Focus on Data Based Medical/Dental Evaluation
(Excerpted and modified from Evaluation for and Use of Psychopharmacological Treatment in Crisis Intervention for People with Mental Retardation and Mental Illness. Zelenski, S. G. in Crisis Prevention & Response in the Community ed. Hanson, Wieseler, Lakin 2002. AAMR Press)
What:
In his 2002 report, Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation, 16th Surgeon General David Satcher delineated the unmet medical, psychiatric and dental needs of individuals with developmental disabilities who lived in the community. This report provided the impetus for a resurgence of energy to attack these deficiencies. Deficiencies in care included inadequately trained or experienced health care providers to deliver the level of care required. This article begins to deliver information to help remedy that deficiency.
Why:
In the individual with developmental disability and mental illness, a fragile balance exists between already disrupted, but basal physical functioning and the dysfunction of acute illness, whether physical or psychiatric. In a brain already sensitized by prior injury, what might not be of concern in the typical brain becomes a traumatic insult.
The importance of assessing multiple factors and using data-based assessment and management in treating acute or chronic dysfunctional behaviors in an individual with a developmental disability is emphasized here. The following is a discussion of an appropriate evaluation in complex clinical presentations.
How:
A physician should always suspect physical explanations for any acute psychiatric signs or symptoms when working with a patient with a developmental disability. Table 1 lists some of the common physical causes of psychiatric signs or symptoms and by its name is intended to heighten the caregiver’s sensitivity to pain/discomfort issues rather than psychiatric diagnosis as an important source of behavioral dysfunction.
Table 1
Common Physical Sites and Medical/Dental Causes of Apparent Psychiatric Signs and Symptoms
HURTS: |
Head (EENT, Dental, Lymph nodes, Headache) |
Urinary tract (calculi, infection, obstruction) |
Reflux and other GI factors (constipation, obstipation, rectal ampulla problems) |
Thyroid |
Seizures |
General Medical Conditions
In evaluating whether a general medical condition is responsible for a particular behavioral or psychiatric crisis, several important clinical clues are available. These include (a) the age of the first episode not being characteristic of the age of onset of the apparent condition, (b) the presence of coexisting physical illness known to cause psychiatric or behavioral symptoms (see Table 1 for a useful acronym), (c) a poor response to multiple psychotropic interventions, (d) a lack of family history of psychiatric illness, (e) a single acute episode, or (f) a change in mental status. While none of these alone clearly indicates a general medical condition as causing the crisis, they provide presumptive evidence suggesting further medical evaluation. Personal experience has revealed that approximately 15% of psychiatric referrals in the general population have a general medical condition that explains the psychiatric signs or symptoms, and more than 75% of psychiatric referrals in a mildly and moderately mentally retarded population have a general medical condition that could explain or contribute to the psychiatric signs or behavioral dysfunction responsible for the referral. Many of these were previously unrecognized medical conditions, such as infection, musculoskeletal problems, thyroid, and vision or hearing loss. Hall (1980) found that 5% of psychiatric patients had unrecognized medical disorders that were causative of psychiatric symptoms; 21% of patients had concomitant medical illnesses contributing to the psychiatric symptoms; and physical disease was found causing psychiatric symptoms in 42% of psychiatric outpatients. Similarly pain, loss of function, change in mouth sensation and discomfort are similar dental correlates to the above medical discussion. Good dental evaluation is an important part of any evaluation of “behavioral” symptoms.
Seizure Disorders
Seizure-Related Behaviors — Seizure disorders have frequently been implicated in behavioral changes. The changes can be acute or chronic and can be debilitating and frequently difficult to diagnose (Manford et al., 1988). Partial seizures of the temporal or frontal lobe are most often implicated. These can resemble primary psychiatric illnesses, including psychoses, mood disorders, panic disorder, and dissociative disorders (Deonna, 1995; Tisher et al., 1993).
Interictal Behaviors — Less widely recognized are the long-standing personality (Swanson, Rao, Grafmen, Salazar, & Kraft, 1995) and behavioral changes that occur between seizures, which can lead to increased irritability and lowering of frustration threshold (Gerald, Spitz, Towbin, & Shantz, 1998).
Psychiatric Disorders
Psychiatric diagnosis in a developmentally disabled individual can be complicated by both "shadowing" effects and communication and insight gaps (Giacino & Cicerone, 1998). Individuals with learning disabilities may experience subsequent head injury, further impairing their abilities (Donders & Strom, 1997). This can lead to a long history of inadequate psychiatric diagnosis improperly guiding medication decisions. In addition, little attention has been paid to the experience and ability of caregivers to help in the process of assessment. Hastings (1997) revealed that experienced care staff and inexperienced students differed in their views on likely causes of challenging behaviors. The experienced staff as a group rated social and emotional variables as likely causes of challenging behaviors, while the inexperienced group was more likely to attribute difficulties to more immediate causes.
Personal experience suggests that experienced non medical staff tend to view social and environmental factors as significantly involved in crisis behaviors, while inexperienced non medical staff expect a physician or psychiatrist to be able to "fix" a problem. This has profound implications for psychopharmacological interventions in crisis situations, because the prescribing physician may be unduly influenced by inaccurate information and the urgings of inexperienced staff. This highlights the need for longitudinal data collection and analysis in any assessment of dysfunctional behaviors.
