for
referral being behavioral disturbance
Subtle or insidiously developing changes in mood, sleep, or appetite are less likely to be detected
Conceptualizing how the presentation might be a synthesis of vulnerability and of precipitating and maintaining
factors (biological, psychological, social, and environmental) is a complex task and requires a coordinated
multimodal and interdisciplinary approach to assessment
In assessing mental health problems in people with developmental disabilities in a comprehensive way, the norm
is to gather information from multiple sources
Requirement that this process be coordinated and managed by one particular team member who is able to
understand and integrate the different strands of information
The length of the interview must also be flexible to accommodate people with memory or attention-span
problems, and several short sessions may be scheduled
The degree of developmental disabilities needs to be considered because people with more severe developmental
disabilities are more likely to show atypical signs and symptoms or behavioral problems
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Dual Diagnosis/Mental Disorders:
Subset with Axis I Psychiatric Disorders
• Definition of Mental Disorder versus normal human emotions e.g.
grief/mourning, etc.
• Is it Behavioral or Psychiatric-it’s all about behavior
• To Medicate or Not to Medicate-behavioral/environmental intervention
first/psychoactive medications second
• Role/Purpose of Psychiatry-help patients consciously control their brain
chemistry through pharmacotherapy and psychotherapy
• Approaches to Treating Mental Disorders-teach coping skills/alter
environment/teach behaviors that alter brain chemistry
• Role of IDT-explore all applicable treatment options, implement via ISP,
integrate treatment with psychoactive drugs into ISP, monitor symptoms
and outcomes, input into psychiatry clinics
• Role of ICF/MR-Active Treatment (acquisition of necessary behaviors,
prevent deceleration or regression or loss of functioning)
• To diagnose Axis I or not to diagnose Axis I (that is “not” the question)-the
issue is the accurate diagnosis (occurs over time and space)
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Mental Health Disorders
• People with ID are vulnerable to the same mental health
disorders as is everybody else.
• Personality disorders and behavior problems, so-called
DSM Axis II conditions, are much more prevalent for people
with ID versus the general population.
• Mental health disorders occur more frequently, last longer,
and have more severe consequences for people with ID,
and people with a dual diagnosis are underserved.
• Posttraumatic Stress Disorder has become a much more
frequent diagnosis in both ID and non-ID populations
because of the expanding definition of trauma.
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Consequences of Dual Diagnosis
• Delay personal growth and/or cause
significant deterioration in overall adaptive
functioning.
• Lead to maladaptive social behaviors that
cause failure in employment settings.
• Cause emotional discomfort and pain.
• Create barriers to residential and educational
opportunities in community settings.
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Diagnostic Guidelines
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Establishing a psychiatric diagnosis for a person with developmental disabilities can be particularly
difficult, because of certain limitations within the current classification systems
Most psychiatric symptoms are described with the use of language-based phenomenology
The severity of any cognitive or language deficits is bound to influence the reliability of such
diagnoses [DM-ID, modify criteria of existing diagnostic classifications, behavioral correlates of
psychiatric symptoms]
People with mild developmental disabilities and good verbal skills present similar psychiatric
symptoms to those presented by people without developmental disabilities
Negative symptoms can be the result of medication, depression, or an understimulating
environment
Diagnose patterns of behavior, not isolated symptoms
Diagnose deteriorations in functioning
Side effects from prescribed medications can sometimes mimic or cause psychiatric symptoms;
therefore, a medication history, including previous dosing, duration of treatment, effectiveness, and
side effects, is always necessary
A comprehensive risk assessment estimating the risk to self and/or others, as well as the risk of
self-neglect, abuse, and exploitation, should be a routine component of the assessment pathway
Do not over diagnose psychiatric disorders
[Developmentally appropriate phenomena, such as talking to oneself or imaginary friends should be
distinguished from psychotic phenomena, such as auditory hallucinations]
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Abnormal Motives
• A need for excessive amounts of attention may
instigate or predict persistent conduct problems
including challenging behavior.
• Although individual with ID receive attention
when they behave appropriately, they receive
much more attention when they behave
inappropriately.
• Consequently people who need excessive
attention may embrace conduct problems as the
only means they have for receiving the amount of
attention they desire.
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Dual Diagnoses: The Scope of the
Challenge
Diagnostic Considerations-Examples (not inclusive)
-Signs and symptoms of certain psychiatric disorders
often present in atypical or unusual ways.
System Challenges
-Identify and obtain the appropriate psychiatric and
psychological services to address the psychiatric
disorders.
Daily Stressors
-Not only contribute but can create psychiatric disorders.
A Future Commitment
-Need to expand our knowledge about dual diagnosis.
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Factors Complicating Psychiatric
Diagnoses
Barriers to Diagnosis and Treatment
1.
Diagnostic overshadowing-overlooking/minimizing signs of mental illness because it is considered less debilitating than mental
retardation or because the symptoms of mental illness are attributed to the mental retardation/attribute signs/symptoms to ID
Behavioral overshadowing-tendency to identify psychopathology as learned
behavior while failing to recognize it is an indicator of mental illness
2. Problems with polypharmacy (medication masking)-sedative effects of certain
medications can suppress, or mask, the presence of significant mental health symptoms
3. Communication Deficits
4. Atypical Presentation of Psychiatric Disorders-DM/ID
[Episodic presentation-significant mental health symptoms may come and go in an unpredictable
manner, and presence of mental disorder may go undetected]
5. Limited life experiences e.g. no spending spree in mania
6. Complications of untreated medical conditions
7. Acquiescence-agreement with all signs/symptoms
8. Imitative or learned behavior-institutional suicidal threats/gestures
9. Lack of behavioral challenges-the good patient
10. Sensory impairments-inability to communicate
11. Division of services-between mental health and mental retardation (no integration of services)
12. Lack of expertise-mental health professionals lack training in mental retardation and vice versa
13. Psychosocial masking-since people with developmental disabilities have limited social experiences, their psychiatric symptoms may be
very different than those of the “normal” population, for example, belief that one can drive a car may be mania
14. Cognitive disintegration-cognitive impairment
15. Baseline exaggeration-Onset of psychiatric illness may increase the severity or frequency of chronic maladaptive behavior. This can also
influence the diagnosis of mental illness
16. Intellectual Distortion: Due to deficits in abstract thinking, receptive and expressive language skills, emotional symptoms may be difficult
to elicit. In fact, emotional symptoms may manifest in behavior.
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Factors Complicating Psychiatric
Diagnoses
Emotional considerations
1. Progressing thru typical developmental milestones, but
at a slower pace (treated much younger than
chronological age)
2. Limited opportunity to experience and learn from the
new challenges
3. Offer an environment that offers age appropriate
opportunities (job, home, relationships, self-help
responsibilities), while providing developmentally
appropriate supports (supervision, coaching, education)
4. Relationship problems
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2015
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Factors Complicating Psychiatric
Diagnoses
Cognitive considerations
1. Expressive Language
2. Receptive Language
3. Short-term memory
4. Long-term retrieval
5. Executive functioning
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2015
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Atypical Presentation of Specific
Psychiatric Diagnoses
• Mood Disorders
• Anxiety Disorders-underreported, OCD versus
stereotypy, PTSD
• Adjustment Disorder
• Psychotic Disorders
• Personality Disorders
• Impulse Control Disorders
• Attention Deficit/Hyperactivity Disorder
• Sleep Disorders
• Dementia
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
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Medical Contributions to Psychiatric
Conditions
Common Medical Conditions in Individuals with
an Intellectual Disability
1. Gastrointestinal conditions
2. Urological conditions
3. Asthma
4. Sleep apnea
5. Seizures
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Medical Issues and Behavior
• Medical issues individuals may have
difficulties reporting or describing to
staff/nurse/physician:
-Headache/Sinus
-Acid Reflux/GERD
-Insomnia (if staff are unaware they are not
sleeping)
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Medical Issues and Behavior
• These medical symptoms may result in behavioral
outbursts if the individual simply feels bad and is
unable to communicate this to staff
-Stuffing toilet with toilet paper-diarrhea
-Frequent trips to the bathroom-constipation
-Unusual behavior focused on one specific part of
the body
-Sudden, unexplained change in mood and
behavior, accompanied by physical symptoms or
complaints
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2015
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What Do We Do?
• Focus on the positive
-Build from a person’s strengths and reward any
positive behavior and effort. Spend time on
“what’s right” with someone instead of talking
about “what’s wrong”
-Provide positive reinforcement and acceptance
as people with thoughts and feelings, before
focusing on challenging behavior
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What Do We Do?
• Know your individuals
-Develop a rapport with the people you work
with
-Take time to learn their history
-Understand their goals, needs and what they
want
-Develop a rapport with the family when
possible
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2015
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What Do We Do?
• Provide ongoing training and education to
support staff
-Training and assistance with behavior management
strategies such as positive reinforcement
-The symptoms/behaviors associated with
psychiatric diagnosis
-Coping skills, impulse control skills
-Welcome questions and concerns of support staff
no matter how small the concerns may be at the
time
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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What Do We Do?
• Practice creative problem solving in order to find
ways to meet the needs of the individuals you
work with
-Consider community resources
-Take the initiative, reward others who take the
initiative to address problems
-Be proactive and fix problems before they become
big problems
-Take a team approach and communicate effectively
with team members
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2015
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What Do We Do?
• Maintain a positive rapport with other
professionals who work with the people you
work with
-Professional support staff, doctors, nurses, and
others all have information, observations and
experience that is valuable
-Be open to consultation with others to the
benefit of the individual
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2015
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What Do We Do?
• Regarding specific individuals
-Do a thorough assessment (talk to everyone who works with the
individual and get all available information that may be relevant)
-Do not disregard information provided as relevant
-Collect baseline data
-Review the history of the individual
-Develop a rapport with family/support staff
-Listen to family and support staff, they spend the most time with the
individual and have the most information
-Meet with the team, or as many of the staff as possible at one time
and brainstorm
-Be a good detective
-Make appropriate referrals for further assessment when indicated
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
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The Hierarchy
1. Are the behaviors the result of medical
conditions? (Would you create a behavior
support plan for physical aggression………that is
caused by pain from constipation)
2. Are the behaviors the result of psychiatric
conditions? (Best practice for medicating
diagnosed signs/symptoms)
3. Are the behaviors learned?
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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Distinguishing Learned Behavior From
Psychiatric or Medical Illness
• Symptom/behavior occurs in most or all settings it is more likely
due to a psychiatric or medical condition
• Symptom/behavior is unresponsive to consistent behavioral
interventions and habilitative programming, it is more likely related
to a psychiatric or medical condition
• Changes in sleep, appetite, sexual, or daily functioning, it is more
likely attributable to a psychiatric or medical condition
• Autonomic symptoms are more likely related to psychiatric or
medical condition
• Onset of mental illness, or medical problem, may worsen already
existing challenging behaviors-baseline exaggeration
• May display usual challenging behavior and simultaneously display
other behavior indicative of mental illness
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Psychopharmacology
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Mental Health supports for individuals with intellectual disability should focus on stimulation
of healthy mental development, prevention of psychiatric disorders, and effective treatment
of psychiatric disorders
One of the most effective treatments for many mental health disorders is the prescription of
psychotropic medication
Far too many individuals with intellectual disability are given psychotropic medication
Inappropriate use of psychotropic medications, primarily the antipsychotic agents, to sedate
individuals with intellectual disability
Caveat-medication prescribed as a substitute for appropriate treatment or habilitation, for
the convenience of staff, or that its use was simply not supported by a relevant diagnosis
Many individuals don’t benefit from their psychotropic drug treatment
The rate of psychotropic medication usage has stabilized with individuals with intellectual
disabilities
Medication usage has begun to reflect the prescribing patterns of the general population,
albeit as a higher level
Persons with intellectual disabilities are one of the most medicated groups in our society
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Guidelines for the Use of Psychotropic
Medication
• Drugs may have a place in the treatment of
mental illness, regardless of whether or not
the person treated has an intellectual
disability
• Guidelines published in Psychotropic
Medications and Developmental Disabilities:
The International Consensus Handbook (Reiss
& Aman, 1998)
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Guideline
• Psychotropic medication shall not be used excessively, as
punishment, for staff convenience, as a substitute for services, or in
quantities that interfere with an individual’s quality of life
• Disallow excessively high dosages
• Inappropriate long-term use of medication
• Not to be used to control someone’s behavior if that behavior is
related to the appropriate expression of a personal right or is
otherwise reasonable given the person’s situation
• Not intended to compensate for insufficient or poorly trained staff,
inadequate environmental conditions or untreated medical issues,
or to serve as a substitute for appropriate behavioral or educational
interventions
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Guideline
• Psychotropic medication must be used within
a coordinated multidisciplinary care plan
designed to improve the individual’s quality of
life
• Role of a multidisciplinary team makes a
significant difference in the rates at which
these medications are prescribed e.g.
reduction
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Guideline
• The use of psychotropic medication must be based on
a psychiatric diagnosis or specific behavioralpharmacological hypothesis resulting from a full
diagnostic and functional assessment
• Prescribed only for a specific diagnosis in the DSM
• In response to a documented connection between the
cause of unwanted behavior and the medication’s
known propensity to act on that cause
• [Psychotropic drugs should not be prescribed simply
for “behaviors” or “aggression” without a proven
cause-and-effect relationship]
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Guideline
• Written informed consent must be obtained from
the individual, if competent, or the individual’s
guardian before the use of any psychotropic
medication and must be periodically renewed
• Presentation of the risks and benefits of taking or
not taking the medication, possible alternatives,
and the right to refuse consent or revoke it at a
later date
• Form that the individual can understand
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Guideline
• Specific index behaviors and quality of life outcomes
must be objectively defined, quantified, and tracked
using recognized empirical measurement methods in
order to monitor psychotropic medication efficacy
• Index behaviors refer to observable signs or subjective
feelings or sensations reported by the individual, by
which changes in their condition may be measured
• Consistently monitored by reliable documentation
systems or through the use of symptom-rating scales
• Implemented prior to the use of medication in order to
establish a baseline for comparison with subsequent
observations
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Guideline
• The individual must be monitored for sideeffects on a regular and systematic basis using
an accepted methodology which includes a
standardized assessment instrument
• Scales or checklists designed to assess for
side-effects should be used at least every 3 to
6 months, or as clinically indicated
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Guideline
• If antipsychotic or other dopamine-blocking drugs are
prescribed, the individual must be monitored for tardive
dyskinesia on a regular and systematic basis using a
standardized assessment instrument
• AIMS, DISCUS should be administered at least once every 6
months to assess for tardive dyskinesia
• Even when a potential tardive dyskinesia-causing
medication is discontinued, assessments should be
repeated at one and two months afterwards to detect the
possible emergence of withdrawal dyskinesia
• In addition, if a person already has tardive dyskinesia but is
no longer taking a dopamine-blocker, assessments should
be conducted at 6 to 12-month intervals
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Guideline
• Psychotropic medication must be reviewed on a regular
and systematic basis
• It is recommended that at least every 3 months, or within 1
month after a medication or dosage change, the positive
and negative effects of psychotropic medication should be
formally reviewed
• Reviewed by individual, all relevant treatment team
members including the psychiatrist or other knowledgeable
clinician
• Goal-lowest effective dosage and simplest possible drug
regimen are utilized
• Ensure therapeutic monitoring is in place for medications
that require it
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Ensure Efficacy Of Individual’s
Medication Regimen
• Identify the changes expected as a result of taking of the
medication
• Identify the time frames by which these changes should occur
• Develop a system to evaluate whether changes are occurring as
planned (e.g. data tracking systems, rating scales)
• Identify one person to collect and summarize relevant data
• Present data to the support team and psychiatrist on an ongoing
basis
• Regularly evaluate the accuracy of initial diagnostic impressions
• Regularly evaluate the effectiveness of the medication regimen (i.e.,
positive and negative effects)
• Adjust diagnostic impressions and treatment approaches as
indicated by data analysis
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American Association of Mental
Retardation
Specific practices that should be minimized:
Long term use of benzodiazepines (e.g. Ativan, Valium)
Use of long-acting hypnotics (e.g. Dalmane, Doral)
Long-term administration of anticholinergic medications (e.g.
benzotropine)
Use of anticholinergics in the absence of extrapyramidal side-effects
High dosages of antipsychotic medications
Employment of phenytoin, phenobarbital, or primidone as
psychotropics or anticonvulsants
[Medications on the so-called “Beers List” should be avoided
whenever possible-outmoded or have replacement options which
are much less likely to cause undesirable side-effects]
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Other Considerations
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The right medication for the right length of time
One of the primary reasons for treatment failure with psychotropic medication is
failure to optimize the dosage or to allow adequate time for the medication to
work
Another reason for poor therapeutic outcome is increasing a dose too rapidlyoften results in adverse side-effects, which then lead to medication
discontinuation or poor adherence to the prescribed regimen
It is important to increase all medication dosages slowly and to decrease them
slowly as well
Recommended to prescribe as few medications as possible and in the lowest
effective dosages, thus reducing the risk of drug-to-drug interactions as well as
adverse side-effects
Unnecessary or ineffective medications should always be discontinued [logic of “If
the problem is still occurring with the medications, imagine how bad it would be if
they were stopped” is seriously flawed.]
The medications are not effective if the individual’s problem persists.
Obtain all of a person’s medication from the same pharmacy in order to facilitate
screening for drug interactions
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Diagnostic & Statistical Manual-fourth
edition-Text Revised (DSM-IV-TR)
• According to the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), Mental Retardation (MR) is
characterized “by significantly sub average intellectual functioning
(an IQ of approximately 70 or below) with onset before age 18
years and concurrent deficits or impairments in adaptive
functioning” (American Psychiatric Association, 1994, p. 37).
Subcategories differentiated by IQ scores include (DSM-IV, p. 40)
• According to the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), Pervasive Developmental
Disorder is characterized by severe deficits and pervasive
impairment in multiple areas of development. These include
impairment in reciprocal social interaction, impairment in
communication, and the presence of stereotyped behavior,
interests, and activities.
• Structural, descriptive basis of the diagnostic categories
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DSM-5
New to the DSM-5, is a chapter on Neurodevelopmental Disorders which
contains seven disorders that share impairments in a number of
developmental areas, including personal, social, academic or occupational
functioning. Some of the disorders are more likely to be detected early, such
as the more severe variants of intellectual disabilities, autism spectrum
disorders (ASD), motor disorders, tic disorders and communication disorders.
However, other disorders in this category, like the specific learning disorders
(SLD) or attention deficit/ hyperactivity disorder (ADHD) have been called the
hidden disabilities because they are not obvious disabilities and often are
detected only after significant failure has been experienced by the individual.
The DSM-5 has clustered these disorders in the same chapter because the
neurodevelopmental disorders frequently co-occur; for example individuals
with autism spectrum disorder will often have intellectual disability
(intellectual developmental disorder), and many children with attentiondeficit disorder (ADHD), also have a specific learning disorder.
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DSM-5: Diagnostic Changes
Change in terminology
Change in diagnostic classifications
Intellectual Developmental Disorder is a disorder that includes both a current intellectual deficit and a deficit in
adaptive functioning with onset during the developmental period. All three of the following criteria must be met.
A.
Intellectual Developmental Disorder is characterized by deficits in general mental abilities such as reasoning,
problem-solving, planning, abstract thinking, judgment, academic learning and learning from experience. Intellectual
Developmental Disorder requires a current intellectual deficit of approximately 2 or more standard deviations in
Intelligence Quotient (IQ) below the population mean for a person’s age and cultural group, which is typically an IQ
score of approximately 70 or below, measured on an individualized, standardized, culturally appropriate,
psychometrically sound test.
AND
B.
The deficits in general mental abilities impair functioning in comparison to a person’s age and cultural group by
limiting and restricting participation and performance in one or more aspects of daily life activities, such as
communication, social participation, functioning at school or at work, or personal independence at home or in
community settings. The limitations result in the need for ongoing support at school, work, or independent life. Thus,
Intellectual Developmental Disorder also requires a significant impairment in adaptive functioning. Typically, adaptive
behavior is measured using individualized, standardized, culturally appropriate, psychometrically sound tests.
AND
C.
Onset during the developmental period.
Code no longer based on IQ level. [based on level of supports]
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DSM-5: Diagnostic Changes
Intellectual disability (intellectual developmental disorder)
Diagnostic criteria for intellectual disability (intellectual
developmental disorder) stress the need for an assessment of
both cognitive capacity (IQ) and adaptive functioning.
Severity is determined by adaptive functioning rather than IQ
score.
Intellectual disability replaces the term “mental retardation
with intellectual disability” with a severity scale to reflect
function, not I.Q.. The term intellectual developmental
disorder was placed in parentheses to reflect the World
Health Organization’s classification system, which lists
“disorders” in the International Classification of Diseases (ICD)
and bases all “disabilities” on the International Classification
of Functioning, Disability, and Health (ICF).
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Intellectual disability codes
Intellectual disability codes all have a direct
conversion code as follows:
Severity
ICD-9 code
ICD-10 code
Moderate ID
318.0
F71
Mild ID
Severe ID
Profound ID
Unspecified ID
317
318.1
318.2
319
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
F70
F72
F73
F79
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DSM-5: Diagnostic Changes
Autism spectrum disorder (ASD)
Autism spectrum disorder is a new DSM-5
name. ASD now encompasses the previous
DSM-IV autistic disorder (autism), Asperger’s
disorder, childhood disintegrative disorder, and
pervasive developmental disorder not otherwise
specified.
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DSM-5: Diagnostic Changes
A large controversy has surrounded this decision.
Some of the comments have to do with:
1. Some persons fear that Asperger’s [less
restrictive] will not meet the criteria for ASD [more
restrictive] and they will lose benefits such as
education, treatment, etc.
2. Some persons with Asperger’s do not want to be
seen in the same light or category as people with
autism.
3. Many mental health professionals believe that
Asperger’s is different as an illness than autism.
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DSM-5: Diagnostic Changes
DSM-IV Asperger’s disorder included:
1. Impairment in social interaction (2 of the
following): nonverbal behaviors, no peer
relationships, lack of shared activities, lack of social
reciprocity.
2. No delay in language.
3. No cognitive delay.
4. Repetitive activities of behavior (1 of the
following): pattern of activity, rituals, motor
mannerisms, fixation on parts of objects.
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Autism Spectrum Disorder
Neurodevelopmental Disorders
[DSM-5 now replaces Rett’s disorder, childhood disintegrative disorder,
Asperger’s disorder, and pervasive developmental disorder not otherwise
specified with Autism Spectrum Disorder]
Autism Spectrum Disorder 299.00 (F84.0)/ICD-10-CM Code
Currently or by history
With or without accompanying intellectual impairment
With or without accompanying language impairment
Symptoms change with development and may be masked by compensatory
mechanisms
Characteristic deficits of social communication, excessively repetitive
behaviors, restricted interests, and insistence on sameness
Typically recognized during the second year of life
Not a degenerative disorder, and it is typical for learning and compensation to
continue throughout life
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DSM-5: Diagnostic Changes
Autism spectrum disorders (symptoms present
in early childhood, 3 levels of severity). Deficits
in communication and interaction-include
reciprocity, nonverbal interaction, having
relationships, repetitive and/or restrictive
behaviors; and expanded list of specifiers (for
example- intellectual, language impairment,
catatonia.
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DSM-5 controversy overview
Combination of autism spectrum disorders into
single category. One of the most publicized
changes in the DSM-5 involves grouping all of the
subcategories of autism into a single category as
autism spectrum disorder (ASD). This move
eliminates previously separate diagnoses of autism
– including autistic disorder, Asperger’s disorder,
childhood disintegrative disorder and pervasive
developmental disorder “not otherwise specified”
(PDD-NOS).
