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PSYCHOEDUCATION MATERIAL ON BIPOLAR DISORDER

Sandra Masih and Dr. Grant Devilly

What is bipolar disorder?

Bipolar disorders (or Manic depression) are known as mood disorders. People who are afflicted with depression on it’s own are said to have a major depressive disorder or “unipolar depression”. People with both manic and depressive episodes or people with manic episodes alone are said to have a bipolar disorder. The term “unipolar mania” and “pure mania” are sometimes used for people with bipolar disorder who do not have depressive episodes.

The relationship between unipolar depression and bipolar depression is not clearly understood. However, the theory regarding the relationship between the two suggests that unipolar depression and bipolar depression represent two different disorders.

People normally experience a wide range of moods including normal, elevated, or depressed and usually there is a sense of control of their moods and affect. Mood disorders are characterised by a loss of that sense of control and is usually accompanied by feelings of helplessness, hopelessness and worthlessness. People with depressed mood have a loss of energy and interests, feelings of guilt, difficulty in concentrating, loss of appetite, and thoughts of death or suicide

People with elevated mood or manic episodes demonstrate expansive or irritable mood, having too many ideas at once, distractibility, decreased sleep, heightened self-esteem, and grandiose ideas. Others signs associated with the mood disorders include change in activity level and functions such as sleep, appetite, sexual activity, and other biological rhythms. These disorders virtually always result in impaired interpersonal, social, and occupational functioning.

Bipolar disorder is less common than major depression. About 1% of the population experience bipolar disorder compared to 10% of men and about 20% of women who experience a major depression. Roughly 1 of every 15 depressed persons experiences bipolar disorder. However, in hospitals the ratio of bipolar disorder to depression is about equal. Unlike major depression, bipolar disorder affects males and females equally. Bipolar disorders can begin from childhood through to about 50 years of age. The average age of onset is about 30 years.

WHAT ARE THE SYMPTOMS?

Bipolar Disorder

This disorder most often starts with depression (75% of the time in females and 67% in males) and is a recurring illness. Most people experience depression and mania , although approximately 10 – 20 % experience only manic episodes. The manic episode typically has a rapid onset (hours or days), but they may evolve over a few weeks. An untreated manic episode lasts about 3 months; therefore, it is unwise to discontinue treatment prior to that time. Time between episodes usually stabilises at about six to nine months.

Manic Episodes

Elevated, expansive or irritable mood is the hallmark for manic episodes. Although uninvolved people may not recognise the unusual nature of the person’s mood, those who know the person recognise it as abnormal for that person. Alternatively, the mood may be irritable especially if the person’s plans are interrupted. Often a person exhibits a predominant mood of euphoria, early in the course of the illness, and irritability later in the process.

In addition to these symptoms, people with mania often exhibit other symptoms such as:

 

– distractibility

attention easily drawn to irrelevant or unimportant things

– decreased need for sleep

the bipolar sufferer may feel rested after only a few hours of sleep.

– excessive involvement in pleasurable activities which have a high potential for harmful consequences

such as shopping where the person engages in unrestrained buying sprees, sexual activity (or indiscretions), or foolish business investments.

– increase in goal-directed activity

either socially, at work or school, or sexually. The person is often preoccupied by religious, political, financial, sexual, or self-defeating ideas that may evolve into thinking that is not reality based.

– increased talkativeness and a pressure to keep talking

their increased talkativeness may be seen by excessive use of the telephone, especially long distance calls during the early hours of the morning.

People with mania often drink alcohol excessively, perhaps in an attempt to self-medicate. Other behaviours that are seen in mania are excessive gambling, a tendency to disrobe in public places, wearing clothing and jewelry in bright colours and in unusual combinations, and an inattention to small details (such as forgetting to hang up the phone). Occasionally, people with mania engage in child-like play.

Mania in adolescence:

Mania in adolescence is often misdiagnosed as sociopathy or schizophrenia. Symptoms of mania in adolescence may include psychosis, alcohol or drug abuse, suicide attempts, academic problems, philosophical brooding, obsessive-compulsive symptoms, multiple physical complaints, marked irritability resulting in fights, and other anti-social behaviours. Although many of these symptoms can be seen in normal adolescence, severe or persistent symptoms should cause the clinician or family members to consider the possibility of the teenager having a bipolar disorder.

Family and friends may notice problems in areas such as:

– school truancy

– school failure

– occupational failure

– interpersonal relationships

– increased antisocial behaviour

 

WHAT CAUSES BIPOLAR DISORDER?

The causes of Bipolar Disorder are currently unknown and no single cause has been identified. However, a number of different factors are believed to be associated with the onset of this mood disorder. These are:

Biological Factors

Certain biochemical substances in the brain (i.e. neurotransmitters called the biogenic amines) are believed to be involved in this condition. It is suggested that some people may have a genetic predisposition to depression because of an imbalance in these brain chemicals. The antidepressant medications work to restore the imbalance in the brain chemicals. Mania is commonly treated with drugs such as lithium carbonate and citrate.

Genetic factors:

Twin and adoptive studies provide strong evidence of a genetic influence for Bipolar Disorder. The fact that this disorder runs in families is also consistent of a biological cause. Approximately 50% of all bipolar sufferers have at least one parent with a mood disorder. If one parent has bipolar disorder, there is a 27% chance that any child will have a mood disorder; if both parents have bipolar disorder, there is a 50 – 70% chance that a child will have a mood disorder.

Life Events and Environmental Stress

Some clinicians believe that life events play the primary role in depression. The environmental stressor most associated with depression onset is the loss of a spouse. However, the triggering event can be from any cause and can also be due to a build-up of smaller events and little perceived support.

Some evidence shows that changes in sleep-wake schedule or sleep deprivation may precipitate or exacerbate a manic or mixed episode.

BIPOLAR DISORDER. HOW CAN THE FAMILY HELP?

1. The family can help by being supportive and acknowledging the person’s emotions.

2. The person with depression will usually find it difficult to cope with normal activities. A demonstrated understanding of this by family and friends is advisable and support for the depressed person with encouragement to engage in “fun” activities (during the depressed stage).