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DSM-5 controversy overview
This merging of categories creates a “sliding
scale” for autism, meaning individuals will be
diagnosed somewhere along the autism
spectrum, given the personal severity of their
symptoms. Many parents and health care
providers have speculated that this
transformation may end up excluding some of
those already diagnosed with an autism
disorder, like Asperger’s or PDD-NOS.
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DSM-5 controversy overview
The specificity is going to go up, meaning the false
positives are going to be less likely. Dr. Alexandar
Kolevzon, associate professor of psychiatry and
pediatrics at Mount Sinai Hospital in New York City,
stated. “This universe of people with PDD-NOS; it’s
possible that some of those patients may no longer
meet those criteria. Some of the debate revolves
around Asperger’s, but it seems to me that most
people diagnosed with Asperger’s will still be on the
autism spectrum.”
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DSM-5 controversy overview
Over the past decade, the United States has seen a
striking increase in the amount of autism diagnoses, with
the Centers for Disease Control and Prevention
estimating that one in 88 children suffers from an autism
spectrum disorder. According to Kolvezon, numerous
epidemiological studies have found that the majority of
children accounting for this incidence are those with
PDD-NOS; a diagnosis given to those with communication
issues and pattern of behavior but who do not meet the
full criteria for autism or another pervasive
developmental disorder. Kolevzon said it’s possible that
over-diagnosis of PDD-NOS has led to this increase in
autism spectrum disorder cases.
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DSM-5 controversy overview
“What happens in the community is that the
diagnosis of autism spectrum disorder virtually
guarantees a whole host of therapies such as
speech therapy, occupational therapy,
behavioral therapy, and potentially physical
therapy.” Kolevzon said “Theoretically it’s
possible that community providers and clinicians
are incentivized to label kids with PDD-NOS,
because it would make it more likely to receive
appropriate services.”
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DSM-5 controversy overview
The autism spectrum disorder scale will further
refine the way providers diagnose autism,
Kolevzon said, by recognizing differences from
person to person rather than trying to
generalize them into one of four categories.
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DSM 5
A developmental focus
New diagnostic criteria
A move toward “dimensional” measures
Increased emphasis on culture and gender
A new section on areas that need further
research
• A commitment to more frequent updating
• Inclusion of International Classification of
Diseases (ICD) codes
•
•
•
•
•
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DSM 5
For the first time ever, the DSM depends on and incorporates evidence
from the neurosciences, genetic studies, twins studies, and overall
areas of research that had been largely ignored in previous editions of
the DSM. One of the biggest changes in the new edition is a
dramatically fresh approach to diagnostics.
•
New classification system
•
Newly organized trauma disorders
•
Changing diagnostics for children & adolescents
•
Impulse control & anxiety disorders
•
Revised categories for schizophrenia, mood disorders
and more
•
New diagnoses
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DSM-5
Guidebook for diagnosis, court evaluations, and insurance
reimbursement. It also defines what is normal and what
is abnormal in our culture, and by implication, where the
limits are of personal responsibility.
Excludes "science" of mental illness. No biological criteria
as part of its description, either from blood work, brain
scan, or genetic markers. The manual remains totally
dependent on client history and clinical observation.
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DSM-5 Guidebook
The Essential Companion To The Diagnostic and
Statistical Manual of Mental Disorders, Fifth
Edition
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Autism
The American Psychiatric Association released new
guidelines for the diagnosis of autism spectrum
disorders last year. Research suggests that the new
diagnostic criteria could miss thousands of children
who have developmental delays without an autism
diagnosis. It was found that under the new DSM-V
criteria, there were 31% fewer autism spectrum
disorders diagnosed, compared to what would have
been diagnosed with the DSM-IV. The decline in
diagnosis could mean that individuals are missing
out on services and support. Honor Whiteman,
Medical News Today 02/26/2014
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Autism
Last year, the American Psychological
Association issued new guidelines for the
diagnosis of autism spectrum disorder. But new
research from Columbia University School of
Nursing in New York, NY, suggests that these
guidelines could leave thousands of children
who have developmental delays without
autism diagnosis, meaning they will miss out
on social services, educational support and
medical benefits.
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Autism
Or . . . . . it could mean that fewer children are
being diagnosed who did not need to be
diagnosed with autism spectrum, which is a
good thing.
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Diagnostic Manual for Individuals with
Intellectual Disabilities (DM-ID)
•
•
•
•
•
The DM-ID
Diagnostic Manual – Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Persons
with Intellectual Disability focuses on issues related to diagnosis in people with Intellectual Disability (ID), the
limitations in applying DSM-IV-TR criteria to people with ID, and adaptation of the diagnostic criteria.
It has been abridged for clinical usefulness from The Diagnostic Manual – Intellectual Disability (DM-ID): A
Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability which was developed by the
National Association for the Dually Diagnosed (NADD), in association with the American Psychiatric Association
(APA), and is a diagnostic manual designed to be an adaptation of the DSM-IV-TR. Grounded in evidence-based
methods and supported by the expert-consensus model, the DM-ID(Textbook) offers a broad examination of the
topic, including a description of each disorder, a summary of the DSM-IV-TR diagnostic criteria, a review of the
research and an evaluation of the strength of evidence supporting the literature conclusions, a discussion of the
etiology and pathogenesis of the disorders, and adaptations of the diagnostic criteria for persons with Intellectual
Disability (ID).
The goal of both volumes is to facilitate a more accurate psychiatric diagnosis of people with ID. Chapters in the
DM-ID cover special issues (i.e., assessment and diagnostic procedures and presentations of behavioral
phenotypes of genetic disorders) as well as the individual DSM-IV-TR categories. For each disorder, descriptive text
and details of how to apply diagnostic criteria, as well as tables of adapted diagnostic criteria, are included.
In addition to adapting the DSM-IV-TR diagnostic criteria where appropriate, the DM-ID provides advice about and
considerations for assessing and diagnosing individuals with ID and coexisting mental health needs. In some cases,
it is not so much that the criteria need to be adapted, as that a different method of eliciting the necessary
information must be used. Information is provided in recognizing common behaviors of individuals with
intellectual disabilities and in how to differentiate these behaviors from psychiatric disorders.
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Diagnostic Manual for Individuals with
Intellectual Disabilities (DM-ID)
•
•
•
•
•
The Problem
Although psychiatric disorders in persons with ID are common, they are often not appropriately identified. The provision of
adequate mental health treatment for people with ID continues to be lacking, in part, because reliable psychiatric diagnosis
remains a clinical challenge. Determining an accurate psychiatric diagnosis becomes especially difficult as the level of
intellectual functioning declines.
Children and adults who have ID coexistent with psychiatric disorders may be one of the most underserved populations in
the United States. These individuals may fall through the cracks in service delivery systems when neither the local mental
health service system nor the developmental disability service system is willing or able to assume responsibility for their
treatment, services, and support. Individuals with ID have been estimated to be 2 to 4 times more likely than those in the
general population to experience psychiatric disorders. Researchers have found that as many as one third or more of all
people with ID have significant behavioral, mental, or personality disorders requiring mental health services. Often people
with ID who exhibit psychiatric problems are denied services or receive inappropriate treatment and services.
During the past few decades, there have been important developments in the field of mental health care for people with ID.
The National Association for the Dually Diagnosed (NADD) has been instrumental in marshaling national and international
attention, providing education and training, and disseminating relevant clinical and policy issues. In spite of these
encouraging developments, however, there remain significant obstacles hindering appropriate care and treatment for this
underserved population. One key problem is the absence of a diagnostic system appropriate for clinical use with the diverse
population of people with ID. As a result, individuals may receive no psychiatric diagnosis even when a mental disorder
exists, or they may receive an inaccurate or inappropriate diagnosis. Because treatments, services, and supports are tied
directly to the accurate evaluation and diagnosis of people who have ID coexistent with mental disorders, the absence of
psychiatric diagnoses is a central issue.
Clinicians need a system whereby they can recognize the presence of DSM-IV-TR-documented mental disorders in persons
who have limited expressive and receptive language skills. A major potential advantage of the DM-ID is that it may enhance
the reliability of psychiatric diagnoses in persons with ID which could ultimately improve treatment outcomes.
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Diagnostic Manual for Individuals with
Intellectual Disabilities (DM-ID)
•
•
•
•
•
•
The Problem (continued)
There are a number of factors associated with the difficulty of making an accurate diagnosis in people with ID. The applicability of
existing standardized classification systems (such as the DSM-IV-TR) for persons with ID has been critically debated in professional
literature. To determine whether a person within the general population has been experiencing psychiatric symptoms, a clinician
typically relies on the person’s description of his or her experiences and feelings. Individuals with cognitive impairments experience
difficulties in receptive and expressive language to varying degrees. Mild limitations in cognitive and verbal skills make it difficult, and
severe limitations may make it impossible, for people with ID to articulate such abstract or global concepts as depressed mood or to
communicate subtle differences among emotional or motivational states.
Other factors that increase the difficulty in making psychiatric diagnoses include the tendency for some people with ID to attempt to
hide their disabilities (to adopt a “cloak of competence”), the tendency not to be forthcoming with respect to self-descriptions, and the
tendency for some to try to please the evaluator by answering falsely or in a manner that is inaccurate (“acquiescence bias”).
Additionally, the symptoms of diverse psychiatric disorders are often expressed differently in people with ID. Four processes that are
common in persons with ID that can influence the diagnostic decision-making process are baseline exaggeration, intellectual distortion,
psychosocial masking, and cognitive disintegration.
Another diagnostic challenge is diagnostic overshadowing. Having a diagnosis of ID can overshadow coexisting mental disorders and
may predispose practitioners to overlook the presence of psychopathology, because unusual or anomalous behavior is attributed by the
clinician to being artifacts of developmental or social delay. For example, a person with Profound ID who is very withdrawn and asocial
might be less likely to be labeled as depressed than would a person with average intelligence.
Accurate diagnosis is important because it provides a sound basis for effective treatment. For many patients and their families
diagnostic understanding will reduce confusion and uncertainty. Positive treatment outcome is based on an accurate diagnosis. Just as
this is true concerning physical health, it is equally true in psychiatric health.
Severe behavioral disturbance in the form of verbal or physical aggression toward others, self-injury (aggression toward self), and
property destruction frequently motivates referrals for diagnosis and treatment prescription. Such severe disturbance occurs at a
clinically significant rate among people with ID, often threatens the stability of family living or the continuation of community living in a
relatively nonrestrictive setting, and can precipitate admission to a public mental health or ID facility. Severe behavioral disturbance of
various types occurs among people with Mild to Profound ID. However, it is important to understand that severe behavioral
disturbances are not part and parcel of a diagnosis of ID. The presence of clinically significant behavioral disturbances mandates a
thorough clinical diagnostic evaluation to determine the presence of comorbid mental disorders that may be responsible for the
behavioral disturbance. The extent to which behavioral disturbances represent symptom equivalents for symptoms such as depression
and anxiety, especially in individuals with severe and profound ID, has been the subject of considerable debate, which remains to be
elucidated by further research
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Diagnostic Manual for Individuals with
Intellectual Disabilities (DM-ID)
•
•
•
Classification and Diagnosis of Mental Illness
The clinician is faced with certain challenges when an individual with ID presents with disturbed or
disturbing behavior. There has been controversy found in the literature concerning the issue of
reliability in making specific DSM-IV-TR diagnosis in persons with ID, especially those with more
severe impairment and intellectual function. Some researchers assert that as intelligence decreases
the validity of psychiatric diagnosis for individuals with ID tends to decrease. They explain this as
the result of both an increase in nonspecific organic factors and the relative inaccessibility of the
individual’s inner life as productive speech decreases with the increased severity of impairment.
Despite a general consensus that mental disorders can be diagnosed using standard diagnostic
criteria for people with mild ID and reasonably good communicative skills, clinicians generally
acknowledge the increased difficulty for individuals with more severe ID and poor verbal skills.
In fact, the DSM-IV-TR itself recognizes that some diagnostic criteria need to be modified when
they are applied to children, both because the symptom profile of some disorders differs in children
(for example, the substitution of “irritable mood” for “depressed mood” in the diagnostic criteria
for Major Depressive Episode and Dysthymic Disorder in children) and because some diagnostic
criteria do not apply to children (for example, there is no requirement in specific phobia
descriptions that children recognize that their fears are excessive or unreasonable). Although
criteria set modifications have been proposed for different cultural groups—for the medically ill and
for geriatric patients among others, as well as those for children—no other modifications are
included in the DSM-IV-TR.
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Diagnostic Manual for Individuals with
Intellectual Disabilities (DM-ID)
•
•
•
•
•
•
•
•
•
10 years in the making thru NADD
Diagnosing Axis I Disorders in individuals diagnosed with different levels of Mental Retardation
Central premise is the thesis that a psychiatric diagnosis is a necessary, but not sufficient, basis to justify the use of psychotropic medication in
individuals with intellectual disabilities (ID)
Mild/Moderate
Severe/Profound
Companion to DSM
Implications of necessity of DM-ID-difficulty in diagnosing Axis I disorders
In 2007, NADD, in association with the American Psychiatric Association (APA), published Diagnostic Manual—Intellectual Disability (DM-ID). The
DM-ID is a companion to and adaptation of the APA’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR) for use with individuals who have an intellectual/developmental (IDD) disability co-occurring with mental illness (MI). The goal of the DM-ID was
to provide more accurate psychiatric diagnoses for individuals with IDD/MI. The DM-ID has been very well accepted and is considered the “gold
standard” for diagnosing psychiatric disorders in individuals with IDD
The DSM is used by mental health professionals to diagnose psychiatric disorders. Among the information it includes is a list of the symptoms
(criteria) that must be present in order to diagnose an individual with a particular psychiatric disorder. Generally the mental health professional will
determine the presence or absence of these symptoms through what the patient states in terms of feelings, experiences, and symptoms. However,
individuals with IDD usually have limited verbal ability and may lack the ability to describe their internal state. Also, various psychiatric disorders
manifest differently in individuals with IDD from the way they manifest in non-disabled individuals. The DM-ID describes these differences and
provides information about how to make an accurate psychiatric diagnosis in an individual with IDD without needing to rely on the individuals selfreport. The importance of this is that a more accurate psychiatric diagnosis will lead to more appropriate treatment, which will, in turn, lead to
improved quality of life for the individual with IDD co-occurring with mental illness. Peer-reviewed, published research clearly indicates the clinical
utility of the DM-ID. For further information about the DM-ID you may visit the DM-ID website.
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DM-ID-2
•
•
•
•
DM-ID-2
NADD has begun work on the revision of its seminal Diagnostic Manual – Intellectual Disability (DM-ID).
In 2007, NADD, in association with the American Psychiatric Association (APA), published Diagnostic
Manual—Intellectual Disability (DM-ID). The DM-ID is a companion to and adaptation of the APA’s
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) for use
with individuals who have an intellectual/developmental (IDD) disability co-occurring with mental illness
(MI). The goal of the DM-ID was to provide more accurate psychiatric diagnoses for individuals with
IDD/MI. The DM-ID has been very well accepted and is considered the “gold standard” for diagnosing
psychiatric disorders in individuals with IDD
The DSM is used by mental health professionals to diagnose psychiatric disorders. Among the information
it includes is a list of the symptoms (criteria) that must be present in order to diagnose an individual with a
particular psychiatric disorder. Generally the mental health professional will determine the presence or
absence of these symptoms through what the patient states in terms of feelings, experiences, and
symptoms. However, individuals with IDD usually have limited verbal ability and may lack the ability to
describe their internal state. Also, various psychiatric disorders manifest differently in individuals with IDD
from the way they manifest in non-disabled individuals. The DM-ID describes these differences and
provides information about how to make an accurate psychiatric diagnosis in an individual with IDD
without needing to rely on the individuals self-report. The importance of this is that a more accurate
psychiatric diagnosis will lead to more appropriate treatment, which will, in turn, lead to improved quality
of life for the individual with IDD co-occurring with mental illness. Peer-reviewed, published research
clearly indicates the clinical utility of the DM-ID. For further information about the DM-ID you may visit
the DM-ID website.
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DM-ID-2
• The APA will be releasing a revision of the Diagnostic and Statistical
Manual in May (DSM-5). With the release of the DSM-5 it becomes
important that the DM-ID be revised to correspond the DSM-5 and
to incorporate the changes in the DSM-5. There are many changes
and revisions planned in this edition. It will be important to
incorporate these changes into a future volume of the DM-ID to
insure the most accurate psychiatric diagnoses for individuals with
IDD.
• NADD has embarked on a multi-year project to revise the DM-ID to
correspond to the DSM-5. Dr. Robert Fletcher will be Chief Editor,
and Dr. Sally-Ann Cooper and Dr. Jarrett Barnhill will be CoEditors. NADD will again use an expert-consensus model, with work
groups of 4-8 experts for each of 22 diagnostic categories. The DMID-2 will use the same diagnostic categories identified in the DSM-5.
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Psychodynamic Diagnostic Manual
(PDM)
A collaborative effort
American Psychoanalytic Association
International Psychoanalytical Association
Division of Psychoanalysis (39) of the American
Psychological Association
• American Academy of Psychoanalysis and
Dynamic Psychiatry
• National Membership Committee on
Psychoanalysis in Clinical Social Work
•
•
•
•
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PDM
• The Psychodynamic Diagnostic Manual (PDM) is a diagnostic
framework that attempts to characterize an individual’s full range of
functioning-the depth as well as the surface of emotional,
cognitive, and social patterns. It emphasizes individual variations as
well as commonalities. We hope that this framework brings about
improvements in the diagnosis and treatment of mental disorders
and permits a fuller understanding of the functioning of the mind
and brain and their development. The goal of the PDM is to
complement the DSM and ICD efforts of the past 30 years in
cataloguing symptoms by explicating the broad range of mental
functioning.
• Treatments that focus on isolated symptoms or behaviors (rather
than personality, emotional, and interpersonal patterns) are not
effective in sustaining even narrowly defined changes.
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PDM
• Neurodevelopmental Disorders of Relating and
Communicating (NDRC)
• Type I: Early Symbolic, with Constrictions
• Type II: Purposeful Problem Solving, with
Constrictions
• Type III: Intermittently Engaged and Purposeful
• Type IV: Aimless and Unpurposeful Other
Neurodevelopmental Disorders (Including
Genetic and Metabolic Syndromes)
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National Association for the Dually
Diagnosed (NADD)
• www.theNADD.org
• Positive Identity Development-Dr. Karyn Harvey
• Trauma-Informed Behavioral Interventions-Dr.
Karyn Harvey
• Founded in 1983 as a not-for-profit Association.
The catalyst for the founding of NADD arose from
the need for an open forum to promote and
exchange of ideas, principals & concepts
concerning individuals who have the co-existence
of ID/D and mental illness.
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American Association on Intellectual and
Developmental Disabilities (AAIDD)
• www.AAIDD.org
• Formerly American Association on Mental Retardation
(AAMR) changes name to American Association on
Intellectual Disabilities (AAIDD)-January 1, 2007
• New name reflects new philosophy
• Supports Intensity Scale (SIS)
• Positive Behavior Supports
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Positive Behavior Supports (PBS)
• Setting the person up to succeed
• A PBS framework maintains a focus on individual
quality of life (QOL) as the predominate outcome of
interest. Challenging behavior becomes a target of
treatment intervention then, not because of some
inherent value of the behavior, but because of the
negative impact a behavior imparts on an individual’s
quality of life. In considering this, it follows that the
focus of intervention is more often on the
environmental context and systemic root of a
challenging behavior than on the simple extinction of
that behavior.
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Behavioral (Health) Assessment and
Functional Analysis
Behavioral (health) assessment is an analysis aimed at identifying the history,
presentation, purpose, and outcome of a particular behavior.
Functional analysis (assessment) is one part of the behavioral assessment. The
functional analysis focuses on the cause and outcome of the behavior. It is used to
identify why a person may be exhibiting a behavior, what needs are being met by the
behavior, and what interventions have been effective or ineffective.
-Observations of the individual in various environments
-A history of the challenging behaviors, including the identified target behavior
-Specific definitions of challenging behaviors
-Interventions that have been attempted and the effectiveness of those interventions
-Outcome of the behavior (how did others respond, etc.)
-Hypotheses about the purpose of the target behavior
-A method of data collection in order to measure and record the target behavior
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Functional Behavioral Assessment
(FBA)
Functional behavioral assessment (FBA) is a variation on procedures
originally developed to ascertain the purpose or reason for behaviors
displayed by individuals with severe cognitive or communication
disabilities (e.g., individuals with mental retardation or
autism). Because these individuals were unable to fully explain why
they were displaying certain inappropriate behaviors, methods were
developed to determine why they demonstrated such actions. These
investigatory procedures, derived primarily from the orientation and
methods of applied behavior analysis were known as "functional
behavioral analysis". By gathering data and conducting experiments
that evaluated the effects of environmental variables on the behavior,
concerned staff members could usually decipher the meaning of the
behaviors (i.e., what emotion or message was being communicated
through the actions), determine why they were occurring, and develop
behavior change programs to help the disabled individual display more
appropriate behavior in meeting his or her needs.
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Role of the Functional Analysis
• It is a systematic way to assess a person’s behavior with the goal of
understanding why it occurs.
• It assumes that all behaviors occur for reasons and have meaning.
• It assumes that behaviors do not occur without specific
antecedents or triggers, even if those triggers are not always
observable by others.
• Identification of the target behavior
• Data collection
• Hypothesis generation
• Plan development
• Plan implementation
• Data collection
• Review of plan effectiveness
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Implementation of PBSPs
Relevance to their job duties from the DSP perspective
Logistical issues with respect to training, implementation, and documentation
New developments in Psychotropic medications and the integration behavioral approaches
Support/accountability from supervisors and administration and implementation of a monitoring system to assess efficacy
and promote continuous program improvements
Conceptual understanding of Positive Behavior Support
“Buy in” by Direct Support Professionals based on how the PBSP is presented/taught and the context in which it is taught
Perception of the individuals we support-whole human beings versus one dimensional entities (patient, client, etc.)-“In defining
quality of life, we must not draw boundaries and relegate everything beyond those boundaries to the ‘abnormal’. Instead, we
must do everything in our power to build the kind of broadminded society in which people living with disabilities do not have
to consider themselves ‘handicapped’ and can manifest their full potential”-Daisaku Ikeda from On Being Human/Positive
Identity Development-Karyn Harvey, Ph. D.
Role of staff and their behavioral change vis a vis the PBSP interventions
Role of staff and their understanding of the concept of behavior change and the role of the environment on behavior change
Reinforcement of staff in the correct implementation of the PBSP
Reinforcement of staff in the incorrect or lack of implementation of the PBSP
Values/education of Direct Support Professionals that impact the PBSP implementation
Bigger picture of the mission/vision of the facility
Conceptualization of the ability to “learn” and the implications of the learning
Hopefulness or hopelessness about their role and the role of the individual
Conceptualization of “mental retardation”, ID, DD
Conceptualization of the usage of medications
Tainted culture by veteran staff to new staff
Engagement in the environment as a first line defense
Sate environment
Social relevance
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State Policies and Practices in Behavior
Supports
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2013, Vol. 51, No. 6, 433–445
AAIDD
DOI: 10.1352/1934-9556-51.6.433
State Policies and Practices in Behavior Supports for Persons With Intellectual and Developmental
Disabilities in the United
States: A National Survey
David A. Rotholz, Charles R. Moseley, and Kinsey B. Carlson
Abstract
Providing effective behavioral supports to decrease challenging behavior and replace it with appropriate
alternative skills is essential to meeting the needs of many individuals with intellectual and
developmental disabilities (IDD). It is also necessary for fulfilling the requirements of Medicaid funded
individual support plans and is important for moral, ethical, and societal reasons.Unfortunately, there is
no national standard for behavioral support practices or source of information on the status of
behavior support policies, practices, and services for adults with IDD at either state or national levels.