3. Encourage the person to properly comply with taking their prescribed medication.

4. Reduce stressful events

5. Do not blame or try to help by suggesting that the person “try harder”.

6. Try to not become over involved or withdraw from the individual.

7. Positively encourage and reward any signs of improvement in behaviours and/or mood.

8. Positively reinforce the person when they have managed to use coping strategies such as self-monitoring their behaviours, adhering to proper sleep schedules, and using problem-solving skills.

DO’S

Validate and express understanding of the person’s feelings. For example:

“I can understand how you might feel that way”

 

Encourage the individual to take action to seek out professional help (this may involve a family member to find the name and contact of an appropriate referral, due to the lack of motivation in the depressed state).

Encourage the individual to learn about the disorder in order to help facilitate an understanding of what they are experiencing and the problems that appear to be commonly associated with bipolar disorder. This may further encourage the person to seek out professional help.

 

DON’TS

Tell them that they shouldn’t feel or act that way or punish them for not demonstrating control of their depressive and manic behaviours.

Tell them that they should think positively without first helping the person to learn how to acquire the necessary skills to achieve this goal.

 

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PSYCHOEDUCATION MATERIAL ON DEPRESSION

Sandra Masih and Dr. Grant Devilly

What is depression?

Depression has been recorded since antiquity, and descriptions of what are now called the mood disorders can be found in many ancient documents including The Old Testament and Homer’s Iliad.

Depression is one of the most common and serious of the mood disorders which interferes with a persons mood (the internal emotional state of a person). Today saying “I’m depressed” is as common as saying “I have a cold”. Depression can make its appearance as a normal mood, as a symptom, and as an illness. Where people experience a normal wide range of moods, there is usually a sense of control over their mood and behaviours. However, the person with a mood disorder has a clinical condition that is characterised by a loss of that sense of control and experiencing feelings of helplessness, hopelessness, and worthlessness.

The essential and distinguishing feature of depression is persistent and extensive sadness which is usually accompanied with the person suffering from a loss of interest or pleasure in all or almost all usual activities and pastimes.

Depression affects approximately 10 in one hundred males and approximately 25 in one hundred females. Depression comes in many types and shows many faces, although in all types the illness effects the day to day functioning of the person.

Depression can begin from childhood through old age, but 50 percent of all patients experience an onset between 25 and 50 years, the average age is about 40 years.

Depression can affect all aspects of a person’s life including work, leisure, relationships and future goals and plans. Furthermore, there is a great impact on the family of the person suffering from depression as the person may find it difficult to communicate feelings and to concentrate. In general the depressed person may find it very difficult to be involved and enjoy the company of others and activities, including sleeping and eating, as they did prior to the depression.

Patients may say that they feel blue, hopeless, in the dumps or worthless. For the patient, the depressed mood often has a distinct quality that differentiates it from the completely normal emotion of sadness. Patients often describe the symptom of depression as either agonising emotional pain or a complete lack of feelings. This can be sometimes seen in the person’s inability to cry.

 

WHAT ARE THE SYMPTOMS?

Depressive Episodes

A depressed mood and a loss of interest or pleasure are the key symptoms of depression. Although depression, like all other illnesses, has certain characteristic symptoms, the symptoms are not identical for each person. A diagnosis of depression is made when key symptoms are apparent.

Family and friends may notice other symptoms including:

 

– significant weight loss or weight gain

Many depressed persons have decreased appetite and weight loss. Some individuals, however, have increased appetite and weight gain.

– fatigue or loss of energy nearly every day.

Almost all depressed patients (97 percent) complain about reduced energy resulting in difficulty finishing tasks. Even the smallest task appears to require substantial effort.

Depressed persons can also experience a decreased interest and performance in sexual activities.

– disturbance in sleep.

About 80% of depressed persons complain of trouble sleeping, especially early morning awakening and multiple awakenings at night, during which they ruminate about their problems. Some individuals have increased sleep.

– anxiety

Anxiety is a common symptom of depression, affecting as many as 90 percent of depressed people. There is also the experience of agitation (inability to sit still) or the slowing of responsiveness (slowed speech, thinking, and body movements).

– irritability

Often depressed persons become irritable, cranky, and frustrated easily. Depressed individuals often display persistent anger, a tendency to respond to events with angry outbursts or blaming others or an exaggerated sense of frustration over minor matters.

– difficulty concentrating and making decisions

Depressed individuals often complain of an inability to concentrate and impairments in thinking.

– recurrent thoughts of death (not just fear of dying) or suicide.

Approximately two-thirds of depressed patients contemplate suicide, and 10-15% commit suicide.

– feelings of worthlessness or excessive/inappropriate guilt.

The sense of worthlessness or guilt includes unrealistic negative evaluations of one’s worth or guilty preoccupations over past events or minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects.

Depressed persons, however, sometimes appear unaware of their depression and do not complain of a mood disturbance even though they may exhibit withdrawal from friends, family, and activities that previously interested them. Some individuals emphasise physical complaints such as bodily aches and pains rather than reporting feelings of sadness.

Symptoms of depression usually develop over days to weeks. Shortly prior to the depression a period of anxiety symptoms and minor depressive symptoms may be apparent and may last for weeks to months before the onset of a full major depression.

 

The duration of depression is variable. An untreated episode typically lasts 6 months or longer, regardless of the age of the person. In a majority of people there is complete recovery of symptoms and functioning returns to the normal state prior to the depression onset. Treated individuals usually have a complete recovery within 3 months on average, although, many recover earlier.

Family and friends may notice deterioration in areas such as:

– school and work

– relationships with others

– involvement in activities once enjoyed

– personal care and hygiene

WHAT CAUSES DEPRESSION?

The causes of depression are at present unknown and no single cause has been identified. However, a number of different factors are believed to be associated with depression onset. These are:

Biological Factors

Certain biochemical substances in the brain (i.e. neurotransmitters called the biogenic amines) are believed to be involved in this condition. It is suggested that some people may have a genetic predisposition to depression because of an imbalance in these brain chemicals. The antidepressant medications work to restore the imbalance in the brain chemicals.

Genetic Factors

A predisposition to depression is seen to run in families and is consistent with a biological cause, as well as a learned response to critical life events.

Life Events and Environmental Stress

Some clinicians believe that life events play the primary role in depression. For instance, one of the environmental stressors most associated with depression onset is the loss of a spouse. However, the triggering event can be from any cause and can also be due to a build-up of smaller events and little perceived support.