The collection of comprehensive data on state behavior support definitions, provider qualifications,
training, and oversight requirements is a necessary starting point for the development of plans to
address needed policy and practice changes. This survey is the first national assessment of state policies
and practices regarding the definition and delivery of behavior support services to people with
intellectual and developmental disabilities receiving publicly financed supports in the United States.
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Psychiatric medication
•
•
•
•
•
•
•
•
•
•
•
•
•
Treat signs/symptoms of diagnosed psychiatric disorder
Anti-anxiety
Anti-depressive
Anti-psychotics
Not for behavior
Placebo better than antipsychotic drugs for treating aggression in the intellectually
disabled
No evidence that MR per se changes the mechanism of action of psychotropic
drugs (pharmacokinetics)
Influenced by a medical/neurological disorder “associated” with MR
“L”ithium-incorrect (not trade name e.g. Lithobid)
lithium-correct (salt)
Standing psychotropic PRN medications are not permitted-use STAT
Use of PRN medications should not be utilized for longer than a few weeks.
Agitation is not a sufficient rationale as it describes an internal state
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Manual for Psychiatric Clinics
• Specific detailed procedures
• Integration of
psychological/behavioral/psychiatric data
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Restraint
Physical: any manual method that restricts freedom of movement or normal access to one’s body, including hand or arm holding to escort an individual
over his or her resistance to being escorted. Physical restraint does not include medical intervention or brief, limited, and isolated use of physical guidance,
positioning, or prompting techniques that are used to teach or redirect an individual or assist, support, or protect the individual during a functional
therapeutic or physical exercise activity; response blocking and brief redirection used to interrupt an individual’s limbs or body without the use of force so
that the occurrence of challenging behavior is prevented; holding an individual without the use of force to calm or comfort, or hand-holding to escort an
individual from one area to another; and response interruption used to interrupt an individual’s behavior using facility-approved techniques. The only
approved physical restraint techniques are hand, arm, and leg holds and techniques covered in the prevention and management of aggressive behavior
(PMAB) curriculum. [Non-contingent physical restraints are not permitted]
Chemical: any drug prescribed or administered to sedate an individual or to temporarily restrict an individual’s freedom of movement for the purpose of
managing the individual’s behavior.
Mechanical: any device attached or adjacent to an individual’s body that he or she cannot easily remove that restricts freedom of movement or
normal access to his or her body. The term does not include medical intervention or any device used to achieve functional body position or proper balance
or to prevent injury due to involuntary movement (e.g., falls due to seizures). Only those commercially available mechanical restraint devices designed
specifically for safe and relatively comfortable restraint are permitted to be used.
Prone: any physical or mechanical restraint that places the individual in a face down position. Prone restraint does not include medical intervention or
brief physical holding of an individual who, during an incident of physical restraint, rolls into a prone position, when staff restore the individual to a
standing, sitting, or side-lying position as soon as possible. Prone restraint is prohibited.
Supine: any physical or mechanical restraint that places the individual on his or her back. Supine restraint does not include medical intervention or brief
physical holding of an individual who, during an incident of physical restraint, rolls into a supine position, when staff restore the individual to a standing,
sitting, or side-lying position as soon as possible. Supine restraint is prohibited.
SECTION 1. Chapter 592, Health and Safety Code, is amended by adding Subchapter E to read as follows:
SUBCHAPTER E. USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS
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Not Restraint
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Adaptive Supportive Devices-provide individual with opportunity to have more normal posture or freedom of independent movement
(bedrails not permitted for “safety”)
Medical Protective Devices-used to treat a medical condition or to aid in wound healing following an injury or surgical lesion
Medical Immobilization-prevents movement during medical procedure
Issue is the function of the restraint not the structure of the restraint
We don’t restrain people because they are upset
We don’t release people from restraint because they are calm
Upset/calm is the establishing operation surrounding the behavior that places the individual at imminent risk of harm to self or
others
Imminent risk of harm to self or others is the criteria
Risk versus Risk analysis: Liability accrues whether the restraint is given or not given (more trouble by not following physician order
and not administering chemical restraint if someone is harmed than by following physician order and administering chemical
restraint and no one is harmed/nurse judgement/how many nurses have lost licenses in both scenarios)
Calm time is the time to administer the chemical (behaviors occur cyclically and therefore there are peaks and troughs, therefore the
chemical restraint is more effective when given at a a trough time/easier to administer/chemical restraint is more effective during
trough time/consider behvioral events leading up to physician order for chemical restraint and that rather than being reactive to the
preceding behavioral episode, being proactive to the possibility of ongoing behavioral episodes/data is important to substantiate
clinical judgment related to the administration or non-administration of the chemical restraint based on the individual’s
behavior/history being the greatest predictor of future events e.g. in the current behavioral episode)
The issue of “calm” is irrelevant and should never be the determining factor in either initiating or terminating a restraint of any
kind. “Calm” is the establishing operation or context in which the challenging behavior is either occurring or is not occurring. The
issue at hand is whether the individual is at imminent risk of harm to self or others. If the individual in question is known to staff e.g.
clinical judgment, to the degree that displaying “calm” behavior does not preclude the ongoing imminent risk of harm to self or
others then the individual may be assessed as such regardless of whether the individual is “calm” or not. Again, the issue of “calm”
is irrelevant to the issue of imminent danger to self or others and thus to the issue of restraint.
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Safe Restraints
No prone restraint
Only approved restraints
Immediate and serious risk of harm
Terminate restraint when no longer danger
No injury to the individual as result of using
restraint
• No evidence restraint was used for punishment
• No evidence restraint used for convenience
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Restraint Not Used As Alternative
– APPROPRIATE ASSESSMENTS
– PBSP TO ADDRESS BEHAVIORS RESTRAINED
– EVIDENCE OF ISP/PBSP IMPLEMENTATION
– STRATEGIES TO REDUCE USE OF RESTRAINT
– ENGAGED MEANINGFULLY
– CONSISTENT PSYCHIATRIC TREATMENT
– COMMUNICATION, IF RELATES TO BEHAVIOR
– NO MEDICAL UNTREATED
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Restrained After Less Restrictive
Measures
– USED PMAB
– USED THE PBSP
– ATTEMPTED LEAST RESTRICTIVE FIRST
– PRIOR TO CHEMICAL CONTACTED BHS TO
REVIEW/ASSESS FOR LESSER RESTRICTIVE
METHODS.
– MEDICAL/DENTAL EVIDENCE TREATMENT
ATTEMPTED WITHOUT RESTRAINT
– NO CONTRAINDICATIONS: ISP, PBSP, MEDICAL
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Restraints
DISCUSS/ DETERMINE RELEVANCY/ACT
– Adaptive skills, biological, medical, psychosocial issues
– Environmental variables (setting events)
– Environmental antecedents
– Variables maintaining the dangerous behaviors (consequences)
– *Is there a current PBSP? Or in development
– *Is there a Crisis Intervention Plan
– The PBSP was reviewed and complete
• Integrity data at 80% within two months of cluster
– The CIP was reviewed and complete
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Senate Bill (S.B.) No. 41
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AN ACT
relating to the use of restraints in state supported living centers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 592, Health and Safety Code, is amended by adding Subchapter E to read as follows:
SUBCHAPTER E. USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS
Sec. 592.101. DEFINITION. In this subchapter, "executive commissioner" means the executive commissioner of the Health and Human Services
Commission.
Sec. 592.102. USE OF RESTRAINTS. (a) The executive commissioner shall adopt rules to ensure that:
(1) a mechanical or physical restraint is not administered to a resident of a state supported living center unless the restraint is:
(A) necessary to prevent imminent physical injury to the resident or another; and
(B) the least restrictive restraint effective to prevent imminent physical injury;
(2) the administration of a mechanical or physical restraint to a resident of a state supported living center ends immediately once the imminent risk
of physical injury abates; and
(3) a mechanical or physical restraint is not administered to a resident of a state supported living center as punishment or as part of a behavior plan.
(b) The executive commissioner shall adopt rules to prohibit the use of prone and supine holds on a resident of a state supported living center
except as transitional holds.
Sec. 592.103. STANDING ORDERS FOR RESTRAINTS PROHIBITED. (a) A person may not issue a standing order to administer on an as-needed basis
mechanical or physical restraints to a resident of a state supported living center.
(b) A person may not administer mechanical or physical restraints to a resident of a state supported living center pursuant to a standing order to
administer restraints on an as-needed basis.
Sec. 592.104. STRAITJACKETS PROHIBITED. A person may not use a straitjacket to restrain a resident of a state supported living center.
Sec. 592.105. DUTY TO REPORT. A state supported living center shall report to the executive commissioner each incident in which a physical or
mechanical restraint is administered to a resident of a state supported living center. The report must contain information and be in the form
required by rules of the executive commissioner.
Sec. 592.106. CONFLICT WITH OTHER LAW. To the extent of a conflict between this subchapter and Chapter 322, this subchapter controls.
SECTION 2. Not later than January 1, 2012, the executive commissioner of the Health and Human Services Commission shall adopt rules required
under Sections 592.102 and 592.105, Health and Safety Code, as added by this Act.
SECTION 3. This Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Section 39,
Article III, Texas Constitution. If this Act does not receive the vote necessary for immediate effect, this Act takes effect September 1, 2011.
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Title 40, Part 1, Chapter 5, Subchapter H – General Principles for the Use of
Restraint, §5.355
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b) Upon an individual's admission to a state MR facility, an IDT must:
(1) with the involvement of a physician, identify:
(A) the individual's known physical or medical conditions that might constitute
a risk to the individual during the use of restraint; and
(B) other factors that must be taken into account if the use of restraint is
considered including, but not limited to, the individual's cognitive functioning
level, size, weight, emotional condition (including whether the individual has a
history of having been physically or sexually abused), and age; and
(2) document the identified conditions and factors and, as applicable,
limitations on specific techniques or mechanical devices for restraint, in the
individual's record.
(c) At least annually, or when significant changes occur to the extent and nature
of the identified conditions and factors documented in the individual's record,
the IDT must ensure that a physician, advanced practice nurse, or physician
assistant reviews and updates, as necessary, the identified conditions, factors,
and limitations on specific techniques or mechanical devices for restraint
documented in the individual's record.
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Senate Bill (S.B.) No. 34
• Administration of psychoactive medications in
facilities
• Takes effect September 1, 2013
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Psychotropic Medication for a
Psychiatric Emergency
This is a relatively new concept, and in the past, this type of processing was
categorized as a chemical restraint. This new concept emphasizes a
psychiatric treatment need and the medication is in response to an escalation
or exacerbation of the signs and symptoms that the psychiatrist and IDT have
discussed and documented as part of the ISP. In contrast to chemical
restraint, if there is a psychiatric emergency, the intent of the medication has
a relationship to treatment of the presenting medical condition. The teams
should be aware of the use of psychotropic medication as part of a psychiatric
emergency and the difference from a chemical restraint. Our psychiatrists
can help with the clarification of this difference.
“Crisis” Intervention Plan-Behavior that is predicted
It would be hard to develop a plan for behavior that isn’t predicted. A CIP is
based on the behaviors that an individual exhibits that requires the use of
restraint
Definition of “emergency” precludes routine, predicted, or expected
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Psychotropic Medication
• Texas Administrative Code (TAC)
• Rules of the Texas Department of Mental Health and
Mental Retardation
• Title 25, Part II
• New Subchapter Governing
• PRESCRIBING OF PSYCHOTROPIC MEDICATION• MENTAL RETARDATION FACILITIES
• Chapter 405, Subchapter B
• EFFECTIVE DATE: August 19, 1994
• Guidelines for the Use of Psychotropic Medication
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Seclusion
• Prevention of egress
• Not allowed: person cannot leave area
whether a room, a central location, or a
building
• Issue is the function (not structure)
• Issue is rights (due process)
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Role of Psychologists in Administration
of Psychotropic Medications
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Psychologists are legally prescribing psychoactive medications in seven states, including the island of Guam, a
territory of the US. This issue has been addressed on a state by state basis thru the psychology licensing boards
over the past twenty five years.
Non-prescriber therapists should communicate with prescribing clinicians if, in their assessment, such
communication may be helpful to the client. In other words, the best interests of the patient should determine
whether the non-prescriber therapist should be engaged with prescribing clinician.
While Consulting With Prescribing Clinician, Non-Prescribing Therapist Should:
Obtain an authorization to release information. Even though HIPAA law allows psychotherapists to discuss
medication and other treatment issues with medicating clinicians, most state laws require that therapists, in most
situations, obtain client authorizations before disclosing any confidential information to the prescribing clinician.
Provide only the minimum information necessary.
Be careful with the release of information related to people who are not your clients but are related to the client,
such as spouses, children, parents, etc.
Suggest different medication, different doses or recommend the discontinuation of medication.
Be advised to document their medication consultation with clients and medicating clinicians or anyone else they
may consult with (i.e., parents, etc).
In summary, non-prescribing psychotherapists can play an important role in helping clients manage their
psychotropic medications. Needless to say, they should never prescribe, discontinue or change clients’ meds,
unless they are licensed to prescribe. Non-prescribing psychotherapists may inform clients about treatment
options, including medications, and consult with the medicating physician as clinically necessary.
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Applied Behavior Analysis (ABA)
• Originated in Psychology
• Implications for licensure/board regulating
BCBA
• Application of learning theory/behavioral
principles to real life
• Classical conditioning: antecedents to the
behavior
• Operant conditioning: consequences to the
behavior
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Role of environment
• Definition-External to individual e.g. density,
structure, temperature, and most importantly
“people”, etc.
• Critical to behavioral change
• Changes to environment
• There is no all inclusive list
• Engagement in the environment as a first line
defense
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Basic Terms
Acquire-attention, tangibles, activity
Escape
Avoidance
Positive reinforcement (within 1 second)
Negative reinforcement
Extinction
Punishment-positive versus negative
Shaping
Successive approximations
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Definition of learning
“These people can’t learn”
Unicellular organisms learn
Change in behavior not due to neurological or
disease, or trauma
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Interdisciplinary Team (IDT)
Not headed by physician
Not medical model
All members equal
Interactions between professionals that lead to a
holistic view of the individual
• Transcends the physical meeting to actual behavioral
scenarios that may preclude disasters resulting from
lack of communication amongst staff from varying
disciplines
• Integration begins at the IDT level (not as an
afterthought to signing a document)
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Interdisciplinary Team (IDT)
An interdisciplinary approach to service delivery
presupposes interaction among the disciplines. Not
only are individuals from several disciplines working
toward a common goal, but the team members
have the additional responsibility of the group
effort (Rothberg, 1981). This approach necessitates
effective communication among the various
individuals involved in the patient’s rehabilitation
(Melvin, 1989). The team includes not only the
professionals but the patient and his or her family
and significant others as well.
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Interdisciplinary Team (IDT)
Benefits and Challenges
The benefits of teamwork are obvious. Team practice has led
professionals to see clients and their families as whole persons, not as
parts of a whole (e.g., mouths, brain, arms, legs). An appreciation of
other disciplines allows professionals to accommodate larger
functional goals and integrated interventions, instead of working on
isolated tasks. From the patients’ and families’ point of view, it is
easier to communicate with a cohesive team, rather than numerous
practitioners who work in isolation. It is also less overwhelming if
information related to intervention is synthesized across disciplines,
rather than presented separately from each practitioner. Teamwork
brings together diverse knowledge and skills and can result in quicker
decision making. As a result of professional collaboration, redundancy
or fragmentation of service can be reduced or eliminated, thereby
increasing the cost efficiency of service.
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Interdisciplinary Team (IDT)
But there are drawbacks to teaming as well.
Certain economic and professional factors must be considered. A substantial amount
of time can be spent by team members from various disciplines in communicating.
Think, for example, of the salary costs of a team conference or rounds [combined
salaries of professionals discussing the logo for the tee shirt]. In addition, most
professionals have a productivity standard that must be met. This can impose a
limitation on the time such individuals have for participating in these and other
interdisciplinary activities. As a further complication, there are personnel shortages in
many of the rehabilitation professions. Costs combined with staff shortages [staff
turnover] can certainly affect the ability to deliver rehabilitation services under an
interdisciplinary model (Melvin, 1989). Some team members and professional groups
are threatened by the notion of giving up some of their autonomy to the group effort.
There is a lack of confidence and trust in the opinions and decisions of individuals
from other disciplines. In addition, team members’ perceptions of their respective
roles and contributions to the team may clash. This may lead to individuals feeling that
others are usurping their domain. This issue of territorialism can destroy a functioning
team (Rothberg, 1981). In spite of these economic and professional factors, the
interdisciplinary approach can improve the delivery of services to patients. All team
members are working toward common goals and not in isolation.
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Person Centered
• The person defines their wishes, hopes, dreams,
and goals
• Individual determines treatment planning
• IDT supports their attainment
• Lowes: “You can do it, we can help”
• Important “to” versus important “for”
• Functional assessment
• PBSP
• Risk Assessment
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Meet people where they are…
• If an individual does not attend class…don’t count
them out…bring class to the individual
• If an individual is determined to be at risk of
suicide…don’t isolate the person…provide
habilitation with the needed supports
• If an individual can only point to a towel…don’t
exclude them from cleaning the oven…..make
that an important part of cleaning an oven
• “Don’t lose the baby with the bathwater”
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Choice
• We all make choices all the time and they all
have reality
constraints/limitations/consequences
• Does not mean overwhelming with continual
choices
• They can’t speak so how do we know
• Self-determination (civil rights movement)
plus choice result in Quality of Life (QOL)
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Compliance vs Cooperation
Compliance is the act of doing what we are told
to do. Cooperation is the act of working
together towards a common goal. Which is
more appealing?
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Compliance vs Cooperation
What’s the compelling reason for someone to
engage in a task?
-If someone simply does not want to engage in a
task, then there is no strategy that will directly
result in them engaging in that task
-So, how do we motivate someone, from their
perspective, to engage in a task that we think is
important?
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Compliance vs Cooperation
Focus Intervention on essential activities first
-Pick and choose your “battles” very carefully
-Use positive reinforcement and modeling to
encourage general positive social behavior, but
focus structured interventions on areas that will
most affect an individual’s health, safety, and
inclusion
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Compliance vs Cooperation
Are we expecting better behavior from the
individuals we work with than we do from
ourselves?
-Are the standards we are holding the individuals
we work with higher than what the average person
living in the community is expected to follow?
-What is a normal standard for behavior, hygiene,
etc?
-Do we allow for normal human error in how we
define behavior and compliance?
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Compliance vs Cooperation
Focus on the positive!
-Don’t define someone as “non-compliant”
-For every non-compliant behavior, there are
many more cooperative behaviors that a person
engages in that go unnoticed. No one is
completely uncooperative.
-Recognize and reward cooperative behavior
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Compliance vs Cooperation
Are we utilizing the team process to
address/resolve ongoing compliance issues
that result in health and safety hazards?
-Don’t get caught up in a battle of wills with the
people we serve
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Laying on of hands
• Power/control/dominance-we don’t “command” people,
we “ask” people
• Getting out of harms way
• PMAB/BMAP/TMAB
• Mandt-Trauma Informed approach to Positive Behavior
Support. The impact of trauma and how that trauma affects
the neurodevelopment of children into adulthood. People
use behavior to cope with their traumatic experiences and
these coping mechanisms become the behavioral
challenges and mental health disorders demonstrated
throughout the lifespan. The neurodevelopmental model
integrates the information into Positive Behavior Support
plans through the use of structural assessments.
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Labeling
• Person first language
• House Bill (H.B.) 1481
• Correct: A person diagnosed with
signs/symptoms of mental retardation
• People are not their diagnoses
• Incorrect: Mentally Retarded people
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Data Collection
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Foundation for assessment, diagnosis, treatment
Closing the loop
Changes in status prompt assessment, etc.
We don’t assess to assess, we assess to treat
Time taken to assess is time without treatment
Data “shmatta”
“Garbage in/Garbage out”
Referral/Enrollment/Attendance/Engagement
Frequency/Intensity or Severity/Duration
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Antecedent-Behavior-Consequence
(ABC)
• Event recording-data on every occurrence
• Time sampling-behavior occurs too frequently
• ABC assessment is the core concept of what
applied behavior analysis practitioners call
functional assessment
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Reliability
• Achieve the same results when you do the
same thing
• “Shoot an arrow”-hit the same spot each time
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Validity
• Measuring what you purport to measure
• “Shoot an arrow”-hit the bulls eye
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Accuracy
Measurement in agreement with an
independent measure
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Inter-Observer Agreement (IOA)
Two observers see and record the same
behavior
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Treatment Integrity
• Treatment Fidelity
• Implementing the PBSP exactly as written
• Conceptualize it as an experiment-once you change the conditions of the
experiment it is no longer valid (you need to collect data to show either
that the plan works or does not)
• Mind-reading versus empiricism- “This plan won’t work” (before the fact)
versus implementing the plan and collecting data to make determination
after the fact
• PBSP is ineffective-we need a new one (represents a giant leap in logic)
• Critically analyze “all” of the elements that may be responsible for the
PBSP appearing ineffective
• Manipulate one variable at a time to determine impact
• PBSP is a composite of many variables therefore one can only determine
whether the PBSP as a whole is effective or ineffective
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Suicide Risk Assessment
• People that say they are going to do it are
more likely to do it
• Correlation of suicide risk and diagnostic
categories e.g. Bipolar Affective Disorder
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Risk Determination/Risk Management
• Focus on risk determination
• Leads to risk management/supports
• A Positive Approach to Risk Requires Person
Centered Thinking- “Holy Grail”
• Purpose is as much about happiness of the
person as about their safety
• People have the right to make “bad” decisions
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Proposed Causes for Increased Risk
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Increased stress
Diminished ability to cope
Brain Dysfunction
Limited mental health care
Rejection
Segregation
Lack of control over one’s life
Limited social support
Limited vocational opportunities
Poor self-image
Limited social skills
Labeling
Increased rates of abuse and neglect
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Communication
• Verbal: spoken language, speech, scream,
guttural
• Non-verbal: behavioral, body language,
gesture, affect, emotional tone
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People are not their diagnoses, signs
and symptoms, verbal/nonverbal
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People are not one dimensional
People should be treated with dignity and respect.
People have hopes and dreams and goals and wishes and trials and tribulations
and troubles and losses and have diagnoses and are prescribed medications
People are people are people
There is no “us” and “them”…there is only “we”
There is nothing intrinsic to the “population” that separates “them” from “us”
The only thing that separates us is the nature of the relationship
They are receiving treatment
We are providing treatment
If I become disabled I am still the same person, the only thing that has changed is
the relationship to the provider
Now I am receiving treatment rather than providing treatment
Diagnosis characterizes the disorder not the person
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Chronological age appropriateness
• ICF/MR guideline
• Not based on emotional/intellectual level
appropriateness but on chronological age
• Think “lollipop” rather than pacifier
• Think art supplies rather than coloring book
and crayons
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Normalization
• Teaching behavior that will result in
integration into the larger world
• “Normalization principle” does not mean
making them normal but enabling them to live
in as normal an environment as possible
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Regulations for prescription of
psychotropic medications
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Chemical restraint shall not be used excessively, as punishment, for the convenience of staff, as a substitute for
habilitative program, or in quantities that interfere with a resident’s habilitation program.