Personality Factors

To date, no single personality trait or type has been established as being uniquely predisposing to depression. All humans, of whatever personality pattern, can and do become depressed under appropriate circumstances; however, certain personality types might be at greater risk for depression.

It has been suggested that vulnerability for depression may exist with an interaction of these suggested causes rather than a single factor existing alone.

 

DEPRESSION. HOW CAN THE FAMILY HELP?

1. The family can help by being supportive and acknowledging the person’s emotions.

2. The person with depression will usually find it difficult to cope with normal activities. A demonstrated understanding of this by family and friends is advisable and support for the depressed person with encouragement to engage in “fun” activities.

3. Reduce stressful events

4. Do not blame or try to help by suggesting that the depressed person “try harder”.

5. Try to not become over-involved or withdraw from the depressed individual.

6. Positively encourage and reward any signs of improvement in behaviours and / or mood.

DO’S

Validate and express understanding of the person’s feelings. For example:

“From what you’ve been saying it sounds as though you see the future as hopeless”

 

Encourage the individual to take action to seek out professional help (this may involve a family member to find the name and contact of an appropriate referral, due to the lack of motivation in depression).

DONT’S

Tell them that they shouldn’t feel that way or punish them for not demonstrating control of their depressive behaviours and feelings.

Tell them that they should think positively without first helping the person to learn how to acquire the necessary skills to achieve this goal.

 

Challenging Behavior of Persons with Mental Health Disorders and Severe Developmental Disabilities

Wiesler and Hanson

1999 American Association on Mental Retardation

 (Information has been edited)

Depressive symptoms – a dysphoric or irritable mood and/or a markedly diminished interest or pleasure in most or almost all activities.

            May be associated with a combination of the following:

•1.      significant weight loss or gain

•2.      insomnia or hypersomnia

•3.      psychomotor agitation or retardation

•4.      fatigue or loss of energy

•5.      feelings of worthlessness or excessive guilt

•6.      diminished ability to become or remain involved in an activity requiring concentrations

•7.      recurrent thoughts of death

 

Depressive Episode: a cluster of emotional and somatic signs and symptoms comprises a depressive episode. A major depressive episode is diagnosed when the individual experiences at least 5 of the above symptoms with one of the primary features and these symptoms represent change from previous functioning – during two consecutive weeks. These symptoms are out of proportion in intensity and duration to particular stressors and thus interfere with the individuals overall functioning.

 

Depressive Disorder: the diagnosis of major depressive disorder is made whenever the criteria for one or more major depressive episodes are met in the absence of any of the following that could account for the symptoms or represent other mental disorders:

•1.      mood disorder due to a general medical condition

•2.      substance induced mood disorder

•3.      dysthymic disorder

•4.      schizoaffective disorder

•5.      mood features associated with schizophrenia

•6.      bereavement

•7.      previous manic or hypomanic episode

 

Dysthymic Disorder: this is a chronic condition characterized by a sad, depressed mood most of the day, more days than not, for at least two years ( irritable mood for a minimum 1 year duration for children and adolescents. The depressed mood is followed by at least two of the following: problems involving appetite, sleep patterns, energy level, concentration,, low self-esteem and feelings of helplessness.

 

Given the presence of a negative mood state, distinguishing factors are particular predisposing situation and the resulting type, range, intensity and duration of symptoms.

Behavioral Equivalents of Depressive Symptoms

Because the presence of severe to profound mental retardation often makes it difficult to detect these classic criteria, symptoms of depression are detected through close attention to various behavioral equivalents, which are changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences.

Depressed Mood, Irritability, Agitation:

            Rarely or never smiles

            Sad expressions

            Cries easily

            Tearful for no apparent reason

            Easily annoyed, provoked or angered

Increased difficulty in tolerating usual aggravations or disruptions in routine

            Easily provoked to disruptive outbursts

If verbal, may repeatedly express desire to return to former residential setting

 

 

Decreased Interest or Pleasure

            Usual activities are refused

            Typical events serving as reinforcers lose their effectiveness

            Social withdrawal

            Spends excessive time alone

            Minimal response to environmental stimuli

            Minimal eye contact

Rarely initiates activity or interactions

 

 

Self-Care Skills

            Toileting and grooming skills may deteriorate

In severe cases of loss of interest and withdrawal, may soil self, become incontinent, and lose interest in grooming such as bathing and changing clothes

 

Cognitive Performances

            Lowered performances in programs such as work activities

            Increased difficulty in maintaining attention to tasks, even routines

Appears confused in attempts to complete routines requiring concentration, focus and span of attention

 

Sleep Patterns

            Hypersomnia: sleep becomes a preferred activity

            Gets upset when attempts are made to awake and direct into usual activities

            Takes excessive naps during the day

            Insomnia: reduction in number of hours spent in sleep during the night

            Difficulty falling asleep

            Repeatedly awakes in middle of night

Awakes one or more hours before time to get up and then remains awake for the rest of the day

May present new or more severe behavior problems at bedtime, during the night or early hours

 

Weight / Appetite

            Increase: significant weight gain (5% of body weight over 1 month)

If free access is not available, may begin or increase frequency of food stealing and/or pica

Decrease: significant weight loss (5% body weight over 1 month)

Decreased food intake

Rejects favorite foods

Resists prompts to attend or complete meals

 

Psychomotor Retardation/Low Energy

Remains in one location with minimal motor activity for lengthy periods of time

            Passive

            Rarely initiates activity or interactions

            Spends excessive time lying or sitting

            May actively resist activities

            May present catatonic signs

            Extremely slow body movements

            Stops talking/communicating

 

Feelings of Worthlessness

In person with verbal skills, uses self-derogatory remarks – “I’m retarded”, “I’m ugly”

 

Excessive Concern for Death and Self-Harm

In person with verbal skills, excessive expression of concern over death of family or friends, funerals, or dying

In more severely impaired, suicidal ideation may take the form of increased fearfulness, clinging dependency, mimicry of a suicidal act, or drawings suggestive of death and burial

Threats or attempts to harm self

 

Nonspecific Behavioral Symptoms

Occurrence/increased occurrence and severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums out of proportion to social or environmental changes or events

            Repeated complaints of aches, pains or physical ailments

 

 

Mania

 

Manic Symptoms

            A distinct period of abnormally and persistently elevated, expansive or irritable mood.