We don’t have anti-aggression medication
We do have medication for mania and paranoia that may be manifested thru physical aggression
We don’t medicate diagnoses-we medicate people who have signs/symptoms of a diagnosed disorder
Or for signs/symptoms that do not meet the criteria for a disorder to be diagnosed
Medications do not teach anything
Goal is to teach the person how to meet the needs that the medication is meeting
Best practice includes the use of medication when indicated
We medicate people for specific signs/symptoms of diagnostic categories that have been applied
People do not necessarily have to have a diagnosis in order to receive a psychotropic medication
People are want to receive medication for anxiety when visiting the dentist without having been diagnosed with an anxiety disorder
Guidelines for the Use of Psychotropic Medication
Texas Administrative Code: Prescribing of Psychotropic Medication-Mental Retardation Facilities Chapter 405, Subchapter B
A Behavioral Diagnostic Paradigm for Integrating Behavior-Analytic and Psychopharmacological Interventions for People with a Dual Diagnosis
Integrating behavioral and pharmacological interventions in treating clients with psychiatric disorders and mental retardation
Q: Can individuals receiving psychoactive medications for inappropriate behaviors have a coping training objective designed to reduce
inappropriate behaviors instead of a formal BMP?
A: Drugs used for control of inappropriate behavior may be used only as an integral part of an individual’s individual program plan (IPP) that is
directed specifically toward the reduction of and eventual elimination of the behaviors for which the drugs are employed. However, individuals who
receive psychoactive drugs for behaviors associated with a diagnosed mental disorder require an active treatment program designed to reduce,
ameliorate, compensate or eliminate the psychiatric symptoms. For an individual with a diagnosed mental disorder, a program to reduce his or her
psychiatric symptoms is more appropriate than a program to reduce his or her inappropriate behaviors. However, the requirement for a program to
reduce psychiatric symptoms does not prevent a facility from also developing a BMP.
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Civil Rights-chemical restraint
• Where have we failed that resulted in the use of a chemical
restraint
• Did we do it right but document it wrong
• Did we inadequately document that the administration of a
chemical was for the correct clinical reason e.g. anti-anxiety, antipsychotic, etc.
• Chemical restraint does not end with the administration of the
chemical versus a physical restraint
• The chemical remains active within our body and has a half-life
(pharmacokinetics)
• Issue of “calm” as criterion for terminating a restraint is a fallacy
(harm to self or others is the issue)
• Is the use of chemicals “truly” more restrictive than the use of
physical methods (philosophical issue)
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Committee structures in place
Best Practice
• Positive Behavior Support Committee
• Functional Assessment Review Committee
• Peer Review
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DOJ/Settlement Agreement-State of
Texas
• Public document
• Anchored in violation of rights
• Department of Justice (DOJ)-Primarily a
federal criminal investigation and enforcement
agency
• Court monitoring
• TN/MS/GA/TX/VA/AL/NE/CA etc.
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Lelsz v. Kavanaugh
Case Name Lelsz v. Kavanaugh MR-TX-0001
Docket / Court 85-2462 ( N.D. Tex. )
State/Territory Texas
Case Type(s) Intellectual Disability (Facility)
Case Summary
On November 27, 1974, the named plaintiffs filed a class action lawsuit pursuant to 42 U.S.C. § 1983 in the U.S.
District Court for the Eastern District of Texas, challenging the adequacy of conditions, care, and habilitation at
the Austin, Denton and Fort Worth, Texas state schools for the ... read more >
On November 27, 1974, the named plaintiffs filed a class action lawsuit pursuant to 42 U.S.C. § 1983 in the U.S.
District Court for the Eastern District of Texas, challenging the adequacy of conditions, care, and habilitation at
the Austin, Denton and Fort Worth, Texas state schools for the mentally retarded.
Plaintiffs alleged that the defendants failed to provide less restrictive community alternatives for residents,
thereby effectively forcing them into large institutions. Plaintiffs alleged that the conditions at the large
institutions were wholly inadequate and that they had been subjected to: diseases, neglect, excessive
medication, unnecessary restraint, unsafe buildings, inadequate medical and dental care, and physical abuse
from other residents and staff in violation of their constitutional rights. Plaintiffs sought declaratory and
injunctive relief, including the forced closure of the Austin, Denton and Fort Worth institutions.
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Activities of Daily Living (ADL)
Eating
Bathing
Grooming
Leisure
Recreation
Money management
Self administration of medication
Transportation
Self advocacy
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Adaptive Functioning
Importance of habilitation
Reflects changes over time (interventions do
work)
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Stability of IQ
The IQ will typically not increase
Remains fairly stable over time-predictive
validity
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Behavioral Issues
• Definition of behavior-anything that we
do/operates thru space and time on
environment
• “Dead man” test-if a dead man can do it then
it isn’t behavior (don’t use as target but as
objective)
• Will exhibit zero episodes of aggression (a
dead man can do that)
• Was blown over by the wind
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BEHAVIORAL INTERVENTIONS
Presented by:
Robb Weiss, Psy. D.
May 18, 2007 1:30-2:30
Fellowship Hall
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Board Certified Behavior Analyst
(BCBA)
• Professionals who design/supervise those who design
PBSPs
• Exponential growth of BACB
• With the governor’s signing of a bill on May 19, Tennessee
became the 18th U.S. state to adopt a law to license (17
states) or certify (Ohio) practitioners of behavior analysis.
• Applied Behavior Analysis-utilized with/for but not limited
to people with ID/DD (Autism Spectrum Disorder)
• Applicable to Mental Health-Behavior is indeed the product
of complex neurochemical processes, but the behaviorenvironment interaction should not be overlooked
• Foundation of practice is based on psychological principles
and theories
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Psychological Interventions
Lack of knowledge and awareness of mental health and emotional
problems experienced by people with intellectual disabilities
Reluctance on the part of therapists to provide these interventions to
people in this population
Lack of good quality evidence to guide practice with this client group
Difficulty of making an economic case in an increasingly challenging
fiscal context
Large-scale provision of psychological therapies for people with
developmental disabilities has been slow to emerge because of
previous assumptions about the suitability of this group for talking
treatments (“therapeutic disdain”/”the unoffered chair”)
Need for appropriate adaptations
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Preparing People with Intellectual
Disabilities for Psychological Treatment
Client Expectations-Clients’ views and expectations of therapy predict therapeutic outcome
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Outcome expectancy-People’s expectations of therapy as they enter the process may be significantly affected by
the way in which therapy is offered
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Role expectations-People with intellectual disabilities are likely to have a limited understanding of the role they
will be expected to take in therapy
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Process expectations-People with intellectual disabilities probably differ little from their nondisabled peers in their
knowledge of how they are going to work with the CBT therapist
The Therapeutic Relationship-Therapeutic relationships may present particular challenges to people with intellectual
disabilities
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Less secure attachment styles may be characterized by higher levels of interpersonal distrust, difficulty in
depending on another person for support, or preoccupation with concerns about possible abandonment
Client Factors-There are challenges and limits to using talk therapies such as CBT with people who have intellectual
disabilities (verbal expression of thoughts and feelings)
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Assessment structure (communicative ability)
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Language
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Recognition of emotion
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Recognition of the link between activating events and emotional and behavioral consequences
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Assessing understanding of the cognitive mediation of emotion
Technique Factors: Preparing Therapists-”ability to foster and maintain a good therapeutic alliance, and to grasp the
client’s perspective and ‘world view” for which the underlying competencies involve understanding of issues of
therapeutic alliance/adapting referral pathways, clinical protocols, and individual therapy for people with lower ability
and functional academic difficulties
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Psychotherapy
THE CO-OCCURRENCE OF mental illness with
mental retardation/developmental disabilities
(MR/DD) has been referred to as “dual diagnosis.” It
is estimated that as many as 30 to 40 percent of
MR/DD individuals are dually diagnosed.
Unfortunately, when a person with MR/DD needs
psychotherapy to treat the mental illness, it can be
difficult to find a psychiatrist who is comfortable
working with the patient.
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Psychotherapy
There are relatively few studies focused on
psychotherapeutic interventions in the mentally retarded
(MR) patient. In 1982, Reiss, et al.,1 hypothesized that
intellectual subnormality is such a salient and obvious
feature of the patient’s presentation that accompanying
emotional disturbances are overshadowed. He coined the
term diagnostic overshadowing to describe this
phenomenon and believes that diagnostic overshadowing
leads to a failure to recognize and subsequently treat the
emotional and behavioral expressions of mental illness in
the developmentally disabled person.
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Psychotherapy
Supportive psychotherapy is a form of
psychotherapy in which the therapist plays an
active role in helping the patient improve his or her
social functioning and coping skills. The emphasis of
the therapy is on improving behavior and subjective
feelings rather than on achieving insight or selfunderstanding and, as such, is particularly relevant
when working with the mildly MR/DD individual.
Although there is limited literature on this, there
are some small studies and case reports
summarizing the benefits of supportive
psychotherapy for this population.
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Psychotherapy/Counseling
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Research
Evidence Base
Efficacy
Psychotherapy for Individuals with Intellectual Disability
Edited by: Robert J. Fletcher, DSW, ACSW
Literature review
Psychotherapy with persons with intellectual disabilities: a review of effectiveness research
H. Thompson Prout and Brooke K. Browning-Findings – The paper concludes that there is evidence that
psychotherapy with persons with intellectual disabilities is at least moderately effective. Further, there is evidence
of effectiveness of psychotherapy for both child and adolescent, and adult populations. There is also evidence that
a range of therapeutic interventions are effective and that a spectrum of problems can be addressed via
psychotherapy. VOL. 5 NO. 5 2011 jADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 59
Practice-Group psychotherapy for trauma-related disorders in people with intellectual disabilities-Findings – This
paper establishes the inverse relationship between the higher-than-average rates of trauma and interpersonal
violence in the ID population, co-occurring with lower-than-average access to treatment, and lower-than-average
treatment model development for this population. Further, this paper provides a description of a theoretically
based therapeutic intervention with preliminary research efficacy.
VOL. 5 NO. 5 2011 jADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 45
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Counseling
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Anger Management
Boundaries
Community Prep
Competency Restoration - The goal is to restore, to trial competency, those individuals who are court-ordered for admission to SGSSLC under
Article 46B of the Texas Code of Criminal Procedure (adults) or under Chapter 55 of the Texas Statutes Family Code (minors). Depending on the
order, the adult admissions have up to 120 days to receive training that may restore their competency to stand trial. The minors who are
admitted have up to 90 days to receive training to support them becoming fit to proceed to trial.
Conflict Resolution
Developing a Positive Identity
Dialectic Behavior Therapy -The goal of DBT is to help individuals enrolled become more present, mindful, and at peace with the world. Participants
in the group will learn tools and techniques for regaining control of one’s behaviors, to help stop self-harmful behaviors, and to develop healthy
coping mechanisms and relationships. Other important components are learning to fully experience emotions and to become reintegrated with and
connected to one’s world. Finally, members will work to take steps to make their lives more meaningful.
Emotions
Empathy and Acceptance
Goal Setting
Healthy Relationships
Individual Counseling
Overcoming Obstacles
Owning My Future
Positive Self-Talk
Process Therapy - The goal of this group will be to increase emotional awareness and relational understanding between self and others. This group
will focus on the here-and-now and learn to become more aware of their immediate surroundings and on one’s thoughts, emotions, and behaviors.
Stress Management
Self-Determination / Self-Advocacy
Self-Empowerment
Self-Esteem
Thinking Errors
Sex Offender Treatment Program (SOTP)-not psychosexual program
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Dialectical Behavior Therapy (DBT)
(Not diabolical behavior therapy)
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Staff are certified in DBT
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Not Diabolical Behavior Therapy
Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, Ph.D., ABPP, at the University of Washington, is a comprehensive cognitive-behavioral treatment that was originally
developed to treat chronically suicidal individuals suffering from borderline personality disorder (BPD). DBT has been found especially effective for those with suicidal and other multiply
occurring severely dysfunctional behaviors. Research has shown DBT to be effective in reducing suicidal behavior, psychiatric hospitalization, treatment dropout, substance abuse, anger,
and interpersonal difficulties.
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Dr. Marsha Linehan-“ask me to tell you about the tale of the hotel room switch”
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Core Mindfulness (awareness)
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Emotion Regulation (understanding emotions – understanding YOUR emotions, decreasing your
suffering, changing your emotion – opposite emotion, increasing positive emotions, using distress
tolerance)
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Interpersonal Effectiveness (dealing with others, getting your needs met, taking care of yourself and
others)
Distress Tolerance (using distraction techniques: activities, self-soothing, observing breathing)
Dialectical Behavior Therapy (DBT) is a voluntary treatment designed specifically for individuals with self-harming behaviors, such as self-cutting, suicidal thoughts, urges to suicide, and
suicide attempts. Many clients with these behaviors meet criteria for a disorder called Borderline Personality Disorder (BPD). It is not unusual for individuals diagnosed with BPD to also
struggle with other problems- depression, bipolar disorder, post-traumatic stress disorder, anxiety, eating disorders, or alcohol and drug problems. DBT is a modification of cognitive
behavioral therapy (CBT) developed by Marsha Linehan, Ph.D. who first tried applying standard CBT to people who engaged in self-injury, made suicide attempts, and struggled with out
of control emotions. When CBT did not work as well as she thought it would, Dr. Linehan and her research team added other types of techniques until they developed a treatment that
worked better. DBT is an empirically-supported treatment with research originally focusing on women diagnosed with BPD, but is now being researched in other populations including
persons diagnosed with Antisocial Personality Disorder, depression, bipolar disorder, as well as numerous behavioral disorders. Four important core skill areas are taught including
Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.
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Anger Control Problems
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Anger is a normal human emotion and is hardwired for survival
It has considerable adaptive value, although there are sociocultural variations in the manner in which it is expressed
Anger can help maintain one’s self –esteem and dignity when confronted by provocation, insult or unjust treatment
In the face of danger, anger can help individuals to mobilize psychological resources and prime behaviors to deal with threat
It can communicate negative sentiment to others, potentiate the ability to face up to and redress grievances, and boost perseverance and determination to overcome obstacles to goal
attainment
Recurrent and poorly controlled anger, however, adversely affects emotional and physical health and is disruptive of social relationships that sustain personal well-being
It is commonly observed in a range of mental health and emotional problems, including personality, psychosomatic, and conduct disorders, schizophrenia, and bipolar mood and organic
disorders, and in conditions resulting from trauma
The central characteristic of anger in the context of mental health disorders is that it is dysregulated-that is, its activation, expression, and ongoing experience occur without appropriate
controls
The life experiences of many people with intellectual disabilities, from childhood onward, are conducive to the activation of anger
The environmental settings and social circumstances in which many such people live and work are intrinsically constraining, potentially threatening, unrewarding, and limited in
satisfaction
Recurrent thwarting of physical, emotional, and interpersonal needs can potentiate anger activation
Cognitive deficits can readily impair effective coping with frustrating or aversive events, and impoverished support systems limit problem-solving options
While it is neither necessary nor sufficient for aggression to occur, anger has been found to predict physical aggression by psychiatric hospital patients prior to admission, in the hospital,
and subsequently in the community following discharge
It has been shown to be strongly associated with and predictive of violence in adults with intellectual disabilities and histories of aggression and offending
There are mixed reviews on the efficacy of anti-psychotic drugs for aggression
Proximity bias-people generally describe (and ascribe) anger responses to events that are temporally close
Consider more distal events and setting conditions that have relevance to recent anger outbursts
Excitation transfer-previous provoking events that did not result in an angry reaction at the time can leave physiological and psychological residues that linger and contribute to and
intensify a person’s response to more recent events
Given its strong association with aggression and predictive relationship with violence, anger is a legitimate therapeutic target for people with intellectual disabilities who are aggressive
and potentially violent
Engaging seriously angry people in therapy is difficult as they tend to be treatment avoidant
Attempts to achieve clinical change can be undermined by the adaptive functions of anger and by its embeddedness in the client’s sense of self- and personal worth
Angry thinking and behavior that is strongly attached to a client’s personal identity is not easily or readily relinquished
Deficits in cognitive functioning can add to the challenges of anger regulation from the standpoint of both clients and those who seek help them therapeutically
Despite the ubiquitous use of medications to reduce aggression in people with intellectual disabilities, there is no conclusive evidence to support their use as first-line treatments
Given their lack of specificity and variable effects, including dampening of adaptive behavior, routine use of these compounds to treat aggression is not thought to be justified
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www.cms.gov
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Centers for Medicare and Medicaid Services
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_j_intermcare.pdf
www.hhs.gov
Shortcut to: http://www.in.gov/fssa/files/ICFMR_Standards_100-489.pdf
State Operations Manual
Appendix J - Guidance to Surveyors: Intermediate Care Facilities
for Persons With Mental Retardation
(Rev. 94, Issued: 12- 06- 13, Effective: 12- 06-13, Implementation: 12- 06-13)
This revised ICF/MR survey protocol is to assist surveyors to focus attention on the
outcomes of individualized active treatment services. The Centers for Medicare &
Medicaid Services (CMS) intends the revised survey process to be less resource intensive
for providers who consistently demonstrate compliance with the regulations. The survey
process is based on the October 3, 1988, regulation and is applicable to all ICFs/MR,
regardless of size.
In 1988, when the current ICF/MR regulation was implemented, it was viewed as a great
step forward in promoting a focus on the actual outcomes experienced by consumers,
rather than on the policies, procedures and paperwork of the facility. Since that time
there has been an evolution on thinking in both the field of developmental disabilities
(DD) and in the field of quality assurance (QA).
The field of DD is increasingly emphasizing supporting individuals in their own homes
and communities, rather than placing people in facilities. In addition services in virtually
all States are placing increased emphasis on person-centered planning and person centered
services that focus on the preferences, goals and aspirations of each individual
and on supporting them in reaching their personal goals. The field of QA is placing
increased emphasis on outcomes related to choice, control, relationships, community
inclusion, and satisfaction with life, as well as satisfaction with services and supports.
Many QA systems also include organizational self-assessment and continuous quality
and advocates that the ICF/MR regulation and oversight process is too prescriptive and
cumbersome, and should be altered to reflect newer values of quality enhancement and
continuous quality improvement.
2015 Changes to the ICF/IID Interpretive Guidelines
H&W Independent Solutions
www.hwisolutions.com
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CMMS
Centers for Medicare and Medicaid
“Title XIX”: ICF-MR Medicaid survey
DATE: January 16, 2015
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Advance Copy of Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID) State Operations Manual (SOM) Appendix J - Interpretive
Guidelines and new Exhibit
Memorandum Summary
Guidance Updated: The Centers for Medicare & Medicaid Services (CMS) has revised the ICF/IID SOM Appendix J – Interpretive Guidelines (IGs) to
clarify the intent of the Conditions of Participation (CoPs) for ICF/IID as well as represent current standards of practice in the field. In addition, the
probes and procedures have been removed from the IGs and placed into an Exhibit in the SOM.
On October 3, 1988, the CMS published the Final Rule for the CoPs for ICF/IID, 42 CFR 483, Subpart I. The Final Rule establishes that a facility may
receive reimbursement only for the cost of care of individuals classified as eligible for the ICF/IID level of care who are receiving active treatment.
Facility compliance with the CoPs and standards are determined in the context of individual experiences within the facility and whether individuals
are receiving needed active treatment services. These associated Interpretive Guidelines have been revised to provide a concise clarification of the
regulation intent and represent current standards of practice in the field of ICF/IID. In addition, the probes and procedures have been removed from
the previous guidelines and placed into an Exhibit in the SOM in the event that additional clarification beyond the guidelines is needed. The revised
ICF/IID guidelines and the new SOM Exhibit are attached to this correspondence.
These are the regulatory standards that guide our practice as we accept their funds.
We don’t receive funds to keep people “busy”.
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Functional Assessment Preventive
Issues
• Assess basic “preventive behavioral support”
procedures are in place (availability of
reinforcers, availability of activities, extent to
which difficult behaviors are inadvertently
reinforced.
• Assess and address potential medical or
physical conditions that may be influencing
challenging behaviors.
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Functional Assessment versus
Functional Analysis
Not limited to physical and verbal aggression and SIB
Subject to all behavior
Functional Assessment-Naturalistic observation
Functional Analysis-Manipulation of variables (Ethical/Legal
Issues)
• Integration of ID with Mental Illness (setting event)
• SIB-not a topography but an outcome based on injury
• Constipation does not cause aggression (the physical pain
from constipation does)
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Consequences versus Punishment
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Proof of necessity-did we implement every conceivable less intrusive treatment
intervention and did we do it properly (treatment integrity), continuously, and
consistently, and do we have the data to verify it
Proof of efficacy-data (treatment integrity, reliability, IOA)
Consequence-follows a given behavior
Punishment-follows a given behavior and results in the diminution of the behavior
that precedes it
Punishment is not intrinsic to the act, but to the consequence of the act
Legal issues
Ethical issues
Moral issues
Clinical issues
Social implications-we are funded by tax dollars so we are accountable to the
public
Standardization
Best practice
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Punishment-Problems and Negative
Side Effects
It has been clearly and repeatedly demonstrated that punishment can very effectively be used to control behavior. So, why do behaviorists usually warn
against using it? Simply because we can almost always control behavior just as effectively by using reinforcement as by using punishment, and without
having to put up with the problems and negative side effects of punishment. If we wish to stop a behavior that is already occurring, we can usually do so
by simply eliminating the reinforcement for the behavior — a process we call extinction.
The following is only a partial list of the problems and negative side effects resulting from the use of punishment to control behavior. Others could easily be
added.
The following most directly apply to corporal punishment, but should also be considered when contemplating other forms of punishment.
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1. PUNISHMENT OFTEN FAILS TO STOP, AND CAN EVEN INCREASE THE OCCURRENCE OF, THE UNDESIRED RESPONSE.
Since attention is one of the most potent rewards available, and since it is difficult to punish without paying attention to the offender,
punishing may serve more as a reward than as a punishment.
2. PUNISHMENT AROUSES STRONG EMOTIONAL RESPONSES THAT MAY GENERALIZE.
Once the strong emotional responses are aroused the degree and direction of generalization is largely uncontrollable. The result may
be excessive anxiety, apprehension, guilt, and self-punishment.
3. USING PUNISHMENT MODELS AGGRESSION.
The meaning of "social power is exemplified.
4. INTERNAL CONTROL OF BEHAVIOR IS NOT LEARNED.
The offender may learn to inhibit the punished response during surveillance, but once surveillance ends there is no internal control
mechanism to continue inhibiting the behavior.
5. PUNISHMENT CAN EASILY BECOME ABUSE.
Most parents who abuse children do not intend to do the damage they inflict. Most of the damage and injury occurs when the parent
loses control, and goes beyond the boundaries of reasonable behavior.
6. PAIN IS STRONGLY ASSOCIATED WITH AGGRESSION.
The pain of punishment often leads to a display of aggression against either the source of the pain or, in some cases, an innocent
scapegoat.
7. PUNISHMENT WORKS BEST WHEN IT OCCURS EVERY TIME.
While reward works best when given on an intermittent basis, punishment works best when a continuous basis. The degree of vigilance
required to constantly monitor behavior so that every occurrence of the undesired behavior can be punished is rarely possible. The
undesired behavior is, therefore, intermittently reinforced when it is not punished, and the behavior continues.
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Punishment
• Punitive
• Convenience
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Reduction of Challenging Behavior
• Time Out is a procedure in which an individual’s opportunity to
access reinforcement is removed or prevented contingent on the
occurrence of an undesired target behavior. (What that means is
that “time out” refers to a time without reinforcement for a
behavior after that behavior occurs.
• Non-restrictive time out is a type of exclusionary time out in which
the person is removed from the setting in which the reinforcers are
available.
• Restrictive time out occurs when we put people into the time out
rooms and bar their egress, is also an exclusionary time out
• Response cost
• Extinction
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Habilitation versus Rehabilitation
• Habilitation: Learning/teaching that which has
not yet been learned
• Rehabilitation: Re-learning/teaching skill that
has been lost (psycho-social model)
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Active Treatment
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Active treatment is the continuous, aggressive, and consistent implementation of
an individualized program plan, based on interdisciplinary evaluations and
assessments, which is aimed at the individual’s recovery and expedient transition
out of the hospital. This means both the acquisition of skills and behaviors that
promote recovery and the prevention of the loss of these skills. Active treatment
assumes greater “action” on behalf of the individual and those providing
treatment. Except for normal rhythm of life rest cycles or medical conditions
requiring inactivity, it holds to the premise that the individual should not have
periods of “down time.” Active treatment does not include services to maintain
generally independent individuals who are able to function with little supervision
or in the absence of a continuous active treatment program.
24/7
Formal
Informal
Teach new skills and/or reduce regression of skills
We don’t receive funds to keep people occupied or busy
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Token Economy
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A token economy is a system of behavior modification based on the systematic
positive reinforcement of target behavior. The reinforcers are symbols or tokens
that can be exchanged for other reinforcers. Token economy is based on the
principles of operant conditioning and can be situated within applied behavior
analysis.
Tokens have to be used as reinforcers. A token is an object or symbol that can be
exchanged for material reinforcers, services or privileges (back-up reinforcers). In
applied settings a wide range of tokens are being used: coins, checkmarks, images
of small suns, points on a counter. These things are worthless. Their value lies in
the fact that they can be exchanged for valued things. Technically speaking tokens
aren’t primary reinforcers, but secondary or learned reinforcers. Lots of research
has been done on token reinforcement, including animal studies.
Token economy is also being applied in settings for adults with developmental
disabilities. Target behaviors can be all kinds of social behavior and self care, or the
decreasing of inappropriate or disruptive behavior.
Not to be used as a “one size fits all” technique.
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Industrial Organizational (I/O)
Psychology
• System issues
• Clinical issues
• Historical standard degree
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Positive Behavior Supports
• Setting the person up to succeed through
antecedent structural modification
• “Efficacy” of a PBSP refers to clinical setting or
research setting
• “Effectiveness” is the measure in realistic
settings or in vivo setting
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Special Supervision
• It is not treatment
• It does not ensure the effective implementation
of the PBSP
• Critical thinking is imperative in applying levels of
supervision (why is it being applied, why is the
particular level being applied, why is the
frequency being applied)
• The fading/discontinuation should be contingent
upon the demonstration of a learned behavior
and not simply the absence of a challenging
behavior for a given period of time
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Role/Impact of psychotropic
medication
• For example-effect on ability to glean reinforcement
• Setting event for the establishment of
behavioral/environmental interventions
• Specificity in ID/DD
• Does not treat ID/DD
• Does treat signs/symptoms
• Who in fact are we treating: the individual or the fear
and anxiety of the treating professional about the
individual
• Research does not support differences in CNS
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PBSP Competence
• Didactic
• Role-modeling/role-playing
• In-vivo
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Functional Assessment versus
Structural Assessment
• Teaching person to meet their needs in more
socially acceptable ways
• Functional-consequence
• Structural-antecedent
• Antecedent versus precursors (behaviors that
the individual engaged in that often predicted
the target behavior)
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“It’s (not) all for attention”
• Hanley, Iwata, and McCord (2003) reported
escape as the most frequent function of
challenging behaviors. Leading function of
problem behavior:
• 34.2% - Escape
• 25.3% - Attention (may be a disguising factor)
• 15.8% - Automatic
• 10.1% - Tangible
• 14.6% - Multiple
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Functional versus Topographical
• Topographical Replacement Behavior-historic: replacing one
behavior with another e.g. sitting on hands to prevent physical
aggression
• Functional Replacement Behavior-current: treatment of behavior
problems includes the specific reinforcement of appropriate
behavior that serves the same function(s) served by the problem
behavior e.g. determine function of physical aggression and then
teach individual a new way to meet that function in a more socially
acceptable way e.g. the social relevance of the behavior
• Verbal praise should only be utilized when it matches the identified
function of the problematic behavior (otherwise it’s like chicken
soup-it can’t hurt)
• DSM-structural/descriptive not functional
• DSM focus is on the what of behavior, not the what for or the
function of behavior
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Medication versus Behavioral
• Behavioral-much more labor intensive than
medication
• Best practice demands the utilization of
medication when clinically indicated
• Not black or white issue
• No medication for Autistic Spectrum Disorders
(ASD)
• Pharmacotherapy is for associated behavioral
and emotional sequelae
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Quality Assurance (QA)
Quality Improvement (QI)
• Outdated/updated/quantity/quality:
FAR/PBSP/Progress Note/APES/PBSP Competency
Assessment/BSMT/Sessions
• New admission: FAR/PBSP/APES/Full Psychological
Evaluations
• Identifying problems
• Root Cause Analysis (RCA)-The 5 Whys
• Recommendations
• Action Plan-Management strategy
• Corrective Action Plan (CAP)-Based on analysis of data
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Specificity of knowledge base
• Most professionals don’t understand ID/DD
• Tendency to overly pathologize ID/DD issues
via Axis I which inevitably leads to medication
therapy
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Psychologists and Psychiatristcompetencies in ID/DD
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Comorbidity of Mental Illness and Mental Retardation
Dual Diagnosis-Psychiatric Disorder and ID (not substance abuse disorder)
Accurately diagnosing mental disorders in the context of a
cognitive/communication/developmental disability
Talking to an imaginary friend is not a hallucination
Talking in an odd voice is not diagnostic of Multiple Personality Disorder (MPD)
Wanting to become a fireman may be considered delusional but for an individual
functioning at the 3-5 year developmental level it would not (impacts diagnosis
and treatment)
Crying/grieving/mourning the loss of someone close does not warrant a
psychiatric consult
Throwing a tantrum does not a manic make
It is necessary but not sufficient to have signs/symptoms-but without impacting
ability to function on a daily basis there is no basis for diagnosing or treating
Psychiatric diagnostic assessment must be comprehensive and multifocal rather
than a medication evaluation based on the choice of drug to suppress a disruptive
behavior
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Behavior Graphs
• Importance cannot be overstated
• It is the basis for determining efficacy of treatment
and/or need for revisions to treatment, both
behavioral and chemical
• It is the basis for determining the impact of
environmental events on behavior
• It reduces the likelihood of attributing a psychiatric
diagnosis to changes in behavior
• Placing a label on an individual does not explain the
foundation for the behavior, it is simply calling it
something else and is circular e.g. he hit me because
he is psychotic.
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Trauma Informed Care-Karyn Harvey,
Ph. D.
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Based upon assumption that individuals with ID/DD have experienced some form of trauma in their lives
Trauma-Informed Behavioral Interventions with Individuals with Intellectual Disabilities is based on the concept that most such
individuals have experienced trauma and are exhibiting behavioral responses to that trauma.
Trauma is under-diagnosed
Why trauma informed care?
Individuals with intellectual disabilities are at much higher risk than the general population of abuse, neglect, and the associated
trauma. Research indicates that:
Individuals with disabilities are 4 to 10 times as likely to be victimized as individuals without disabilities. Individuals with cognitive
disabilities experience the highest risk of violent victimization.
Children with intellectual disabilities or behavior disorders are at an increased risk for neglect, physical abuse, and sexual abuse as
compared to children with other types of disabilities.
Children with behavioral and neurological disorders are physically abused at rates 2 to 7.3 times higher than children without
disabilities.
Adults with developmental disabilities are at risk of being physically or sexually assaulted at rates 4 to 10 times greater than other
adults.
Behaviors caused by trauma are often attributed solely to the disability with minimal attention to the individual’s mental health. As
defined by the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma-informed care engages people with
histories of trauma in a way that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in
their lives. Understanding the impact of trauma on behavior and using trauma-informed strategies can help reduce the use of restraint
on individuals with intellectual disabilities in both facility and community settings. Only by understanding that trauma can be the root
cause of behavior challenges can service providers help to heal past pain and provide support that avoids re-traumatization.
Trauma Informed Care to Effectively Reduce the Use of Restraint to Manage Challenging Behaviors of Individuals with Intellectual
Disabilities.
People are greater than the sum of their behavior
The definition of trauma has been expanded thus greater interest in this area
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Trauma Informed Care-Karyn Harvey,
Ph. D.
Update on Quality Supports
By Karyn Harvey, PhD, Assistant Executive Director of Quality Supports
What does it feel like to have an intellectual and developmental disabilities (I/DD)? On one level, the answer to that question is different for each person. No two people have the same
experience. On the other hand, however, there are some universalities. One is that having an intellectual or developmental disability means experiencing a certain degree of social trauma:
bullying, exclusion and/or rejection. It may also mean experiencing a significant degree of loneliness and isolation.
Recent studies have shown the effects of social exclusion and/or rejection on the brain. In one particular study, participants were included in a game and then deliberately excluded. Their brains
were connected to electrodes that could then show which part of the brain was stimulated and thus active during the experience. When participants were excluded, all of their brains fired in the
anterior cingulate cortex. This is the part of our brain that fires when we feel physical pain. They experienced exclusion from a simple game as physical pain. Imagine what people who have been
rejected over and over again have experienced.
The Quality Supports Division at The Arc Baltimore has been attempting to reduce the pain and suffering due to exclusion, rejection and loneliness through increased in-house therapy from the
psychology department, trauma and sensitivity training for Arc staff, and finally, through involvement in our Connections program.
Science 10 October 2003:
Vol. 302. no. 5643, pp. 290 - 292
DOI: 10.1126/science.1089134
REPORTS
Does Rejection Hurt? An fMRI Study of Social Exclusion
Naomi I. Eisenberger,1* Matthew D. Lieberman,1 Kipling D. Williams2
A neuroimaging study examined the neural correlates of social exclusion and tested the
hypothesis that the brain bases of social pain are similar to those of physical pain.
Participants were scanned while playing a virtual ball-tossing game in which they were
ultimately excluded. Paralleling results from physical pain studies, the anterior cingulate
cortex (ACC) was more active during exclusion than during inclusion and correlated
positively with self-reported distress. Right ventral prefrontal cortex (RVPFC) was active
during exclusion and correlated negatively with self-reported distress. ACC changes
mediated the RVPFC-distress correlation, suggesting that RVPFC regulates the distress
of social exclusion by disrupting ACC activity.
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Trauma Informed Care-Karyn Harvey,
Ph. D.
H.B. No. 2789
A BILL TO BE ENTITLED
AN ACT
relating to trauma-informed care training for certain employees of
state supported living centers and intermediate care facilities.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter D, Chapter 161, Human Resources Code,
is amended by adding Section 161.088 to read as follows:
Sec. 161.088. TRAUMA-INFORMED CARE TRAINING. (a) The
department shall develop or adopt trauma-informed care training for
employees who work directly with individuals with intellectual and
developmental disabilities in state supported living centers and
intermediate care facilities. The executive commissioner by rule
shall require new employees to complete the training before working
with individuals with intellectual and developmental disabilities
and shall require all employees to complete an annual refresher
training course.
(b) The training required under this section may be provided
through an Internet website.
SECTION 2. This Act takes effect September 1, 2015.
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Trauma-Informed care:
Purpose: provide information on signs and symptoms of trauma; how trauma affects development and behavior, and specifically the widespread impact it has on people with intellectual
and developmental disabilities and co-occurring disorders; include strategies for using trauma-informed practices for people with an intellectual disability and co-occurring disorders;
include both individual-centered and system-centered information; provide information on how to support and empower individuals and prevent re-traumatization; include information
on developing trauma sensitive environments and interventions that emphasize physical, psychological and emotional safety for both individuals and DSWs.
Short Term Objective: Participants will be able to identify signs and symptoms of trauma and express the importance of understanding trauma when dealing with individuals with
challenging behaviors.
Long Term Objective: Participants will be able to assist in creating a trauma informed care environment and interventions where they work.
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Peer Review
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Internal
External
Individual-based
Home-larger environment
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Psychological Evaluation
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IQ
Adaptive Ability
Psychopathology
Importance of the results in the person’s life
that include though not limited to potentially
affecting supports, services, waivers, etc.
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PBSP (BSP/BMP/WTP)
format/instructions
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The “genius” in creating a PBSP that is understood by staff will be more readily
implemented
If we continue to do the same thing and expect a change in behavior of another
individual we are engaging in scapegoating-definition of insanity
The change in behavior begins with “us” via the intervention section to effect
change in the individual
Our own behavior is all that we have control of-we can set the stage for behavioral
change but ultimately cannot control another human being
Skill Acquisition Program (SAP)-teaching the component parts of a behavior
(motivational issue if behavior occurs at a low frequency)
Determination as to existence of a given behavior in person’s repertoire vis a vis
baseline or at a low level of frequency
In the absence of data/baseline the default is to assume the behavior is not
evident in the behavioral repertoire and thus needs to be trained via a SAP
Baseline-pre-treatment
Present level of functioning-ongoing treatment
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Positive Behavior Support Plan (PBSP)
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Rationale/purpose of the plan
Description of potential function (s) of behavior
History of prior intervention strategies and outcomes
Consideration of medical, psychiatric, and healthcare issues
Operational definitions of target behaviors (challenging behavior)
Operational definitions of functional replacement behavior
Behavioral objectives for one or more target behaviors
Behavioral objectives for one or more replacement behaviors
Strategies/Skill Acquisition Programs (SAPs) to promote the acquisition or occurrence of replacement or
alternative behavior (or stated why not)
Baseline data for one or more target behavior
Antecedent-based or preventative strategies
Consequence-based strategies (what to do when behavior occurred)
The use of positive reinforcement
Descriptions of data collection procedures
Signed and dated
Environmental Supports
Prompt the replacement behavior as early in the antecedent behavior chain as possible then provide
reinforcement
Written as instructions to staff e.g. “do this” or “don’t do this”
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Data and monitoring progress of PBSP
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Scan Data Cards
Behavior Data Sheets
Is PBSP effective
Is PBSP ineffective
Progress (or lack thereof) captured in progress
note
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Approval & Consent
PBSP
• Practice-approval (not consent)
• Rights-approval (not consent)
• Consent-obtained from individual or guardian-Legally Authorized
Representative (LAR)
• Consent for medication-must state clearly a reason for administering the
drug and a legitimate benefit anticipated.
• “Hearing voices” does not necessarily equate to experiencing
hallucinations, and experiencing hallucinations does not justify the risks
associated with antipsychotic drugs unless there is some impairment of
daily functioning associated with the experiencing of hallucinations.
• The reason given for administering a psychotropic drug should refer to the
problem or impairment the symptom(s) creates for the client.
• If we can’t articulate how a client is being harmed or impaired by a
symptom, then we can’t justify a drug to address that symptom.
• Risk:Benefit Analysis
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Guidelines
• Behavior Analysis & Programming Guidelines
• Guidelines for Supporting Adults with
Challenging Behaviors in Community Settings
• Guidelines for Providing Behavior Supports in
the Adolescent Specialty Treatment Unit
• A Guide to Behavior Supports Planning and
Implementation
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Systematic Desensitization
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Medical/Dental procedure/Clinic appointments
A behavioral approach in its’ own right
Predicated on fear/anxiety
Utilized for procedure that requires pre-treatment sedation
that would not ordinarily require sedation in the
“community” e.g. cleaning, etc. [TIVA is Total Intra Venous
Anaesthesia]
• Progressive muscle relaxation
• Alternatives: A Review Of Non-Pharmacologic Approaches
To Increasing The Cooperation Of Patients With Special
Needs To Inherently Unpleasant Dental Procedures
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Methods to develop toleration for medical and dental procedures
in order to decrease the need for use of restraint and sedation-I
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The PST should develop an individualized approach to increase toleration for medical and dental procedures by selecting applicable methods from
the following. A single method or a combination of methods may be appropriate, dependent on the individual. Some of the methods are practical
for appointments at SGSS and away from SGSS. Some are practical only for appointments at SGSS. Sensitivity to the attributes, emotions, past
history, and capabilities of the individual is crucial.
Behavioral rehearsal – This is reinforced practice under simulated conditions. Example: Taking the individual to the exam or treatment room many
times when it is not in use. Greeting and talking with a doctor, nurse, dentist, and/or hygienist at the site. Sitting in the dental chair or sitting or lying
on the exam table. Going through a simulation of what is expected of the individual during the procedure. Positively reinforcing the individual many
times during the process with something the individual is known to find highly reinforcing. No medical or dental procedures are performed.
Communication training – This involves teaching the individual communication skills to use prior to or during medical or dental procedures, such as
teaching the individual to communicate in some manner if pain or discomfort starts during a medical or dental procedure.
Contracting – entering into an agreement with the individual that following the medical or dental procedure a reinforcer that is highly desired by the
individual will be provided
Counseling – Counseling strategies such as: finding out the individual’s immediate goals and explaining how that going through with the procedure
makes achieving his/her goals possible, talking about fears and discomfort related to the procedure and assisting the individual to work through
them, educating the individual about the procedure and what is to be expected, having the individual meet and talk with someone else who has had
the procedure done, and/or assisting the individual in reaching an understanding of the benefits of the procedure and the risks of not taking having
the procedure done.
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Methods
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Personal support – If permitted, someone who is trusted or liked by, or who is important to the
individual, encourages the individual and provides reassurance during the procedure. To reduce the
potential for acting out, the authority structure in the situation must be clear to the individual
receiving services. If a staff person or other support person will be with the individual during the
exam or treatment, at the initiation of the appointment the dentist or physician should direct the
staff or support person to do a few simple brief tasks. The staff or support person should
immediately and cooperatively follow the directions. This makes the authority structure clear to
the individual, and also provides a model to follow.
TLC provided by the medical or dental staff prior to and during a procedure are also means of
supporting the individual.
Positive reinforcement – The doctor, nurse, dentist, and/or dental hygienist gives the individual
something that is known to be highly reinforcing to the individual each time the individual has a
procedure completed, or as soon as possible following the procedure.
Priming – preparing an individual in advance by talking with the individual (possibly many times)
about the medical or dental procedure in a relaxed and informal manner
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Methods
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Relaxation therapy – teaching the individual methods to reduce tension and to induce relaxation, such as systematic tensing and releasing of
different muscle groups. Relaxed, slow, deep breathing may be also used. The staff person teaching the individual should also describe pleasant and
calming situations in a soothing voice. The intent is to teach the individual to recognize physical tension, to experience deep muscle relaxation,
and/or to learn how to physically relax. Trigger words such as “relax” may be paired with deep relaxation. The trigger may be used by the individual
to begin relaxation upon self-recognition of physical tension if possible, or by the dentist, doctor, or other staff person to assist the individual to begin
relaxing when signs of tension are observed during the procedure.
Role playing – while being observed by the individual, a staff member acts as if he/she is going through the steps of the procedure and is heavily
reinforced. Preferably this is done on site. The individual may need to be prompted to give attention to what is occurring.
Self-calming skills – teaching the individual self-calming skills to use during a medical or dental procedure such as focusing on a central point,
repeating to self over and over to be calm or an encouraging verse, focused breathing, remembering pleasant things, or listening to music known to
be calming to the individual.
Shaping – This is systematically reinforcing successive approximations to cooperation with the procedure. An individual may immediately react to
the exam or treatment room due to past experience and may try to escape or resist. This approach can involve many steps that lead closer and
closer to cooperation with the procedure, such as the following scenario: Taking the individual many times as close to the exam or treatment room
as the individual will tolerate and positively reinforcing the individual with something the individual is known to find reinforcing. Once the individual
appears to tolerate that step of the process, having the individual go closer to the exam or treatment room prior to providing the positive
reinforcement. Additional steps may include entering the exam room, standing in the exam room, sitting in the exam room, touching the dental
chair or exam table, sitting on the dental chair or exam table, laying on the exam table, staying seated or laying down with the dentist or doctor
standing close to the individual, staying seated or laying down with the dentist or doctor providing physical support, opening the mouth when
requested, remaining in place when instruments are exposed, removal of applicable clothing at appropriate times. The actual process likely will not
require the number of discrete steps described in the example. The type and number of steps, and the number of times the steps should be
repeated and reinforced, should be tailored to the individual.
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Methods
Systematic desensitization - The first step in this method is to teach the
individual to relax; then the individual is exposed to the medical or dental
procedure degrees at a time while being prompted to remain relaxed. For
example, the staff person providing the desensitization training presents the
least anxiety provoking description of the dental or medical situation and asks
the individual to imagine himself or herself in that circumstance. The staff
person prompts use of the relaxation skills to remain relaxed. If the individual
feels anxious, the same item is repeated until the individual can remain
relaxed for several trials. Each next higher degree of exposure is progressively
presented in the same manner, including actual on site exposure. A variation
may involve accustoming the individual to less intrusive procedures, such as
dental cleanings, prior to more invasive dental work.
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The NADD Accreditation/Certification
Program: Standards for
Quality Services
• 3 Separate but interrelated competency-based
quality standards programs:
• Certification for direct support professionals
(DSP)
• Certification for clinicians
• Accreditation for programs
• Joint Commission is not for ICF/IIDs
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Offenders With Developmental
Disabilities
People with developmental disabilities who offend pose significant philosophical, ethical, and pragmatic
dilemnas for the criminal justice system and developmental disabilities services
Despite reports of increased frequency of offending among people with developmental disabilities, it is
generally believed that there is no conclusive evidence of a general causal link
The distinction between behavioral disorder and offending behavior is elusive and depends on individual,
service, and societal factors
People with developmental disabilities are more likely to be disadvantaged by the criminal justice process
because of issues of competence in following and understanding necessary legal processes
They are also known to admit to crimes they have not committed because of acquiesence and are
considered unreliable witnesses when they themselves have become victims of crime
A number of people with developmental disabilities are inappropriately placed in the penal system or in
conditions of higher security than they actually need
The capital punishment of people with developmental disabilities in some countries continues to provoke
public outcry and passionate debate
Treatment and rehabilitative programs based on behavioral, educational, and cognitive models have been
reported, with length of treatment appearing as a significant positive prognostic factor in reducing
recidivistic reoffending
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Sex Offenders
Sex Offender Treatment Program (SOTP)
Licensed Sex Offender Treatment Professional (LSOTP)
Based on the Cognitive-Behavioral Approach, the Texas Penal Code,
the best practices in the field of sex offender treatment, and the
standards of the Council on Sex Offender Treatment for the State of
Texas, the purpose of the Sex Offender Treatment Program is to ensure
that sex offender treatment by a Licensed Sex Offender Treatment
Provider (LSOTP) is provided to individuals who have been adjudicated
by the courts as registered sex offenders or individuals who have
engaged in sexual offending behaviors and who reside in State
Supported Living Centers and the ICF-MR component of the San
Angelo State Supported Living Center (SgSSLC). This program parallels
community sex offender treatment. Treatment is to ensure the safety
of the community as well as the individual in the program.
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All behavior is communicative
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What is the individual communicating
How do we choose to respond
Individual bangs their head-mittens on hands
What is the individual communicating
What is our intervention
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All behavior has function
• This is a “given” that guides assessment and
treatment
• Goal is to teach individual a better way to
meet the function thru differential
reinforcement
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Stability of MR diagnosis
Developmental window
Adulthood
Exceptions utilized in changing diagnosis
Diagnosis of MR is in question e.g. inaccurately
diagnosed
• Level of mental retardation is typically not changed
after criterion age of 18
• Mental Retardation is not necessarily lifelong
• After age 18 a diagnosis of Dementia may be assigned
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“Post hoc ergo propter hoc”
“Post facto ipse propter facto”
Latin for “after this, therefore because of this”
Title of West Wing episode
Correlation versus causation
“The rooster crows therefore the sun rises”
Critical problem in our thinking
“Because something occurs before something else does not mean
that it caused it to happen”-corollary: it doesn’t mean that it didn’t
“Because something occurred after an event does not mean that
the event caused it to happen”-corollary: it doesn’t mean that it
didn’t
Administration of medication caused the cure
Prozac causes people to commit suicide
Need for ABAB experimental design to provide support for
causation
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Adaptive Living Skills
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The “significant limitations” in adaptive behavior” criterion is operationalized as performance that
is approximately two standard deviations below the mean.