            Related symptoms:

                        Inflated self-esteem or grandiosity

                        Decreased need for sleep

                        Increased talkativeness

                        Flights of ideas or subjective experience that thoughts are racing

                        Distractibility

                        Psychomotor agitation

Increased goal-directed activity (may be social, work, school or sexual)

Excessive involvement in pleasurable activities that have a likelihood of painful consequences

 

Manic Episode

A period of persistent and abnormally elevated, expansive or irritable mood lasting a minimum of 1 week (less if hospitalization is required)

This abnormal mood occurs in the presence of at least three of the above symptoms of mania (4 symptoms if the mood is only irritable)

The mood disturbance must be sufficiently severe to produce marked impairment in the person’s functioning

 

Hypomanic Episode

            A period as above that lasts for at least 4 days.

Must be different from the person’s usual demeanor, be clearly a change in functioning, and not due to the direct physiological effects of a substance or general medical condition

 

Mixed Episode

When symptom patterns for both a manic episode and a major depressive episode are present for at least one week

Experiences of rapidly alternating moods of sadness, irritability and euphoria along with the symptom patterns of both conditions

 

Bipolar I; Bipolar II; Rapid Cycling Bipolar Disorder; Cyclothymic Disorder – see DSM_IV for detail

 

Behavioral Equivalents of Mania

Presence of symptoms reflect changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences

 

 

Euphoric/Elated/Irritable Mood

Appears boisterous, excited; easily provoked to disruptive outbursts; periods of acute and excessive anger

 

            Inflated Self-Esteem/Grandiosity

                        Has unrealistic notions of own skills

                        Views self as peer to staff or bosses

 

            Sleep

                        Decrease in total sleep time

Behavior problems occur at night when prompted to go to and remain in bed

 

Cognitive

                        Flights of ideas

                        Racing thoughts

                        Jumps from one topic to another in a frantic manner

 

            Speech

                        Pressured speech

                        Increased rate of verbalization/babbling

                        Nonstop vocalizations/does not seem to be able to stop

 

            Attention Span/Focus

                        Distractibility

                        Unable to stay on task when other activities occur

 

            Psychomotor

                        Psychomotor agitation

                        Seems wired

                        Unable to stop an activity

 

            Interests/Pleasures

                        Excessive involvement in pleasurable activities

Masturbates excessively or at inappropriate times/locations

                        Sexually provocative

                        Excessive teasing

                        Persistently requests reinforcers

 

            Self-Care Skills

                        Loss of skills

                        May become incontinent of urine and feces during day or night

                        Decrease in daily living skills

                       

            Nonspecific Behavioral Symptom

Occurrence or increased occurrence, severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums that are out of proportion to social or environmental changes or events

                        Repeated complaints of aches, pains, or physical ailments

 

Diagnostic Protocol for Detection of Mood Disorders

            Individual clinical contact may reveal some impressions

Interviews with others who have knowledge of the person’s affect, social and problem behavior responsiveness through daily contact

Should be supplemented by direct observation of the person being assessed in selected residential, work, and related settings and conditions

Graphic display of behavioral data may be helpful

 

Structured interviews with informants, rating scales, and checklists of potential value in identification of mood disorder symptoms:

            Aberrant Behavior Checklist

            Children’s Depression Inventory

            Emotional Disorders Rating Scale for Developmental Disabilities

            Diagnostic Assessment for the Severely Handicapped

            Psycopathology Instrument for Mentally Retarded Adults

            Reiss Scale for Maladaptive Behavior

 

Integrative Psychosocial Model of Depression in People with Severe Mental Retardation : this model views the occurrence of depression as a product of both environmental events and personal vulnerability features.

            Immediate Disruptive Effects

            The process begins with stressors or life events that serve as onset instigators. For people with severe impairments, these stressors may represent a wide range of events or changes may be somewhat idiosyncratic and personal. Seemingly minor losses may have considerable meaning to a person who may also lack alternative skills in accommodating the losses.

            The antecedent life events are of significance to the extent that they disrupt substantial important and relatively automatic behavior patterns. Predictable and expected valued daily patterned behaviors are no longer possible.

           

Reduction of Positive Reinforcers

This creates a loss of meaningful reinforcers and reduction in positive affective experiences. Interactions with the environment become balanced in a negative direction. Often these people have a limited number of alternative behavior patterns that consistently provide predictable and valuable positive consequences.

 

Emotional Consequences

The disruption of patterned behaviors and the loss of valued reinforcers result in an immediate negative emotional reaction, the intensity and the pervasiveness of which is related to the importance of the loss to the person, the availability of the alternative sources of valued reinforcement and the person’s skill in obtaining these.

The aversiveness of the unpleasant event and the number of major stressors represent the best predictor of depressive onset. For people with severe impairments, limiting coping skills, a relatively impoverished motivational structure and a limited number of valued personal relationships, a hospitalization, separation from a friend or roommate, removal from a familiar environment with a structured familiar routine may represent huge stressors, especially if they are concurrent.

 

Turning Inward

Following limited or unsuccessful attempts to gain replacements for the losses or to reduce the stressors, the person begins to focus excessively on the current state of emotional distress produced by the change. This excessive self-focus on the internal distress interferes with alternative attempts to gain environmentally based experiences that will replace the loss of the reinforcers. This results in intensification of the distressing dysphoric affective reactions; increasing withdrawal from social and program participation; a downward cycle is perpetuated. The limited cognitive and associated internal speech of severely impaired people become unduly influenced by the internal state of distress.

 

Appearance of Multiple Depressive Symptoms

The self-focus and dysphoria reduce the person’s social competency and render the person less attractive to others, further perpetuating the social isolation and dysphoria. A state of irritability or exaggerated need for emotional support evolves. Excessively dysphoric or irritable mood correlates with regression in basic self-care and bodily functions.

 

Vulnerability Influences

Personal characteristic may serve as a significant vulnerability influence. Personal histories that include experiences with rejection, restricted opportunities, segregation, inadequate social supports, victimizations, and infantilization are not uncommon in this population. Such personal features as learned helplessness, limited behavioral repertoires, limited skills of coping with negative emotional stress and an aberrant motivational structure may reflect the effects of the damaging histories. Additionally, current socioenvironmental factors such as a lack of or inconsistent social supports and limited access to a range of reinforcing events and associated emotionally enhancing experiences are vulnerability influences. All of this can contribute to intense emotional consequences when individuals lack the means of gaining valuable alternatives.

Learned helplessness: a helpless and inactive state produced whenever a person is unable to escape from or avoid punishing conditions. The experiences of many individuals with severe impairments especially of those with lengthy placement in institutional settings, are consistent with the development of a general characteristic of learned helplessness.

 

Social and Coping Skill Deficits

Limitations in the range and complexity of interpersonal and pother socially related skills such as those involving leisure and work as well as the skills of effectively coping with unfamiliar and emotionally laden incidents are inherent in the definition of severe and profound mental retardation. Limited social skills, excessive attachment and dependency on a small number of significant others, activities and objects, and limited leisure and work skills that restrict opportunities for obtaining significant sources of positive feedback all serve as significant psychosocial vulnerabilities.

 

Limited Range of Affective Attachments

Affective attachments are, in general, limited and with the continued loss of these attachments, people are a high risk for depressive responding upon loss of the objects of attachments. The person has limited replacement alternatives and thus, is without sources of valued social support. Observations suggest that some people with developmental disabilities may become emotionally blunted after a series of losses involving valued peers or caregivers and excessively cautious in developing further attachments.

 

Emotional lability and generalized irritability

Emotional lability related either to a pathological psychological history or to neurological and neurochemical abnormalities may represent a further vulnerability for development of depression. Without skills to cope and calm, the person would be increasingly likely to be influenced in daily activities by the internal distress produced by losses.

 

Additional motivational limitations

The life experiences of the people with severe and profound cognitive impairments frequently result in a highly constricted motivational structure. Due to limited exposure, the person does not learn to value a variety of activities and objects. The person is prone to become very dependent upon a limited number of reinforcers and may appear to be insatiable relative to them. When these are lost or greatly restricted, the person becomes vulnerable to depressive responding due to the lack of responsiveness to alternative sources of reinforcement.

           

 

Implications for treatment

            Treatment for depression from a psychosocial perspective entails two major objectives. Therapeutic efforts initially address the current depressive symptoms with the objective of reducing or eliminating these as a means of returning the person to the level of functioning present prior to the current episode. The second objective involves the therapeutic efforts to reduce the psychosocial vulnerabilities that place the person at continued risk for future development of oppressive symptoms. Drug treatment may alleviate depressive symptoms but does not change the underlying pathophysiology or psychological or environmental vulnerabilities responsible for the disorder. As psychosocial therapies are designed to teach new coping strategies and to change other critical personal and socioenvironmental vulnerability features, they offer unique opportunities for increasing a person’s immunities that should mitigate the impact of the future psychological losses or disappointments.

            Treatment strategies for meeting the initial therapy objective of regaining the predepression functional status:

•1.      Whenever possible, prepare the person for major change or loss when these can be anticipated. Develop substitute or alternative personal relationships and routines that will be available on occurrence of the loss or change. If such preparation is not possible, or if ineffective, intervene as early as possible in the depressogenic process. Identify the losses that the person has experienced, the resulting behavioral routines that became nonfunctional and the range and types of interpersonal and activity reinforcing experiences that are lost. Develop alternatives to these valued routines.

•2.      Provide frequent and consistent emotional support during the grieving and adaptation period. Remove excess demands and minimize additional aversive experiences. Recall, however, that depressive behaviors attract positive social reinforcement (sympathy, assurance, physical presence) and may be strengthened if the focus of the depressive behaviors is prolonged. Minimize attention to dependency and helplessness.

•3.      Concurrently, expose the person to people, activities, and environments that offer suitable replacements. Provide a variety of social stimulation offered by a number of favored caregivers and peers. Expose to social models who predominately demonstrate positive affective behaviors. Identify activities (eating out, dancing, bowling) and objects (pictures, jewelry, miniature cars) that are valuable to the person and make these available. Use the necessary verbal and physical assistance needed to insure that the person does not withdraw into unresponsiveness.

 

Following resolution of a depressive episode, the range of personal and socioenvironmental vulnerabilities present with any specific person would become the focus of longer term therapeutic endeavors. The specific approaches selected would be determined by the particular constellation of psychosocial risk factors present for that individual.

 

Affective Disorders and Disruptive Behavioral Symptoms

            Noted an increase in:

            Aggression

            Self-injury

            Self-injury

            Property damage

            Pica

            Difficulties of:

            Mood and irritability

            Appetite changes

            Sleep disturbances

            Following a diagnosis of depression and successful pharmacological treatment, pica became a minimal problem.

           

A diagnostic case formulation model that accounts for the occurrence as well as the persistent recurrence of nonspecific behavioral symptoms should thus consider:

•1.      The complete stimulus complex that precedes and serves to instigate these symptoms

•2.      the persons biopsychosocial vulnerabilities or risk factors for engaging in these nonspecific symptoms when confronted with this instigating stimulus complex as well as,

•3.      those proximate consequences that follow behavioral occurrences and may contribute to their functionality and strength

 

The instigating stimulus complex may include the arousing/activating features of various components of a mood disorder. In these instances, the objective of a comprehensive diagnostic assessment is to “see past” the mood disorder and to ascertain the specific role served by the features of this condition in contributing to the occurrence, severity, fluctuation, and chronic recurrence of the behavioral symptoms. In this manner, informed speculation can be made about the extent of the reduction in critical features of the nonspecific symptom to be expected following effective treatment of the mood disorder.  

           

Multimodal Contextual Behavioral Analytic Model

            A multimodal(bio-, psycho-, and socioenvironmental modalities of influences) contextual ( contexts of instigating, vulnerability, and maintaining conditions) behavior analytic model is offered  as a representation of this broader diagnostic-treatment case formulation process. (Holistic assessment).

            Mood disorder features as instigating conditions – preceding events that, when present, influence the occurrence of nonspecific behavioral symptoms. These instigating conditions may serve either:

•1.      A sufficient role

•2.      or a contributing role

in influencing occurrence of these symptoms.

            The sufficient role may sometimes represent the internal psychological condition such as a profoundly mentally retarded person without verbal skills communicating his needs by autoaggressive ear slapping associated with a dysphoric mood. The internal painful distress serves as a sufficient instigating stimulus condition for the auto aggression independent of any additional provocation from social or physical sources.