Evolution from a global description to specifying particular adaptive skills.
Vineland Adaptive Behavior Scales (VABS)
American Association on Mental Retardation Adaptive Behavior Scales (AAMR)
CALS
Scales of Independent Behavior – Revised (SIB-R)
Assesses what a person can or cannot do
The Inventory for Client and Agency Planning (ICAP) is one of the most widely used adaptive
behavior assessments in the United States. The ICAP can be used to assess children and adults with
developmental disabilities, people who become handicapped as adults through accident or illness,
and elderly people who have gradually lost their independence. Often, these individuals need
special assistance at home, at school and at work. The ICAP can identify the skills requiring
assistance to allow the individuals to live as independently as possible.
Adaptive Behavior Level (ABL)
01 = Mild ABL deficit
02 = Moderate ABL deficit
03 = Severe ABL deficit
04 = Profound ABL deficit
Level of Care (LOC)
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Supports Intensity Scale (SIS)
• Philosophical underpinnings in new definition of disabilities
• Developed by the American Association on Intellectual and
Developmental Disabilities (AAIDD) (formerly the AAMR)
• Designed to determine the level of support needed for an
individual to do the same things that you and I do-the
comparison is to a “typically functioning” individual
• Based on 7 days per week, 24 hours per day
• The focus is NOT on whether or not someone can do
something, or whether or not the “community” can provide
the supports, but rather on what supports are needed
• Is completed in conjunction with the individual
• Looks at several areas of life
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Psychopathology Screening
• Reiss Screen for Maladaptive Behavior (RSMB)-total score
e.g. score above 9 on the 26 key items
• Aberrant Behavior Checklist (ABC)-not based on DSM
• Psychiatric Assessment Scale for Adults with Developmental
Disabilities (PAS-ADD)-psychiatric assessment schedule for
adults with a DD
• Psychopathology Inventory for Mentally Retarded Adults
(PIMRA)
• Assessment of Dual Diagnosis (ADD)
• Diagnostic Assessment of the Severely Handicapped-II
(DASH-II)
• Charlot Semi-structured Interview for Individuals with
Intellectual Disabilities (CSI-intellectual disabilities)
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Instruments Assessing Quality of Life
Quality of Life Questionnaire (QOLQ)
COMPASS
Lifestyle Satisfaction Scale (LSS)
Multifaceted Lifestyle Satisfaction Scale (MLSS)
Life Experiences Checklist (LEC)
Quality of Life Interview Schedule (QUOLIS)
Quality of Life Instrument Package
Comprehensive Quality of Life scale
Personal Wellbeing Index-Intellectual Disability
(PWI-ID)
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“People behave normally in an
abnormal environment”
• Examine the contingencies in the environment
• What would you do if you lived in a controlled
environment where you had little control
• We inadvertently reinforce the behavior that
we “seek” to diminish
• Maladaptive-or is it?
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Rights
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Choice-It is our responsibility to teach skills that become choice
Rights
Responsibilities
ICF/IID Regulations/Guidance
Human Rights Committee (Specially Constitute Committee) [W261-W265]
Rights [W122-W138]
ID Team/IPP [W238-W239, W278, W285-W289], W295-W297, W310W315]
CMS-”QIDP”
Overemphasis on Rights teaches Psychopathy
Prioritization of Rights-safety
Rights restriction-need to put in place a plan to reduce restriction to
preclude civil rights violation
Risk versus Risk-particularly relevant (risk on restricting rights versus risk
of not restricting rights)
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Rights and Responsibilities
JOURNAL OF APPLIED BEHAVIOR ANALYSIS
1990, 23, 79-89 Number 1 (Spring 1990)
BALANCING THE RIGHT TO HABILITATION WITH THE RIGHT TO PERSONAL LIBERTIES: THE RIGHTS
OF PEOPLE WITH DEVELOPMENTAL DISABILITIES TO EAT TOO MANY DOUGHNUTS AND TAKE A
NAP
DLANE J. BANNERMAN, JAN B. SHELDON, JAMES A. SHuA.N, AND ALAN E. HARCHIK
UNIVERS=Y OF KANSAS
In the pursuit of efficient habilitation, many service providers exercise a great deal of control over
the lives of clients with developmental disabilities. For example, service providers often choose
the client's habilitative goals, determine the daily schedule, and regulate access to preferred
activities. This paper examines the advantages and disadvantages of allowing clients to exercise
personal liberties, such as the right to choose and refuse daily activities. On one hand, poor
choices on the part of the client could hinder habilitation. On the other hand, moral and legal
issues arise when the client's right to choice is abridged. Recommendations are offered to protect
both the right to habilitation and the freedom to choose.
DESCRIPTORS: developmentally disabled, ethics, client rights, choice behavior, mentally retarded
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Rights Restrictions vs. Supports
“Rights Restrictions” are any externally imposed limitation to an individual’s exercise of his or her rights. Typically this refers to an IDT and HRC
approved instruction to staff to keep an individual from doing something they want to do.
“Supports” are services, therapy, equipment, transportation, training, etc. provided by the staff/facility to an individual in order to
increase/improve/facilitate an individual’s health, safety, independence, and exercise their rights.
The way an individual expresses a choice must be determined on an individual basis. Choice or opposition can be expressed vocally, through
facial expression, refusals, and/or actions.
Rules of thumb for IDTs when making decisions regarding restrictions vs. supports:
If the individual opposes the action, it’s a restriction. (e.g. Not allowed second helpings at meals.)
If the purpose is to control deliberate behavior, it’s a restriction. (e.g. Not allowing the individual to leave the home.)
When the IDT determines that an action is a support, the team must still assess, document deliberations, and as necessary implement any
training and services needed to increase the individual’s independence, to improve the quality of the person’s life, and to expose/offer the
individual more choices and options. The team has a proactive responsibility to help individuals exercise their rights.
Any limitations placed on an individual by their legal guardian that fall within the limits described in the guardianship are not considered
restrictions and do not require HRC approval but do require a plan by the team to restore the individual’s freedom of choice. Examples may be
voting, clothing, hairstyle, religious observance, etc.
NOTE: When a person is “adjudicated incompetent” and given a full guardian, they lose their fundamental rights and there is no need for a
review from a legal perspective. The actual limitations of the person should be matched with the guardian’s power and responsibility as it is not
legally considered a restriction if it is within the scope of the guardianship as written. However, from a facility policy and best practice
perspective, the facility should take the position of making sure the guardianship remains the "best" match of support for the person. There is
not a procedural safeguard nor does the court ensure that the guardian acts in the best interest of the individual. This is how the IDT and HRC
annual review requirement connects to the essence of the role the HRC is supposed to play. If the IDT or the HRC find a pattern of the guardian
not acting in the best interest of the individual, they would need to address this concern.
Note: Individuals with disabilities are expected and taught to comply with commonly accepted rules of behavior that apply to everyone whether
disabled or not. For example, no one has the right to stay uninvited in someone’s office, sit in the middle of the street, use state computers to
view pornography, etc.
ALL RESTRICTIONS REQUIRE DUE PROCESS.
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Civil Rights of Institutionalized Persons Act
(CRIPA)
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Foundation for Settlement Agreement
The Civil Rights of Institutionalized Persons Act (CRIPA) of 1980 is a United States
federal law[1] intended to protect the rights of people in state or local correctional
facilities, nursing homes, mental health facilities and institutions for people with
intellectual and developmental disabilities.
CRIPA is enforced by the Special Litigation Section in the United States Department
of Justice Civil Rights Division, which investigates and prosecutes complaints in
terms of this legislation.[2] The Special Litigation Section is allowed to investigate
state or locally operated institutions in order to ascertain if there is a pattern or a
practice of violations of a residents' federal rights.[2] The section is not allowed to
investigate private facilities. They are also not allowed to represent individuals or
address specific individual cases, but they are able to file lawsuits against facilities
as a whole.[2]
Authorizes DOJ to investigate facilities that show a pattern or practice that
prohibits residents from the free exercise of their federal constitutional or
statutory rights. DOJ’s work is directed at obtaining broad reform of conditions in
institutions.
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Change in population
Increase in individuals with:
Mild/Moderate ID
Dual Diagnosis
Forensic issues
Aging
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Person Centered Planning
Individual determines treatment planning
Interdisciplinary team approach-not medical
model
Composition of team includes the individual
All members have an equal voice
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Senate Bill (SB-41)
• Utilization of Restraints
• The passage of SB 41
• Passed in 2011, state Senate Bill 41 codifies the DOJ
recommendations for SSLCs to stop the use of prone
holds and straitjackets, eliminate standing orders for
restrictive controls, limit the use of mechanical
restraints to emergencies, only use the least restrictive
restraint techniques, and conduct an administrative
review after all restraints. SB 41 also requires that
each incident of physical or mechanical restraint in a
SSLC must be reported to the executive commissioner
of the Texas Health and Human Services Commission.
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Direct
Support Professionals Week
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H.B.ANo.A504
AN ACT
relating to designating the second full week in September as Direct
Support Professionals Week.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTIONA1.AASubchapter E, Chapter 662, Government Code, is
amended by adding Section 662.155 to read as follows:
Sec.A662.155.AADIRECT SUPPORT PROFESSIONALS WEEK. The
second full week in September is Direct Support Professionals Week
to honor the work of direct support professionals as an integral
part of the long-term support system for individuals with physical
and mental disabilities.
SECTIONA2.AAThis Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2015.
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Direct Support Professional
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Direct Support Professional Week is this week. For insight to their daily duties, below are the job description and job functions required for their role.
Job Description:
Direct Support Professional is responsible for the routine and emergency care, treatment, and training for specified individuals with developmental
disabilities in routine and crisis situations. Responsibilities may include such duties as grooming, bathing, feeding, observing and reporting client
conditions and behaviors; interacting with clients therapeutically, participating in individualized training and/or active treatment programs. The DSP
is required to accurately document client behavior(s) throughout the daily schedule, including response to home activities, home training and
unusual incidents. Completion of work requires use of simple and/or routine duties, while decision making is based on simple and well-defined
guidelines. This position may be required to drive a state owned vehicle. May perform other duties as assigned. Works under close supervision with
minimal latitude for the use of initiative and independent judgment.
Essential Job Functions:
Assists persons served with training to teach daily living and vocational skills. Provides behavior intervention by following the recommended behavior
intervention techniques to ensure that persons served are protected from harm or injury due to abuse/neglect, sexual incidents, serious injuries, or
other sources of immediate danger and provides emergency care as needed. Participates in delivering therapeutic and individualized training per the
clients active treatment program, and documents client progress. Assists persons served with carrying out necessary self-care skills (i.e., bathing,
dressing, oral hygiene, toileting, feeding and grooming.) Insures environment is free of safety hazards by correcting any hazards found and reporting
them to the supervisor. Observes persons served for signs and symptoms of disease, injury, reactions to medications, or other conditions that
warrant medical intervention. Perform other related work as assigned. May prevent or manage aggressive behavior among clients and administer
CPR in emergency intervention. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to
meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an
alternate shift pattern assignment and/or location.
These 2 paragraphs do not begin to describe their many duties or the caring and giving they provide. As quoted from a post to the National Alliance
for Direct Support Professionals:
“Direct Support Professionals bring hope into the lives of so many. Hope for friendships. Hope for belonging. Hope to be loved. Hope for
opportunities to make money, pursue one’s passions, to make difference in one’s community and Hope to enjoy a life one’s choosing.” DSP’s take
that hope and help people turn it into reality!!
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Antecedents
• Importance cannot be overestimated
• Historically there has been an emphasis on
consequences of behavior
• Versus precursors behaviors (i.e. behaviors that
an individual engaged in that often predicted the
target behaviors
• Antecedent behavior e.g. precursors to the
challenging behavior
• Establishing operations/discriminative stimuli in
the environment that set the stage for the
demonstration of the challenging behavior
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Definition of insanity
• “Doing the same thing and expecting a
different result”
• Change has to begin with your own behavior
• Think about the difficulty in changing your
own behavior, and how easy it is to tell
somebody else to change theirs
• Results in scapegoating
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Trauma Informed Care
• Understanding that the person is greater than
the sum of their behaviors
• Trauma is underdiagnosed
• “Happy People Don’t Hit People”
• Trauma Informed Coordinator
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Genetic/Metabolic Abnormalities
• Necessity of assessing/diagnosing/treating”closing the loop”
• Practical Implications of Genetic Diagnoses for
people with Intellectual Disabilities
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Dramatic Changes
• Need for increased staff, money, resources
• Best practices
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Functional Assessment-Important “to” vs.
Important “for” (person centered approach)
• Assess perspectives of person, family, friends,
and staff
• Detective work in all areas of life
• Arrive at hypothesized function of challenging
behavior
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Changes in Nomenclature
• QDDP-Qualified Developmental Disabilities
Professional
• QIDP-CMS-Qualified Intellectual Disabilities
Professional
• ICF/IID-Intermediate Care Facility/Individuals
with Intellectual Disabilities
• Mental Retardation/Intellectual Disability
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Definition of Community
• We are part of the community
• What we really mean is outside of the
institution
• Need to conceptualize a flow from the
institution to the larger community and vice
versa
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Programming
• People may attend a program/programming
(noun)
• Demeaning-we don’t “program” people (verb)
• Acceptable-we teach/educate/habilitate
people
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Documentation
“Paper follows the person…….the person does
not follow paper”
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Discrimination versus generalization
• It’s appropriate to scream at football game but
not in dining room
• It was sanctioned to kill in Vietnam but not at
home
• Teach person to exhibit same behavior in
multiple settings
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Skill Acquisition Plan (SAP)
When there is no baseline data to support the
existence of a given behavior the default is to
assume that the behavior is not in the
behavioral repertoire, therefore, a skill
acquisition plan is developed.
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Skill Acquisition Plan (SAP)
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SAPS PRACTICAL, FUNCTIONAL, MEANINGFUL
SAP involves teaching of a skill that is not in the behavioral repertoire e.g.
contrived/classroom setting
Maintenance plan involves the level of prompting necessary for the learned skill to
be demonstrated in the natural/in vivo environment
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RATIONALE; REVIEW ISP, FSA, PSI, VOC, DAY HAB
OBSERVATIONS OF SAP IMPLEMENTATION
INTERVIEWS WITH STAFF AND INDIVIDUAL
CONSISTENT WITH PERSONAL GOALS
RELATE TO INDEPENDENCE OR QUALITY OF LIFE
ASSESSMENTS SHOW GROWTH OR QUALITY FROM PREVIOUS ISP YEAR
NOT A SAP FOR SKILL THAT THE INDIVIDUAL CAN DO
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Maintenance of skills versus regression
of skills
• It is not always about enhancing skills
• Minimize regression of skills
• Maintain gains made in skills
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First line of defense
• Don’t create a PBSP for physical aggression
that is caused by constipation
• Address medical conditions e.g. a functional
assessment that indicates that the person has
no corpus callosum (Agenesis and Dysgenesis
of the Corpus Callosum
• Address engagement in the environment
• Environmental/Genetic/Physiological factors
can influence behavior
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Errors
• Omission-not doing the right thing
• Commission-doing the wrong thing
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Names in the field
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Nirbhay Singh
Brian Iwata
Stephen Reiss
Johnny Matson
Dennis H. Reid
Karyn Harvey
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Resources
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American Journal on Mental Retardation (AJMR) Volume 105, Number 3, May 2000, Special Issue, Expert Consensus Guideline Series: Treatment of
Psychiatric and Behavioral Problems in Mental Retardation
Expert Consensus Guidelines Update: Treatment of Psychiatric and Behavioral Problems in Mental Retardation 2004
American Psychologist, Journal of the American Psychological Association, January 2012, Volume 67, Number 1, Practice Guidelines, Guidelines for
Assessment of and Intervention With Persons With Disabilities, Page 43-62
Olmstead v. L.C. & E. W., The Story of the Olmstead Decision and Three Determined Women from Georgia
Functional Analysis of Problem Behavior, A Practical Assessment Guide, Robert E. O’Neill, Robert H. Horner, Richard W. Albin, Keith Storey, Jeffrey R.
Sprague
The International Consensus Handbook, Psychotropic Medications and Developmental Disabilities: Steven Reiss and Michael G. Aman, Editors
Journal of Mental Health Research in Intellectual Disabilities, 6:208–224, 2013 Copyright © Taylor & Francis Group, LLC
ISSN: 1931-5864 print/1931-5872 online
DOI: 10.1080/19315864.2012.680681
Family Members’ Views on Seeking Placement
in State-Supported Living Centers in Texas
Teaching Anger Management to Persons with Mental Retardation. Betsey A. Benson, PH. D. 1992
Mental Health Aspects of Developmental Disabilities (formerly The Habilitative Mental Healthcare Newsletter)
Cooper/White Book/BCBA
Autism Speaks/Family Services/Challenging Behaviors Tool Kit
www.qualitymall.org – Intellectual Disability Mental Health First Aid Manual 2nd edition
http://aadmd.org – American Academy of Developmental Medicine and Dentistry
http://www.ncd.gov/ - National Council on Disability
Association of Professional Developmental Disabilities Administrators (APDDA)
State Policies and Practices in Behavior Supports for Persons With Intellectual and Developmental Disabilities in the United States: A National Survey
David A. Rotholz, Charles R. Moseley, and Kinsey B. Carlson
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2013, Vol. 51, No. 6, 433–445 AAIDD
DOI: 10.1352/1934-9556-51.6.433 D. A.
International Journal of Developmental Disabilities
http://www.txdisabilities.org/ Coalition of Texans with Disabilities
May Institute
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Graduate Certificate in
Developmental Disabilities
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University of Kentucky
The Human Development Institute (HDI) began offering a Graduate Certificate in Developmental
Disabilities in the Fall semester of 2001. The purpose of this Graduate Certificate is to prepare
professionals from a broad range of disciplines to play a leadership role in providing services and
supports for people with developmental disabilities and their families. The curriculum emphasizes a
life span and interdisciplinary perspective. Students will also have the opportunity to participate in
a practicum and learn directly from individuals with developmental disabilities and their families.
The Human Development Institute is Kentucky's University Center for Excellence in Developmental
Disabilities Education, Research and Service. We focus our efforts on improving lifelong
opportunities and services for individuals with disabilities, their families and the community.
The Institute provides a strong foundation for more than 40 research, training and service projects,
addressing a wide range of topics and issues in areas such as early childhood, education and
alternate assessment, transition across the lifespan, employment, community living, and personnel
preparation.
HDI is a unit of the Office of the Vice President for Research at the University of Kentucky and a
member institution of the Association of University Centers on Disabilities (AUCD).
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Certificate of Completion in
Intellectual/Developmental Disabilities
• Minot State University
• Bachelor of Science in Human Services with a major in
INTELLECTUAL/DEVELOPMENTAL DISABILITIES
• North Dakota Center for Persons with Disabilities
Training Tools and Resources on Providing Supports for
Persons with Developmental Disabilities
• Department of Special Education
• www.minotstateu.edu/sped/
• [email protected]
• Minot, ND
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College of Our Lady of the Elms
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Unique Programs in
Autism Spectrum Disorders (ASD)
Graduate Programs in
Autism Spectrum Disorders (ASD)
* MS in ASD with BCBA six-course sequence
* Accelerated MS in ASD with BCBA six-course sequence
* CAGS in ASD with BCAB six-course sequence
* Certificate in Asperger's Studies
Undergraduate Graduate Programs in
Autism Spectrum Disorders (ASD)
* Concentration in ASD
* BCaBA Course Sequence
www.elms.edu/asdgrad
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VOR
• VOR Mission Statement
• VOR is a national organization that advocates
for high quality care and human rights for
people with intellectual and developmental
disabilities.
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Universal LifeStiles
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THOMAS E. POMERANZ, Ed. D.
Dr. Tom Pomeranz is a nationally recognized
authority, trainer, clinician and consultant in the field of services for people with disabilities.
The focus and spirit of Universal Enhancement© is found in how we need to behave in
supporting others in improving the quality of their lives. For most individuals, a quality life is
realized through friendships and meaningful relationships with others. Possessing things of
meaning and value further enhances one’s quality of life. Hobbies, employment, spirituality and
education are representative of the “things” most people cherish. The vision of Universal
Enhancement© is to support people with disabilities to realize their quality of life outcomes;
those outcomes to which we universally aspire. Universal Enhancement training provides
participants with the specific tools-ways of behaving- needed to support others in realizing their
preferred future.
www.universallifestiles.com/pomeranz.html
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DSM-5
• The recommendation of new categories for learning disorders and a single
diagnostic category, "autism spectrum disorders" that will incorporate the
current diagnoses of autistic disorders, Asperger syndrome, childhood
disintegrative disorder and pervasive developmental disorder (not
otherwise specified). Work group members have also recommended that
the diagnostic term "mental retardation" be changed to "intellectual
disability," bringing the DSM criteria into alignment with terminology used
by other disciplines.
• Autism organizations-happy
• The diagnosis of Asperger’s syndrome has been removed from the DSM-5
and is now part of one umbrella, “Autism Spectrum Disorder”. This is
controversial because according to the ICD-10, those suffering from
Asperger’s syndrome have “no general delay or retardation in language or
in cognitive development”. [Therefore why would they place this
diagnostic category under "autism spectrum disorders“]
• Asperger organizations-angry
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Management versus Support
• Management implies a reduction in the
challenging behavior only.
• Support implies a teaching/habilitative/educative
component that supports the attainment of
replacement behaviors.
• Our mission is to teach functional replacement
behaviors.
• To do anything less implies that we are
scapegoating individuals for exhibiting behaviors
that they have learned in the absence of teaching
better ways to meet their needs.
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Requesting versus informing
• As “chronological” adults we should be teaching
such individuals to inform others of their desires
rather than requesting.
• Adults don’t need to be “asking permission” to
leave an area.
• Adults provide information that they are leaving
an area.
• This speaks to the issue of dominance and control
and a paternalistic environment.
• We don’t command people, we ask them.
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Self-Injurious Behavior In Mental
Retardation
• Self-injurious behavior or SIB refers to an array
of heterogeneous behaviors that typically
create exasperating problems for the affected
individual and for the surrounding human
support system including parents and family
members, teachers, direct care staff,
paraprofessionals and professionals
• The primary concern is that SIB poses a threat
of lasting and irreversible physical harm
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Characteristics of SIB
Prevalence rates vary greatly
Epidemiology of SIB
-negative correlation between the prevalence
of SIB and the level of mental retardation
Topographies and Targeted Body Areas
-invariant
-individuals engage in their very own,
idiosyncratic form of SIB
-neither the targeted areas nor the inflicted
damage are random
-self-hitting or banging (i.e. butting, hitting, striking,
slapping) that is either directed at the head or face, or at some
other body parts
-banging themselves with their own body parts (i.e. palms, fists, knees), or they
use stable, hard objects against which to bang themselves
-second most common form of SIB is self-biting
-others include scratching, pinching, hair pulling, deliberate vomiting and rumination, and different
forms of digging, poking or gouging
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Mechanisms Controlling The
Emergence and Maintenance of SIB
Establishing Operations (EO)
Distal Variables
-predispose a person to a greater likelihood to
develop a certain behavior as compared to
peers who are similar in most other respects,
with the exception of the predisposing
attribute
-SIB as a behavioral phenotype is a case in
point (predisposing genetic/biological conditions
and syndromes)
Proximal Variables
-control SIB more immediately from one occurrence to the next and
are the primary targets of manipulation in a behavior program
-antecedent events (such as establishing operations, discriminative stimuli), or
consequence events
Establishing operations are events that temporarily affect the effectiveness of a reinforcer, and
simultaneously change the probability of occurrence of the operant that had produced that reinforcer
in the past [physiological conditions-sleep deprivation, menses, anxiety, stress and over or under arousal of the CNS]
[psychotropic medication-anhedonic effects of neuroleptics may impact the effectiveness of primary reinforcers, as well
as the availability of desirable behavioral alternatives or the lack thereof, or reinforcer satiation]
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Functional Assessment And Analysis
(SIB)
Designed to identify both response antecedent and consequent events that
control the target behavior in order to select proper intervention strategies
The role of behavioral assessment in selecting treatments based on the specific
controlling variables of the target behavior of a specific individual has been a
mainstay of behavior therapy from its beginning
Functional assessment typically encompasses empirical, but non-experimental
assessments that do not involve the removal of the individual from the natural
environment in which the target behavior occurs (interviews, unstructured
observations, data collection/scatter plots, contingency observations, rating scales)
Functional analysis refers to the systematic, experimentally controlled exposure of
the individual to stimulus conditions (analog conditions) suspected to be
maintaining SIB
Leads to individualized, function-relevant treatments
Produces effective behavioral treatment programs and also reduces the likelihood
of unwarranted and unnecessary psychopharmacological treatment or intrusive
punishment procedures
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Behavioral Interventions (SIB)
• In many instances, multiple controlling variables are functionally
related to SIB
• Effective interventions must be comprised of multiple components
• Focus of function-relevant treatment is not so much suppression of
SIB, as it is altering the contingencies to render the SIB irrelevant,
inefficient, and ineffective, and to replace it with behavior that is
more beneficial to the focus person and those around her or him
• Though biological determinants may increase probability of a
particular topography’s emergence, or contribute to sustenance, it
that does not mean that the behavior is immune to environmental
influence (genetic, acquired brain injury, physiological basis)
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Behavioral Interventions (SIB)
Manipulation of Antecedents-does not directly contact the behavior, but instead alter the circumstances under
which the behavior is most or least likely to occur, thereby indirectly affecting the behavior, and have been called
“passive behavior management”
-Manipulating Establishing Operations (EOs)-motivating antecedents (alter momentary potency of
consequences) that
enhance or degrade the relative momentary effectiveness of a reinforcer
(sleep deprivation, physical discomfort related to menstrual periods, otitis, fooddeprivation or satiation, allergies, illnesses)
Treatments-establishing regular sleep patterns, medically addressing physical discomfort and
illness, ensuring adequate dietary intake, addressing physiology relevant establishing operations
may substantially reduce or eliminate SIB for some individuals
Sensorially or materially impoverished environments have been implicated as establishing
operations promoting value of various reinforcers (remedying environmental deficits)
Transition from one activity or location to another may also be an establishing operation that promotes SIB for
some
Clinical utility of altering value of reinforcers initially accessed contingent on SIB, by presenting those (or
equivalent) reinforcers non-contingently (NCR)
Preferred stimulus satiation (vary the sets of empirically identified stimuli used to enrich an environment
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Behavioral Interventions (SIB)
• Manipulation of Antecedents (continued)
• Manipulating Discriminative Stimuli-increase or decrease
the momentary probability of a behavior by having
preceded the response when it was reinforced or not
increased in the past
• Alter momentary probability of a particular response class
by virtue of their presence when prior occurrences of the
response class were followed by particular consequence
operations
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Behavioral Interventions (SIB)
• Response Based Interventions
• Active behavior management operates
directly on the SIB
• Altering properties of the response itself, such
as effort (arm splints or wrist restraints)
required to attain reinforcement, or by
altering consequence aspects of contingencies
that require less effort for an alternative
behavior
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Behavioral Interventions (SIB)
Manipulating Consequences
Differential reinforcement & Extinction for SIB
Difficulty in exerting control over automatic, sensory reinforcement
Providing sensory experience that successfully competes with that
produced by SIB, irrespective of the SIB, can render the SIB
inefficient and irrelevant
Punishment procedures
Restraining devices-helmet/splint (require fading procedures)
Personal/physical restraint
Devices that mask sensory stimulation-glove
Caution-iatrogenic injury or exacerbation of behavioral difficulties
Risk versus Risk analysis is necessary
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Behavioral Interventions (SIB)
• Manipulating Consequences
• Identifying properties of consequences that
exert reinforcer function
• Providing sensory experience that successfully
competes with that produced by SIB,
irrespective of the SIB, can render the SIB
inefficient and irrelevant
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Self-Injurious Behavior (SIB)
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SIB refers to behaviors, such as head-hitting or scratching, that people direct towards themselves and that results
in tissue damage
SIB does not define a topography
SIB is dependent upon an outcome of an “injury” whether acquired immediately or over time
Etiology is poorly understood
Poses serious risk to those who engage in the behavior
It represents a formidable challenge to those who are responsible for treating it
The only treatments that have been consistently effective are those based on punishment in the form of aversive
stimulation
Research suggests that within-subject variability is a function of distinct features of the social and/or physical
environment e.g. different sources of reinforcement
Genes do not code for specific behaviors; rather, they influence the “organism as a whole” developmental system
The assertion is that environmental pathogens cause behavioral disorders and genes influence susceptibility to
these pathogens
Recent research “Monitor on Psychology” July/August 2015 Vol. 46. No.7: non-suicidal self-injury (NSSI) in the
DSM-5 “new disorder in need of further study” as well as a symptom of borderline personality disorder (BPD)
Dialectical Behavior Therapy (DBT)
Emotional benefits versus motivations behind it
Pain offset relief-removal of pain stimulus does not return individual to pre-stimulus state, rather a short but
intense state of euphoria (associate self-injury with relief)
Risk factors-body objectification (viewing body as object), body devaluation, lack of internal bodily awareness,
emotional dysregulation, eating disorders, pain endurance, low feelings of self-worth, negative self-image,
associating pain with relief, associating negative thoughts with self-related words
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Stereotypy vs. OCD
• Stereotypy refers to motor behavior that is repetitive,
often seemingly driven, and nonfunctionalcharacteristic feature of Pervasive Developmental
Disorder (PDD)
• OCD refers to a dynamic involving a reduction in
anxiety
• Obsession refers to the thought
• Compulsion refers to the behavior-more complex and
ritualistic and performed in response to an obsession
or according to rules that must be applied rigidly
• Intermittent Explosive Disorder refers to a reduction in
anxiety (not mere physical aggression)
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Stereotyped Acts
• Defined as repetitious, topographically invariant motor
movements (or sequence of motor movements),
where reinforcement is not apparent and the act of
performing the behavior is considered pathological
• Defined as voluntary, developmentally inappropriate,
repetitive motor movements, which serve no apparent
adaptive function
• Defined as a movement disorder characterized by
repetitive, seemingly driven, non-functional motor
behavior
• Distinguished from self-injurious behavior
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Stereotyped Acts
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Hand flapping
Finger twirling
Gazing at complex hand/finger movements
Body rocking
Body posturing (tensing)
Jumping
Spinning
Toe-walking
Light gazing
Eye pressing
Hair twirling
Finger sucking
Mouthing objects
Vocalizing
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Stereotyped Acts
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Learning Theory-results under schedules of reinforcement, either positive or negative
-Positive Reinforcement (Discriminative Stimulus) Hypothesis-created and
produced by the individual and acquires reinforcing properties by the mere
performance of the behavior/discriminative stimuli for gaining the social
attention of others
-Negative Reinforcement Hypothesis-maintained through the termination, escape, or
avoidance of an aversive stimulus
Homeostatic Theory-self-stimulatory in the form of arousal-inducing or arousal-reducing behaviors
Self-stimulation Hypothesis-based on the notion that a certain minimum degree of stimulation is
necessary
Arousal Reduction and Filtering Hypothesis-modulates general arousal
Developmental Theory-occurs during the normal progression of early developmental stages and
reflects the child’s maturational process/may serve adaptive functions e.g. promote motor and personality
development
Cognitive Development Hypothesis-reflect early stages of cognitive development and resemble infant behavior
observed during the sensorimotor period of developmental
Motor Development Hypothesis-may emerge when coordinated motor behavior has been delayed
Organic Theory-resulting from aberrant or abnormal physiological processes
Biological Theory-evidence of a dysregulated central nervous system
Dopamine Agonist-Induced Stereotypy-can be induced through stimulant administration
Opioid Theory of Stereotypy-endogenous overactivity of the opiate system in the brain
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When Should Stereotyped Acts Be
Modified
• Potential to harm the individual
• Potential to harm someone else
• Interferes with the individual’s potential to
learn or work or otherwise interact adaptively
with the environment
• Socially odd or bizarre and serves as a “Scarlet
Letter” of exceptionality that compromises
potential for normalization within the
community
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What Treatments Are Available To
Modify Stereotyped Acts?
Behavior Modification
Indirect Strategies
-Environmental modification
-Positive reinforcement
-Functional communication training
-Differential reinforcement (DRO, DRI, DRL)
Direct Strategies
-Extinction
-Avoidance extinction
-Sensory extinction
-Punishment
-Response prevention
-Overcorrection
-Multiple interventions
Psychopharmacology
Exercise
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Exposure to the World
• Mandate is to expose and teach people to the
larger world-foundation on which to make
choices
• Socialization is not defined by a van ride to
Walmart as it is stigmatizing and does not
provide individualized habilitation
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The fabric of our lives
• How we treat human beings the other 23 hours
of the day
• So many examples of the impact on people
• “You can’t sit at the staff table”
• “You can’t have another iced tea”
• “You can’t buy a coke from the vending machine”
• How is it that we hold people that we support to
a higher standard than we follow (aka members
of congress)
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ID versus Dementia
• ID-prior to age 18
• Dementia-subsequent to age 18
• Life expectancy of many persons with developmental disabilities has
increased, an increasing number of people are being diagnosed with
dementia
• Higher incidence of early-onset Alzheimer’s disease in people with Down
syndrome
• Diagnosis of Dementia in individuals with ID
• Epidemiology of Alzheimer Disease in MR
• Practice Guidelines for the Clinical Assessment and Care Management of
Alzheimer and other Dementias among Adults with Mental Retardation
• Purchasing Information for Test Battery
• Test Battery for the Diagnosis of Dementia in Individuals with ID
• Accurate diagnosis requires data over space and time
• Impact on daily life is of critical importance for diagnosing
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Dementia in I/DD
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http://www.medpagetoday.com/upload/2013/8/20/PIIS0025619613003716.pdf
The National Task Group on Intellectual Disabilities and Dementia Practices Consensus
Recommendations for the Evaluation and Management of Dementia in Adults With Intellectual
Disabilities
Researchers recommend a nine-step approach for assessing health and function. These include:
Taking thorough history, with particular attention to "red flags" that potentially indicate premature
dementia such as history of cerebrovascular disease or head injury, sleep disorders, or vitamin B12
deficiency
Documenting a historical baseline of function from family members of caregivers
Comparing current functional level with baseline
Noting dysfunctions that are common with age and also with possible emerging dementia
Reviewing medications and noting those that could impair cognition
Obtaining family history, with particular attention to a history of dementia in first-degree relative
Noting other destabilizing influences in patient's life such as leaving family, death of a loved one, or
constant turnover of caregivers, which could trigger mood disorders
Reviewing the level of patient safety gleaned from social history, living environment, and outside
support
Continually "cross-referencing the information with the criteria for a dementia diagnosis"
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Early Detection Screen for Dementia
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Assessment of Dementia
Diagnostic Instruments
-The Cambridge Cognitive Examination
(CAMCOG) part of the Cambridge Examination
for Mental Disorders of the Elderly-Revised
(CAMDEX-R; Roth et al., 1986 Roth et al., 1998.
-Severe Impairment Battery (SIB; Saxton et al.,
1993)
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Assessment of Dementia
Direct Performance-Based Neuropsychological
Assessments
-DYSPRAXIA scale for adults with Down
Syndrome (Dalton & Fedor, 1997, 1998)
-Dalton/McMurray Visual Memory Test: Delayed
Matching to Sample Cognitive Test (Dalton,
1995)
-The Rivermead Behavioural Memory Test
(RBMT); Wilson et al, 1985, 1991.
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Assessment of Dementia
Informant-Based Assessment Instruments
-Dementia Questionnaire for Persons with
Mental Retardation (DMR; Evenhuis, 1990,
1992, 1996)
-Dementia Scale for Down Syndrome (DSDS;
Gedye, 1995)
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Mental Retardation & Psychiatry
• Psychiatric Assessment of the Person With
Mental Retardation
• Essentially the same save for level of selfreport versus behavioral observations
• The Role of the Psychiatrist in Mental
Retardation
• The Patient with Mental Retardation
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Expert Consensus Guideline Series
American Journal On Mental Retardation (AJMR)
Volume 105, Number 3
May 2000
Treatment of Psychiatric and Behavioral Problems in Mental
Retardation
Guideline 1. Diagnosis and Assessment
Guideline 2. Informed Consent
Guideline 3. Psychosocial Treatment
Guideline 4. Medication Treatment General Principles
Guideline 5. Selection of Medications
Guideline 6. Managing Inadequate Response to Initial Medication
Treatment
Guideline 7. Medication Dosing
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Debriefing 101
Debriefing the use of restraint
Debriefing: a one-time semi-structured
conversation with an individual or individuals who
have experienced a stressful or traumatic event.
Purpose: to reduce any possibility of psychological
harm by informing people about their experience or
allowing the individuals involved to talk about it.
Purpose: to determine the cause of the incident
that required intervention.
Purpose: to determine how to avoid such incidents
in the future.
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Developmental Disabilities and Law
Enforcement
Training for police officers
“They’re all just people”
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Consent
• Informed
• Risk/Benefit-Risk of implementing treatment
versus benefit of implementing treatment
• Risk/Risk-Risk of implementing treatment versus
risk of not implementing treatment
• Impact of signs/symptoms on daily life (we do not
obtain consent for an individual who is
hallucinating but for the impact that the
hallucinations have on the life of the individual)
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Empiricism
• “This intervention won’t work”
• Don’t engage in crystal ball reading
• You cannot predict the outcome of a given
intervention until you implement it and obtain
data as to the effectiveness
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Psychology is a Science
Not because of the nature of the information,
but by the way in which the information is
obtained e.g. the scientific
method/experimental method/research design
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Motivational Assessments
• Reinforcer Survey
• Premack Principle
• Reiss Motivation Assessment
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Normalizing
• We get “used to” people acting the way they
do
• Result is that we “normalize” or minimize the
clinical significance which results in
minimizing the importance of treatment
• “Johnny is just being Johnny”-when in fact
Johnny is suicidal, homicidal, and floridly
psychotic
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The Importance of Work (Vocation)
Cannot be overestimated
Freud: Love/family and work
Key aspect of human and social functioning
If an individual wants to be an astronaut begin by
providing them with a book about astronomy
• Employment in the community for people diagnosed
with ID is both an international as well as national
right.
• PL (Public Law) 106-170, or the Work Incentives
Improvement Act-required networks to serve people
with significant disabilities
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Murdoch Center Foundation
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Murdoch Method
Task Analyses-never reduce the criterion for success for completion of a task [break down the task
to enhance success]
Standard Measure of Success (MOS) is 80%
Individualizing the approach does not require “reinventing the wheel” but applying the appropriate
step based upon task analysis
Developmental Disabilities Support Needs Assessment Profile (DD-SNAP)
The Murdoch Center Foundation is a private, nonprofit corporation dedicated to education,
research and professional advancement in the field of intellectual and developmental disabilities
(IDD). The Foundation publishes a curriculum guide and an assessment tool for use with persons
having IDD. Sales of these products fund activities that benefit the people who live and work at
the Murdoch Developmental Center in central North Carolina. The Murdoch Center Foundation is
an Internal Revenue Service 501(c)(3) corporation (not directly affiliated with the Murdoch
Developmental Center).
The Murdoch Center Program Library is a collection of almost 1000 task analyses of specific skills
which are particularly applicable to the habilitation of persons with severe and profound mental
retardation.
http://www.murdochfoundation.org/index.htm
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Delayed Gratification
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Delay of Reinforcement.
Not feasible to immediately gratify needs.
Address the need-binder effect.
Guidelines for programming indiscriminable contingencies.
Indiscriminability of the contingency (i.e. the learner cannot tell exactly
when emitting the target behavior in the generalization setting will
produce a reward at a later time.)
Use continuous reinforcement during the initial stages of acquiring new
behaviors or when strengthening little-used behaviors.
Systematically thin the schedule of reinforcement based on the learner’s
performance.
When using delayed rewards, begin by delivering the reinforcer
immediately following the target behavior and gradually increase the
response-to-reinforcement delay.
Each time a delayed reward is delivered, explain to the learner that he is
receiving the reward for specific behaviors performed earlier.
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Psychology Discipline
Ownership of Functional Assessment
Ownership of PBSP
No ownership of psychoactive medication consents
No ownership of psychoactive prescription
Discipline specific issues and competency/credential issues
Example: the discipline of Medicine owns medical
procedures so why should other disciplines own Psychology
procedures
• Example: when creating a “consult” the genius is in the
formulation of the question to the “expert”, not dictating to
the expert what procedure to perform
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State Policies and Practices in Behavior
Supports
• State Policies and Practices in Behavior Supports
for Persons with Intellectual and Developmental
Disabilities in the United States: A National
Survey
• David A. Rotholz, Charles R. Moseley, and Kinsey
B. Carlson
• INTELLECTUAL AND DEVELOPMENTAL
DISABILITIES
• 2013, Vol. 51, No. 6, 433–445 AAIDD
• DOI: 10.1352/1934-9556-51.6.433
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State Policies and Practices in Behavior
Supports
Abstract
Providing effective behavioral supports to decrease challenging behavior and replace it with
appropriate alternative skills is essential to meeting the needs of many individuals with intellectual
and developmental disabilities (IDD). It is also necessary for fulfilling the requirements of Medicaid
funded individual support plans and is important for moral, ethical, and societal reasons.
Unfortunately, there is no national standard for behavioral support practices or source of
information on the status of behavior support policies, practices, and services for adults with IDD at
either state or national levels. The collection of comprehensive data on state behavior support
definitions, provider qualifications, training, and oversight requirements is a necessary starting point for
the development of plans to address needed policy and practice changes. This survey is the first
national assessment of state policies and practices regarding the definition and delivery of behavior
support services to people with intellectual and developmental disabilities receiving publicly financed
supports in the United States.
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The Flynn Effect
(The impact of an IQ score)
Rising IQ scores
Educational Implications: Who Receives MR Services
Financial Implications: The Costs of MR
Legal Implications: The Flynn effect and the Law-A Matter of Life
and Death-International and U.S. Law on the Execution of Those
with Mental Retardation-Under US law, the execution of the insane
- someone who does not understand the reason for, or reality of his
or her punishment - violates the US Constitution (Ford v
Wainwright, 1986). 1989 Penry v. Lynaugh Executing persons with
mental retardation is not a violation of the Eighth Amendment.
(Overturned in Atkins v. Virginia (2002)
• Occupational Implications: The Flynn Effect and the Military
• Placement Decisions
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Practice Effects
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Practice effects refer to gains in scores on cognitive tests that occur when a person
is retested on the same instrument, or tested more than once on very similar ones.
These gains are due to the experience of having taken the test previously; they
occur without the examinee being given specific or general feedback on test items,
and they do not reflect growth or other improvement on the skills being assessed.
Such practice effects denote an aspect of the test itself, a kind of systematic, builtin error that is associated with the specific skills the test measures.
These effects relate to the test’s psychometric properties, and must therefore be
understood well by the test user as a specific aspect of the test’s reliability.
Retesting occurs fairly commonly in real circumstances for reasons such as
mandatory school reevaluations, longitudinal research investigations, unwitting or
deliberate duplication by different professionals who are evaluating the same
individual, a parent’s or teacher’s insistence that a child be retested because the
test scores imply that the child was not trying, and so forth.
A keen understanding of differential practice effects facilitates competent
interpretation of test score profiles in those instances in which people are retested
on the same or a similar instrument perhaps several times.
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Practice Effects
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No specific length of time between tests is required to study practice effects; it
depends on the generalization sought or needed.
If the interval is very short-for example, a few hours, or a couple of days-then
examinees are likely to remember many specific items that were administered.
They are likely to retain specific picture puzzles, arithmetic problems, or block
designs, and recall the strategies that proved most successful; the results is an
inflated estimate of the practice effect; that is, relative to an inference about
established (learned) effects.
In contrast, intervals that are long, perhaps six months or a year or two, are
confounded by variables other than the test’s psychometric properties and
practice as such.
Long intervals allow forgetting of the test’s content, and therefore reduce the
magnitude of the practice effects, at the same time, in lengthy intervals there can
be real growth or decline of the abilities measured.
When change has occurred, it becomes difficult to separate the test’s practice
effects, as such, from the person’s improvement or decay on the skills.
For preschool children, who experience rapid development even three or four
months may be too long an interval for studying a test’s practice effects.
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Practice Effects
• The most commonly useful intervals for investigating a
test’s practice effects are between one week and about two
months, with one month or so representing a reasonable
midpoint.
• Intervals of that approximate magnitude are typical of the
test-retest reliability investigations reported in the test
manuals of popular individually administered intelligence
and achievement tests.
• The Administration and Scoring Manual for the test
cautions against serial testing because of practice
effects. There is no justification to disregard or even
question this caution for adults with ID.
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Factors That May Affect Test Scores
• Practice effects
• “Flynn effect” (i.e., overly high scores due to out-of-date test norms)
• Invalid scores may result from the use of brief intelligence screening tests
or group tests; highly discrepant individual subtest scores make an overall
IQ score invalid
• Instruments must be normed for the individual’s sociocultural background
and native language.
• Co-occurring disorders that affect communication, language, and/or motor
or sensory function may affect test scores
• Individual cognitive profiles based on neuropsychological testing are more
useful for understanding intellectual abilities than a single IQ score. Such
testing may identify areas of relative strengths and weaknesses, an
assessment important for academic and vocational planning
• IQ scores are approximations of conceptual functioning but may be
insufficient to assess reasoning in real-life situations and mastery of
practical tasks
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Re-Testing of IQ
Implications
-Requires parent/guardian consent
-Results above IQ of 70 may result in loss of
waiver funds
-In some cases the institutionalization
represents the best treatment option
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IQ & Death Penalty
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High court bars rigid IQ cutoff for executions
May 27, 2014
The Supreme Court ruled in the case of Freddie Lee Hall, on Florida's death row for more than three
decades. (Photo: AP)
WASHINGTON — The Supreme Court made it more difficult Tuesday for states to execute prisoners
who claim an intellectual disability, marking the first time it has fine-tuned its landmark 2002
decision barring the death penalty for those with mental impairments.
The court ruled that Florida must apply a margin of error to IQ tests administered to Freddie Lee
Hall, 68, who killed a 21-year-old pregnant woman and a deputy sheriff in 1978. The state had
argued that any test score above 70 made prisoners eligible for a death sentence, despite medical
guidelines that permit scores to reach 75.
"Intellectual disability is a condition, not a number," Justice Anthony Kennedy said in the 5-4 ruling,
joined by the court's four liberal justices.