            Whenever a persons nonspecific behavioral symptoms occur only in the presence of a critical level of discomfort produced by a dysphoric mood, a state dependent relationship is present. In this instance, effective treatment of the underlying stimulus condition (eg dysphoric mood) should remove or eliminate the instigating aversive internal state and the associated behavioral symptoms.

            In other cases, a person’s behavioral symptoms, such as aggression or self-injury, may also be instigated by antecedent stimulus conditions unrelated to features of the person’s depression. In this instance, as the behavioral symptoms may appear in the absence of the mood disorder, a state-dependent relationship would not be present; interventions addressing both sets of instigating conditions would be necessary.

 

Contributing instigating events reflecting mood disorders.

            In individuals with mental retardation diagnosed with rapid cycling disorder, occurrence of the behavioral symptoms was dependent on the psychological state associated with the psychiatric disorder plus occurrence of various staff prompts, even though different external prompts served as the instigating events during the different phases ( depression or mania) of the disorder. During the depressive episodes, the staff prompts intended to get the person involved in an activity, produced the problem behavior. During manic episodes, prompts to slow the person down or focus attention produced the behavioral symptom.

            Those prompts, even though necessary conditions, were not sufficient in the absence of the mood state to instigate the nonspecific behavior. Both the staff prompts and the mood state formed the stimulus complex that represented the necessary precursors for the nonspecific behavior symptoms. Neither was sufficient, independent of the other, to produce the behavioral symptoms.

            In this state dependent role, interventions resulting in removal of either of the contributing and necessary components of the stimulus complex (mood states or the prompt) would effectively manage the occurrence of the nonspecific behavior problem. The obvious focus of intervention, nonetheless, would be that of eliminating the aberrant mood states that rendered the staff prompts as aversive conditions to be removed or avoided through use of aggression or autoaggression. Following successful medication treatment of the bipolar disorder and removal of the associated instigating stimulus conditions (ie aberrant mood states), reduction or elimination of the nonspecific behavioral symptom would coincide with the concurrent reduction of the aversiveness  of the staff reduction.

            In state exacerbated relationship, the behavioral symptoms predate the mood disorder and increase in frequency and/or severity on occasion of the disorder. Instigating features of the mood disorder combine with other sources of provocation to increase the frequency and/or intensity of the behavioral symptoms but in isolation are neither necessary nor sufficient to produce these. In this instance, effective treatment of the mood disorder would result in reduction of the nonspecific behavioral symptoms related to the instigating features of the disorder.

            Mood disorder features serve various roles as instigating conditions for nonspecific behavioral symptoms. On some occasions, various aberrant stimulus components resulting from the disorder may serve as contributing instigating conditions. These conditions may occasionally serve as necessary conditions for the occurrence of the behavioral symptoms.

Treatment of a person’s mood disorder may indeed be effective in reducing or eliminating the primary symptoms of the disorder but be ineffective in reducing the person’s nonspecific behavioral symptoms unless features of these mood disorders do contribute to the stimulus complex producing these behaviors.

 

Vulnerability Influences

            Some personal; features associated with mod disorder may put a person at risk for engaging in nonspecific behavioral symptoms due to stress:

•1.      The fluctuating intensity of mood states

•2.      the mood lability

•3.      increased likelihood of physical fatigue associated with sleep disturbances

•4.      energy loss associated with eating difficulties

•5.      and the aberrant activity levels

These states may either produce nonspecific behavioral symptoms or may increased the likelihood of these behaviors when the person is exposed to other sources of provocation. Add to that the deficits of coping skills, and an increase is likely in the occurrence of nonspecific symptoms.

 

Mood Influences on Functionality of Nonspecific Symptoms

            Occurrence of nonspecific behavioral symptoms may result in changes in the internal affective states associated with a mood disorder. These changes may contribute to the strength and functionality of the behavioral symptoms. For instance, responding aggressively may remove a staff directive to attend a scheduled training program rendered aversive by a dysphoric mood state. As a result, aggressive responding is strengthened. Self-injurious face slapping may become functional as it results in frequent personal attention in a person who becomes excessively emotionally needy during periods of sadness. In these instances, the nonspecific behavioral symptoms become more likely under similar instigating conditions as these result in consequences valuable to the person.

 

Facts and Fiction About Behavior and MR/DD

Myth: Behavior always has functional significance and is under the control of the affected individual.

Premise: Behavior is an adaptive response to an external or internal stimulus.

Reality: Some behavior is involuntary and nonadaptive (eg, tics, and vocalizations of Tourette’s disorder)

Treatment implications: involuntary behavior may not respond to psychological interventions.

Myth: If a behavior has functional significance, it is unlikely to be related to a psychiatric disorder.

Premise: Determining the “meaning of the behavior” means that it can be explained in behavioral terms.

Reality: Behavior may represent an adaptive response to stress associated with a psychiatric disorder. (The onset of the illness may reproduce state-dependent behavior or result in an increase in state exacerbated behavior.

Treatment Implications: State-dependent and state-exacerbated behavior should be managed with treatment directed toward the underlying psychiatric disorder.

           

Myth: A person with severe or profound disabilities is too impaired to develop classic psychiatric disorders.

Premise: Because impairments in communication and functional skills preclude obtaining information about psychiatric symptoms (eg, suicidal ideation), people with severe impairments cannot manifest psychiatric disorders such as major depression.

Reality: DSM IV diagnostic criteria represent only approximations of syndromes, many of which have biochemical underpinnings. Criteria are based on the assumption that the diagnostically relevant behaviors and emotional experiences are highly associated.

Treatment implications: All patients, irrespective of the severity of their disabilities, who are treated with psychotropic drug therapy should have a DSM IV diagnostic formulation.

 

Myth: Bizarre behaviors, such as talking to yourself out loud, fantasy play or talking to an imaginary friend, represent manifestations of psychosis.

Premise: Bizarre behaviors indicate the presence of delusions or hallucinations.

Reality: Talking to yourself out loud, fantasy play and imaginary friends are best considered to be normal developmental behaviors that have persisted.

Treatment implications: These behaviors do not respond to antipsychotic drug therapy.

                       

Myth: Drug therapy is a restrictive form of behavioral control. All regimens must, therefore, include a behavior plan and a timetable for discontinuing treatment.

            Premise: Drug therapy directly affects behavior.

Reality: Behavior such as self-injury and aggression are too nonspecific to be considered as direct targets for drug therapy.

Treatment implications: The appropriate targets for drug therapy are the changes in neurophysiological function that mediate behavior associated with psychiatric disorders and central nervous system dysfunction.

 

 

            The traditional view that all behavior is functionally defined is limiting. The traditional view was that people with MR/DD displayed maladaptive behavior because they lived in deprived environments and that the remedy to this situation was to provide an enriched lifestyle, value each person as an individual and enhance self-esteem. If problems persisted, a behavioral program would help retrain the person to a more adaptive behavior pattern. The belief was that these interventions would eliminate all the challenging behaviors; clinically, however, this is not always the case.

            The provision of psychosocial treatment implies that some functional purpose accounts for its etiology. For example, the assumption is that if a person is provided with more alternatives to communicate his needs, to respond in different ways, and to have more meaningful daily life experiences, he will not engage in challenging behaviors. This is true for some people (with MR/DD, or without); but for many it is not true. Manic overactivity, for example, is not a functional response to the environment, it is totally driven by biological neurochemical structures and pathways. In a manic state, individuals need little sleep. Once awakened, and feeling uncomfortable, the person in the manic state may begin to roam around the house, which may attract the attention of housemates or staff. In this situation, misguided caregivers have assumed that such behavior is attention-getting and that it will respond to a behavior program.

            The reality is that some behavior is involuntary. It is not under the control of the individual and may not respond to social consequences. Behavioral symptoms may be managed, but it is not the same as treating the underlying biological condition. Psychosocial and behavioral interventions may serve as containment that keeps the person safe, but only while the programmatic restrictions are in place. In many instances, pharmacological intervention may be the treatment of choice and may be the active and necessary component for healthy change.

 

            A dysfunctional behavior may have functional significance and it may be an adaptive response at the same level. The person with MR/DD may be able to moderate either internal or external stress in the case of a psychiatric disorder by performing a dysfunctional behavior. For example, a person suffering from a major depressive episode may avoid social contact because of the discomfort and negative self-thoughts generated by socialization. The social avoidance behavior serves to reduce the discomfort. This adaptive-maladaptive response has a strong functional relationship to the environment, but it is associated with major depression. Recommended treatment usually consists of cognitive-behavioral psychotherapy in concert with anti-depressant medication.

            If the target behavior is a manifestation of a psychiatric illness, then the active treatment should be directed to the underlying psychiatric illness, not just the behavioral manifestations. The treatment of first choice for a drug responsive psychiatric disorder is pharmacotherapy. Sometimes a disservice is performed by insisting that the behavior therapy is the active treatment and that the pharmacotherapy is just a containment measure necessary until the active treatment takes effect. In cases of severe depression, the person will generally be unable to initiate any self-correcting behavioral or other therapeutic measures. Once pharmacotherapy has lessened the physical symptoms associated with depression, the person will be more able to address difficulties in life and change any cognitive or behavioral habits that contribute to the depression.

            If service providers are not fully trained in mental health, consultations may be misguided. If a person with MR/DD has become irritable, disruptive, and aggressive, a behavioral consultation may be sought. During the assessment, it may become apparent that the individual reacts negatively with aggression in response to task demands. Rather than jump immediately to a purely behavioral plan, a more comprehensive assessment would ask about sleep patterns, eating patterns and general mood change to assess for depression or mania. Physical symptoms could be present suggesting a medical disorder. Physical and psychiatric disorders need to be fully explored.

 

            Cognitive limitations do not preclude psychiatric diagnosis. The problem with diagnosing criteria for mental illness is that it is based on self-reported information from people with normal intelligence. This does not imply the disorder is a function of intelligence, but the person who is non-verbal with MR/DD cannot describe negative feelings or will not express them in the typical manner.

            Research has shown that self-injury is associated with depressive disorders in people with MR/DD. Self-injury, assaultive behavior and tantrums were more prominent in people with severe developmental disabilities. This prominence suggests that the greater the intellectual disability, the more undifferentiated are responses to life, perhaps because of a limited repertoire of responding.

            Psychiatric disorders can be diagnosed in people with severe or profound disabilities, but they may not display the full syndrome – meet all the necessary criteria – because many of the criteria require the ability to verbalize and self-report symptoms. Partial criteria may be met and a diagnosis given. A person should not receive psychoactive medications without a DSM IV formulation Axis I – IV, even if they are severely disabled.

 

Bizarre behavior and psychosis

            Developmental delay, limited cognitive organization, stress, and prior traumatic experiences can result in behaviors that are regularly misdiagnosed as psychotic. Behavior must be considered in a neurodevelopmental perspective prior to being diagnosed as psychotic and other possible precipitating factors must be examined.  Considerations for: how organized the person’s behavior appears given latitude for the person’s developmental disabilities.

            In stressful situations, people with MR/DD often become overwhelmed and suffer cognitive deterioration. A similar situation called pseudodementia, is well known in the geriatric psychiatry. Memory problems may be seen, as well as apathy and loss of hygiene or adaptive daily living skills. In these cases, an elderly person suffering from a major depressive episode shows dramatic deterioration and may frequently be diagnosed with dementia, thought to occur because of neurobiological changes in the aging brain. People with MR/DD suffer the same cognitive disintegration under stress or when suffering from a mental illness, but mental health clinicians are not all as aware of this situation, frequently misdiagnosing psychotic conditions.

            From a developmental viewpoint, talking to oneself, having an imaginary friend, fantasy play and to some extent, hallucinations are not necessarily psychotic, but should be considered within the context of the person’s developmental level and present quality of life. Based on past history, a person may be having flashbacks to a former traumatic situation. Post traumatic stress may be revisited under extreme stress.

 

Behavioral Therapy and Pharmacotherapy

            For some, pharmacotherapy is seen as a restrictive form of treatment and that there must be a behavioral plan and a timetable for discontinuing the medication. Pharmacotherapy is therapeutic and may be the first line of treatment for some mental illnesses. For major depression, manic states, and schizophrenia, pharmacotherapy must be offered and encouraged as the first treatment. For people with MR/DD, problematic behavior may be secondary to the psychiatric disorder. If this is the case, the treatment of the psychiatric disorder is the primary consideration while the behavior program focuses primarily on the containment.