The decision will affect a handful of states with similar policies among the 32 states with death
penalties on the books. Though very few prisoners with intellectual disabilities will be granted
reprieves as a result, the ruling clarifies a delicate area of criminal law.
It comes as states' capital punishment procedures are under siege, beset by a shortage of drugs
needed to perform lethal injections and rejuvenated efforts by disability rights groups to stop
executions of prisoners with mental impairments. A federal appeals court blocked Texas this month
from executing a death row prisoner claiming intellectual disability.
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The Death Penalty and Intellectual
Disability
• In a landmark decision in Atkins v. Virginia in 2002, the Supreme Court
ruled that executing someone with ID is a violation of the Eighth
Amendment of the U.S. Constitution, which prohibits cruel and unusual
punishment. In its 2014 decision, Hall v. Florida, the Court ruled that,
while states have the right to establish their own rules for handling Atkins
cases, they cannot ignore scientific and medical consensus regarding
intelligence and the nature and diagnosis of ID. The Court rejected the use
of an IQ test score of 70 as a bright-line cutoff for determining ID and
ruled that all evidence pertinent to the claim, including adaptive
behavior assessments, should be considered.
• Critical topics: foundational considerations, including diagnostic criteria,
the definition of ID, the analyses of Atkins cases; assessment
considerations; intellectual functioning, including IQ testing and the Flynn
effect; adaptive behavior; and related topics, such as cultural and linguistic
factors, competence to waive Miranda rights and to stand trial,
retrospective diagnosis, malingering, comorbid disorders, educational
records, and professional issues.
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“Briseno Factors”
[regarding adaptive behavior]
When the issue of mental retardation is raised post-conviction in a death penalty
case, the Sixth and Eighth Amendments require that either the convicting court or the
Court of Criminal Appeals review the evidence provided in the writ application to
determine whether the evidence propounded by the applicant is sufficient to make a
prima facie showing of mental retardation, and, if so, whether the evidence argued in
the party's brief conclusively establishes that the applicant is mentally retarded. If
the court finds, based on the pleadings, that the applicant has conclusively proven
mental retardation, the court may, without empaneling a jury, grant the relief to
which applicant is entitled. The applicant would receive no greater relief from a
jury determination. If the applicant has only established a prima facie case, the Sixth
and Eighth Amendments require the convicting court to empanel a jury and hold a
hearing for the limited purpose of resolving the factual issue of mental retardation.
At that hearing, the applicant carries the burden of proof and the jury is required to
come to a unanimous conclusion regarding whether the applicant has shown by
preponderance of the evidence that he is mentally retarded. Depending on the jury's
answer, the convicting court must then provide this Court with a recommendation to
either deny relief on the applicant's allegation of mental retardation or commute the
applicant's sentence to life. - See more at: http://caselaw.findlaw.com/tx-court-ofcriminal-appeals/1333303.html#sthash.rz0CRBdy.dpuf
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“Briseno Factors”
[regarding adaptive behavior]
Did those who knew the person best during the developmental stage-his family,
friends, teachers, employers, authorities-think he was mentally retarded at that
time, and, if so, act in accordance with that determination?
Has the person formulated plans and carried them through or is his conduct
impulsive?
Does his conduct show leadership or does it show that he is led around by others?
Is his conduct in response to external stimuli rational and appropriate, regardless
of whether it is socially acceptable
Does he respond coherently, rationally, and on point to oral or written questions or
do his responses wander from subject to subject?
Can the person hide facts or lie effectively in his own or others' interests?
Putting aside any heinousness or gruesomeness surrounding the capital offense,
did the commission of that offense require forethought, planning, and complex
execution of purpose?
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“Briseno Factors”
[regarding adaptive behavior]
http://caselaw.findlaw.com/tx-court-of-criminal-appeals/1333303.html
Based on “Of Mice And Men” by John Steinbeck
http://damiencomerford.com/tag/briseno-factors/
Texas Continues To Execute People Who Have Severe Intellectual Disabilities
The Texas definition is bizarre to put it mildly. Many would be familiar with the
John Steinbeck 1937 novella, Of Mice and Men. It is a classic piece of American
literature. But in Texas the book is more than just a classic, it has legal status.
Under what are known as “Briseno factors”, the State establishes the profile of an
individual who ordinary Texans would agree was intellectually disabled. It points to
Lennie Small, the lumbering and childlike character in John Steinbeck’s book,
identifying him as the legal yardstick. In other words, the Texas definition of
intellectual disability has to match the degree of mental impairment depicted by a
character in a fictional novella.
The writer, John Steinbeck once said, Texas was a state of mind. But, if the State of
Texas continues to use one of his characters, as a legal benchmark for intellectual
disability, out of its mind might have been a more accurate description.
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
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CURRENT DEVELOPMENTS 2012-2013: Of Mice and Men, Fairy Tales, and Legends: A Reactionary Ethical Proposal to
Storytelling and the Briseño Factors
Fall, 2013
Georgetown Journal of Legal Ethics
In reviewing Texas' adherence to the Briseño factors--non-scientific standards inspired by the character
Lennie in Of Mice and Men and not by actual science or clinical protocol 1--it is evident that the use of
storytelling can have a result that even Critical Race theorists would not desire. Critical Race theorists
have traditionally been against the conservative trends of adhering strictly to law, precedent, and
controlling cases. Instead, they advanced theories that examined legal issues on a case-by-case basis
while paying attention to how society shaped the individuals who are likely to be affected by legal
decisions. Typically, a marginalized person, such as a minority with an intellectual disability, would be a
part of the constituency that Critical Race Theory (CRT) would choose to protect. Unfortunately, CRT
supports Texas' divergence from Atkins v. Virginia, which holds that the execution of intellectually
disabled persons is a violation of the Eighth Amendment's prohibition against cruel and unusual
punishment, and supports the Of Mice and Men-influenced Briseño factors. It perpetuates a general
misunderstanding of persons with intellectual disabilities and hinges an individual's life on non-scientific
and non-fact based assertions. Tempering the practice of storytelling with an ethical guideline will avoid
the manipulation of information that is presented to the trier-of-fact. 2
Recently, the Texas courts refused to classify Marvin Wilson as an intellectually disabled person
protected by the Supreme Court's decision in Atkins, 3 making Wilson one of seventy individuals who
have contested their death sentence under ...
https://litigationessentials.lexisnexis.com/webcd/app?action=DocumentDisplay&crawlid=1&doctype=cite&docid=26+G
eo.+J.+Legal+Ethics+859&srctype=smi&srcid=3B15&key=319fa09f59c7d5dce8457f2fdd17f9fe
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
360
Punishment Model
• We do not provide a punishment model-harsh,
demeaning, negative, etc.
• By “punishing” an individual for behavior by
precluding the involvement in preferred activity
we effectively set the person up to fail due to the
lack of habilitation, engagement, etc.
• The only justifiable means for precluding an
individual from engagement in a preferred
activity is current/imminent danger to self or
others
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Court
Three things that the Judge wants to know:
1. Does the individual meet the criteria for a
diagnosis of ID
2. Is the individual competent to stand trial
3. What is the best placement for the individual
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Forensic Evaluations
Texas Code of Criminal Procedure
Competence Assessment for Standing Trial for Defendants with Mental
Retardation (CAST*MR)
Evaluation of Competency to Stand Trial-Revised (ECST-R)
Under age 17- “Unfit to Proceed” Texas Family Code Chapter 55
Over age 17- “Incompetency to Stand Trial” Texas Code of Criminal
Procedure Chapter 46B
Article 46C, “Insanity Defense”
Court does not currently recognize DSM-5 changes to ID
Court currently recognizes IQ and MR
Competency-This standard relates to the defendant’s ability to relate
to the criminal justice system
Presumption of competency
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Forensic Evaluations
Hi Robb: Very nice talking with you in Austin. CST is clearly a functional
analysis of current functioning. Sanity, on the other hand, is a retrospective
analysis of what an individual was capable of knowing sometime in the past.
Sanity relies much more heavily on collateral information. Statute precludes
continuing with sanity if, in your opinion, the person is not competent to
stand trial. This is because if a person is not competent at the time of the
evaluation, chances are the person is also incompetent to comprehend your
disclosure (or informed consent if the evaluation is not court ordered). It is
also not clear that the individual would be able to give you truly helpful
information regarding sanity under these circumstances. Mary Alice
Mary Alice Conroy, Ph. D., ABPP
Sam Houston State University
Assuming the individual has not been transferred to adult court, a 17 or
under would fall under Chapter 55—same standard for competence (fitness
to proceed), different standard for sanity (responsibility for conduct). Mary
Alice
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House Bill (H.B.) No.807
Determination of Mental Retardation
(DMR)
DMR is equivalent to Full/Comprehensive Psychological Evaluation
H.B.ANo.A807
AN ACT
relating to the practice of psychology; authorizing a fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTIONA1.AASections 593.004 and 593.005, Health and Safety
Code, are amended to read as follows:
Sec.A593.004.AAAPPLICATION FOR DETERMINATION OF MENTAL
RETARDATION. (a) In this section, "authorized provider" means:
(1)AAa physician licensed to practice in this state;
(2)AAa psychologist licensed to practice in this state;
(3)AAa professional licensed to practice in this state and certified by the department; or
(4)AAa provider certified by the department before September 1, 2013.
(b)AAA person believed to be a person with mental retardation, the parent if the person is a minor, or the guardian of
the person may make written application to an authorized provider [the department, a community center, a physician,
or a psychologist licensed to practice in this state or certified by the department] for a determination of mental
retardation using forms provided by the department.
Sec.A593.005.AADETERMINATION OF MENTAL RETARDATION. (a) In
this section, "authorized provider" has the meaning assigned by
Section 593.004.
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Diagnostic Assessment Rule
March, 2015
Chapter 5, Provider Clinical Responsibilities--Intellectual Disability Services
Subchapter D, Diagnostic Assessment
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§5.151. Purpose.
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The purpose of this subchapter is to describe the criteria to be used and the process to be followed:
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(1)
by an authorized provider employed by or contracted with a local intellectual
and developmental disabilities authority (LIDDA) or a state supported living center (SSLC), to conduct a diagnostic
assessment for intellectual disability, autism spectrum disorder (ASD), and a related condition;
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(2)
by a LIDDA or SSLC, to review a DID or a diagnosis of ASD or related condition
for endorsement; and
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(3)
by DADS, to approve an employee of a LIDDA or an SSLC as a certified
authorized provider.
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(10)
DID (determination of intellectual disability)--An assessment conducted in accordance with §5.155 of
this title (relating to Determination of Intellectual Disability (DID)) by an authorized provider to determine if an
individual meets the criteria for a diagnosis of intellectual disability.
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§5.158. Related Condition (RC).
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If an individual is determined not to have an intellectual disability, an authorized provider described in
§5.155(c) of this title (relating to Determination of Intellectual Disability (DID)) may use information from the DID
to assist in establishing the individual’s eligibility for certain Medicaid services based on the existence of a related
condition, as described in the DADS-approved list of related conditions and §9.238 of this title (relating to ICF/MR
Level of Care I Criteria) or §9.239 of this title (relating to ICF/MR Level of Care VIII Criteria).
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DIAGNOSTIC ELIGIBILITY FOR SERVICES
AND SUPPORTS
http://www.dads.state.tx.us/providers/LA/DMRBestPracticesOctober2000.pdf
MENTAL RETARDATION PRIORITY POPULATION
CHAPTER 415, SUBCHAPTER D
BEST PRACTICES GUIDELINES
OCTOBER 2000
1. Choosing Appropriate Intellectual Testing Instruments
2. Overall Intellectual Functioning
3. Standard Error of Measurement
4. IQ Scores Needed to Qualify for Mental Retardation Services funded by General Revenue vs. Medicaid (70 vs. 69)
5. Suggested Instruments and Procedures to Use When an Individual is Unable to Participate in Traditional Standardized
Intellectual Testing
6. Assessing Adaptive Behavior
7. Determining and Documenting that Mental Retardation was Present During the Developmental Period
8. Accessing Information from Public Schools
9. Endorsing Reports or Validating Assessments Conducted by Others
10. Interpretation of Results of the DMR
11. When to Conduct DMR Updates and Reevaluations
12. Evaluating Very Young Children
13. Addressing the Needs of Persons with Other Conditions who can be Served in Mental Retardation Services
14. Capacity Assessment Instrument for Use in Guardianship Hearings
15. Competency to Stand Trial under Chapter 46.02 of the Criminal Code
16. Assessments under the Family Code Chapter 55.33
17. Reimbursement for DMRs
18. Ethical Standards that Apply to the DMR Process
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SB 1664 (The ABLE Act)
Texas Legislative Session ending 06/01/2015
Current law essentially requires people with disabilities to remain in abject poverty to
access necessary services and support from the state and federal government. With
the passage of SB 1664 (The ABLE Act) individuals with disabilities will be able to set
up a tax-free savings account for health care, education, transportation, personal
support services, housing, and other qualified expenses.
This program is not a government handout that produces government dependency.
Instead it is a hand-up that allows an individual use their own funds to manage their
disability which will lead to greater independence and healthier living at no cost to the
state.
This legislation is a game changer for the disability community by allowing individuals
to save their own money and contribute towards their own independent living.
http://www.txdisabilities.org/able-act
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Endorsement/Validation/Concurrence/
Update
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Endorsement of a report refers to accepting the entire report and assessments of another
professional without any changes or additions. Validation refers to accepting the results
of specific assessment measures obtained by another professional. An endorsement
should, at minimum, identify the results and include a statement referring to the report
being accepted with the report attached. All the required elements of a Determination of
Mental Retardation (DMR) report specified in the rule must be present. If any element is
missing, the MRA (Mental Retardation Authority usually referred to now as the Local Authority)
will need to complete its own assessment to include that missing
element, but can use the test results by validating them. Validated testing may be
included in a report when additional current assessments are also included. For
validation, a statement should be included noting that the results of the testing done by
the other professional remain valid.
Concurrence signifies that the reviewer agrees that the information reviewed is still a valid representation of the individual.
Update involves the addition of new information.
Upon application, the court will require a DMR that is current within 6 months.
DADS policy and the TAC on DMRs, permits a concurrence.
The PMRA (Persons with Mental Retardation Act)-Standard civil commitment
requires an IDT report current within six months of the court hearing but does not specifically require the DID/DMR to be current within six months,
although some courts may have that requirement.
All adult forensic commitments are based on the maximum time they would’ve received if convicted of their crimes. For many, their max time may
be 6 mo. to 2-5 years. Each one will need to be assessed by their team for community transition prior to their max time deadline. If they are not
referred the LA will be asked to obtain a new commitment. This procedure needs to be implemented for all adult forensic cases.
A concurrence should work. The PMRA (Civil Commitment) requires an IDT report current within six months of the court hearing but does not
specifically require the DID/DMR to be current within six months, although some courts may have that requirement. (46B maximum time out ).
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• Satiation
• Variety
Reinforcement
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Noncontingent Reinforcement (NCR)
• Reduction of challenging behavior from baseline (i.e.
reinforcement) levels
• Delivery of an aberrant behavior’s known reinforcer on
a response-independent basis i.e. fixed time (FT) or
variable time (VT)
• Conceptualized as establishing operation (EO)
manipulations
• Attenuating a deprivation state (weaken the
reinforcement for the aberrant behavior)
• Think about “attention”-if we provide attention then
attention will not be so important for the individual to
obtain
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Self-Soothing
• Teaching self-calming
• Providing the environment conducive to selfcalming
• No “quiet/time-out” rooms based on structure
but based on function
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Sexuality & Love
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“I was not attempting to evaluate its’ moral
implications” Spock
Whose issue is it anyway: “ours or theirs”
Needs to be addressed
Intellectually/developmentally disabled does not
equate with sexually disabled
Education is paramount
Still in the caveman days
Vital part of functioning
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Sexuality
People with intellectual and developmental
disabilities (IDD) have a history of being seen as
asexual. Separated from society at large, they have
been denied access to life experiences afforded to
the typically-abled population, the most glaring of
which is access to an intimate partner. Like most
adults, many people with IDD have a desire to
engage in sexual activity with another person. The
penal laws in many states dictate that this sexual
interaction should only occur if both parties are
consenting.
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Sexuality
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Choices and Consent: Adults with developmental disabilities have the right to make their own decisions about relationships. A person with a
developmental disability has the right to engage in sexual activity with another person providing he/she is capable of providing informed
sexual consent.
Friendships and Relationships: Most relationships are not sexual, but some are physically affectionate. All people have the right to be
physically affectionate with an agreeable party. Physical affection differs from sex. Sex is the touching of the sexual parts (breasts, vagina,
penis, anus) of the body for sexual gratification. Physical affection does not require the ability to provide consent, but rather, just a willing
partner.
Education and Information: ...education and information depending on interest and need, at a level and pace people with a developmental
disability can understand, including the following in this suggested order: Development of self-awareness and self-esteem, awareness of
others, body language, assertion, relationships, body changes and awareness, awareness of self as a sexual being, abstinence, sexual
expression, awareness of laws relating to sexual expression, avoiding abuse, personal and sexual hygiene, STDs and HIV/AIDS, pregnancy and
contraception, marriage, and parenting skills.
Sexual Expression: We also recognize that people have different sexual orientations and preferences. Stated in our policy is the following:
"Accept that people with developmental disabilities may be heterosexual, lesbian, gay, bisexual, transgender, monogamous or not
monogamous, and have the right to express themselves accordingly." As previously stated, staff do not have the right to impose our values.
As long as the sexual act is legal and involves consenting adults, we don't interfere.
Reproduction and Contraception: Most people with ID/DD would have significant difficulties raising a child. Yet there are some people who
can. If the person is a consenting adult, he or she has the right to determine a method of contraception if so desired. A person with ID/DD
who is a consenting adult and gets pregnant has the legal right in our state to carry the child to term and attempt to raise the child, or to have
an abortion, or to give the child up for adoption, and we support those rights. For those who do decide to parent, we offer parenting groups
to support them in raising their children.
Sexual Behaviors: Some of the people we support try to meet their sexual needs through the Internet and/or 900 numbers. We are very
concerned that they might be exploited or abused due to their cognitive limitations and possible emotional vulnerabilities. Our policy states
that we "Ensure that the treatment team is aware of consumer's use of technology (such as accessing personal ads, calling sexually explicit
900 numbers, etc.) in fulfilling sexual expression." Also that we "limit the use of the Internet and/or monitor telephone calls if there is
probable cause that the person is engaging in illegal activity." Because the chat lines also have per-minute calling charges, we also try to keep
a close eye on the expenditures of those who use them and catch any financial problem as early as possible.
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Texas Statutes - Subtitle D: PERSONS WITH MENTAL RETARDATION ACT
(PMRA)
• Texas Health & Safety Code-formerly known as PMRA
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Chapter 591 GENERAL PROVISIONS
Subchapter A GENERAL PROVISIONS
Subchapter B DUTIES OF DEPARTMENT
Subchapter C PENALTIES AND REMEDIES
Chapter 592 RIGHTS OF PERSONS WITH MENTAL RETARDATION
Subchapter A GENERAL PROVISIONS
Subchapter B BASIC BILL OF RIGHTS
Subchapter C RIGHTS OF CLIENTS
Subchapter D RIGHTS OF RESIDENTS
Chapter 593 ADMISSION AND COMMITMENT TO MENTAL RETARDATION SERVICES
Subchapter A GENERAL PROVISIONS
Subchapter B APPLICATION AND ADMISSION TO VOLUNTARY MENTAL RETARDATION SERVICES
Subchapter C COMMITMENT TO RESIDENTIAL CARE FACILITY
Subchapter D FEES
Subchapter E ADMISSION AND COMMITMENT UNDER PRIOR LAW
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Texas Statutes - Subtitle D: PERSONS WITH MENTAL RETARDATION ACT
(PMRA)
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Chapter 594 TRANSFER AND DISCHARGE
Subchapter A GENERAL PROVISIONS
Subchapter B TRANSFER OR DISCHARGE
Subchapter C TRANSFER TO STATE MENTAL HOSPITAL
Chapter 595 RECORDS
Section 595.001 CONFIDENTIALITY OF RECORDS
Section 595.002 RULES
Section 595.003 CONSENT TO DISCLOSURE
Section 595.004 RIGHT TO PERSONAL RECORD
Section 595.005 EXCEPTIONS
Section 595.0055 DISCLOSURE OF NAME AND BIRTH AND DEATH DATES FOR CERTAIN PURPOSES
Section 595.006 USE OF RECORD IN CRIMINAL PROCEEDINGS
Section 595.007 CONFIDENTIALITY OF PAST SERVICES
Section 595.008 EXCHANGE OF RECORDS
Section 595.009 RECEIPT OF INFORMATION BY PERSONS OTHER THAN CLIENT OR PATIENT
Section 595.010 DISCLOSURE OF PHYSICAL OR MENTAL CONDITION
Chapter 597 CAPACITY OF CLIENTS TO CONSENT TO TREATMENT
Subchapter A GENERAL PROVISIONS
Subchapter B ASSESSMENT OF CLIENT'S CAPACITY; INCAPACITATED CLIENTS WITHOUT GUARDIANS
Subchapter C SURROGATE CONSENT FOR ICF-MR CLIENTS
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ASSESSMENT OF STIMULUS PREFERENCE AND
REINFORCER VALUE WITH PROFOUNDLY RETARDED
INDIVIDUALS
Reinforcement is a central mechanism in the development of operant
behavior. In attempting to apply operant techniques to establish or
maintain socially desirable outcomes, considerable emphasis is placed
on the selection of suitable reinforcement schedules and
contingencies; however, the process of reinforcer identification is often
taken for granted. Thus, it is likely that at least some of the failures to
effect behavior change can be attributed to defective stimulus
selection rather than to contingency management.
Potential reinforcers may be identified quite readily for some
individuals by simply asking them what they prefer, or by exposing
them to an array of stimuli and recording the duration or frequency of
interaction with each stimulus. In contrast, for many impaired
individual who may be nonverbal and do not engage in spontaneous
play, or who have limited sensory and motor capabilities, the
identification of reinforcing stimuli has been problematic.
JOURNAL OF APPLIED BEHAVIOR ANALYSIS 1985, 18, 249-255 NUMBER 3 (FALL 1985)
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Great Quotes
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“What do we call them?” They have names just like you do…….
“We can’t treat them…..they’re psychotic” That is what you should be treating…….
“These people can’t learn” Perhaps you can’t learn…….single celled organisms can learn
“Why are you doing that” What difference does it make…..
“He has multiple personality because he is talking in funny voices” Read your DSM
“He has intermittent explosive disorder because he hit someone” Read your DSM
“He is cycling” He does not have a bicycle…..His symptoms are cyclical
“If they drool and look funny it doesn’t mean they are mentally retarded” DSM criteria in plain English
“Sheila is just being Sheila” Sheila just ripped the artery out of her arm with a piece of wood. I believe she is
suicidal.
“Randy is just being Randy” Randy has no corpus callosum and is jumping out in front of 18 wheelers on the
highway……and by the way don’t you think such information should be captured in the functional assessment
under the heading of medical issues
He’s not seeing things…. Don’t presume to tell another individual what their reality is. All you can say is that you
don’t see what he is seeing.
“I’m going to jump out the window and kill myself” Nurse replies “I’ll go get the key to open the window for
you”…….Countertransference?
“It’s genetic so there is nothing we can do”……Think about genotype versus phenotype…..genotype does not code
for behavior
“He’s crying over the loss of his friend”…..He needs a psychiatric consult……Grief is a normal human emotion
“He’s having tantrums”…..He is manic….No, he is having tantrums
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The End
Hope you enjoyed my presentation
Thank you
Copyright Dr. Robb Weiss, Psy. D., BCBA-D
2015
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