            For people of normal intelligence, no timetable to end medication is mandated. They can voice there opinions on options to continue or not, on side effects. If the person is tapered off from medications and begins to feel depressed again, they can tell the physician. Most people with MR/DD cannot do this and must wait until their symptoms are so difficult that they have serious decompensation. In the meantime, they may have to endure treatment aimed at making their behavior more adaptive. Such an approach is a form of disability discrimination.

            Because of the advances in biological psychiatry and neurobiology, it is now understood that mental illness is strongly influenced by brain neurochemistry. Many and perhaps the vast majority of people with MR/DD may have neurobiological brain abnormalities as the cause of their disability, either due to prenatal or perinatal difficulties, the effects of toxins, illness, accidents or genetic factors. Therefore, it is more likely that these abnormalities would contribute to an increased incidence of mental illness.

            Because people with MR/DD have received inadequate general habilitative care in this country until recent years, advocates have erroneously focused on pharmacotherapy as a treatment to be avoided. Today, pharmacotherapy is among the most effective treatments available for mental illness and it should be available for all individuals with intellectual disabilities.

 

Psychopharmacology for People With Profound and Severe Mental retardation and Mental Disorders

            All classes of psychotropic medications have been shown to be useful in treating psychiatric disorders in clients with profound and severe mental retardation, but drug response tends to be more unpredictable in this population than in the general population.

            Psychotropic medication classes include antidepressants, mood stabilizers, antipsychotics, anxiolytics, stimulants, and others ( eg, opiate antagonists and antihypertensives). Antiepileptic medications may also have pronounced behavioral effects.

            Because diagnosis is difficult, selection of psychotropic drug treatment in clients with profound and severe mental retardation is complicated. Generally, diagnosis is based on target behaviors and symptoms, which are interrelated and guide treatment toward reasonable drug choices. Defining the meaning of the target behavior is challenging. If the client is agitated, does this stem from depression, agitated mania, agitation because of sleep disorder or psychosis, or perhaps an anxiety disorder? Drug trials are utilized because of this unclear origin of symptoms. If a drug trial is effective, it often assists in clarifying the diagnosis.

            Drug history information is extremely important in developing medication trials because it can provide information that increases the possibility of success. Every effort should be made to acquire information relating to previous effective and ineffective treatments, along with the adverse effects that have occurred. Repeating ineffective drug trials needs to be avoided. In some cases, adverse effects can be minimized by using newer drugs with fewer side effects.

            Due to some amount of genetic linkage, family history of mental disorders may provide beneficial information. For example, the diagnostic history of family members treated effectively for mood disorders or schizophrenia can provide insight into drug trial development for the client.

            Target behaviors are identified and prioritized, baseline behavior data are collected and the client is treated symptomatically. Behaviorally defined target behaviors and qualified severity levels are extremely useful for assessing treatments. Drugs that can treat an array of symptoms are likely to be primary choices. The goals of pharmacological treatment are:

•1.      keep the drug treatment as simple as possible

•2.      provide the client with the greatest chance of success early in therapy

•3.      use the safest drug available to avoid side effects.

 

Initiating Drug Treatment

            Psychotropic drugs should be initiated at low doses and slowly titrated to avoid side effects. Clients with profound and severe mental retardation are frequently found to be especially sensitive to the effects of medications. Toxicity may occur at the typical dosage range used for psychiatric clients without cognitive disabilities. Additionally, drug response can be observed at lower than usual doses. If the drug is well tolerated, the drug trial may last 1 to 6 months or longer, depending on the specific drug. This period allows for an evaluation of the drug response based on the empirical data on index behaviors.

 

Side Effects Versus Disorders

            Once a drug is initiated, it is often difficult or impossible to determine whether a client is having side effects from the medication. Clients with profound or severe retardation are not able to communicate information directly about the side effect discomfort. Staff need to be aware of the common side effects of the psychotropic medication and consider how these might affect behaviors. Regular and frequent monitoring of drug specific effects is very important in this population. Baseline laboratory values and vital signs before and after the initiation of some medications are also helpful.

            Side effects may manifest as increases in target behaviors. This may occur with antipsychotic drugs that cause akathisia ( a subjective feeling of restlessness). In a client who otherwise has anxious symptoms, or becomes easily agitated, akathisia would likely cause increased rates of target behaviors. The selective seratonin reuptake inhibitors like fluoxetine (Prozac), can cause some nervousness or agitation, but this is more often observed at higher doses as can buspirone (Buspar), an anxiolytic. A client with mood symptoms and target behaviors of screaming and crying may display more if experiencing a headache as a medication side effect. Side effects may cause a person with self-injurious biting to begin banging his head because the medication is causing headaches.

            Side effects of medications can also result in decreased behaviors. Sedation and fatigue are effects of many psychotropic drugs, including antipsychotics, antidepressants, mood stabilizers, anxiolytics and antihypertensives (eg beta blockers). The resultant chemical restraint from sedation is not an acceptable outcome of drug treatment.

            When mild side effects occur, tolerance of them can develop over time. Common side effects like nausea, sedation, agitation and blood pressure changes often subside over time. In some cases, the doses can be decreased to lessen the adverse effect or the medication may need to be discontinued. If a drug is effective, but the side effects are a concern, another drug in the same class may be substituted.

 

Psychotropic drug Classes and Specific Drugs

            Drugs may be used in combinations in cases of comorbidity or as augmentation treatment. It is important to remember that psychotropic medications have the potential to interact with one another, with nonpsychotropic drugs, and both prescription and nonprescription drugs. When a drug interaction is significant, it may result in treatment failure or toxic effects.

 

Antidepressants

            Antidepressant medications include selective serotonin reuptake inhibitors (SSRI’s), tricyclic antidepressants (TCS’s), monoamine oxidase inhibitors (MAO’s), and other miscellaneous agents. Antidepressants can be useful in treating depression, anxiety, panic, obsessive-compulsive disorders, eating disorders and sleep disturbances. TCA’s and MAO’s are not use as first line treatment due to their  many side effects and interaction with foods and because they require more monitoring than the newer antidepressants.

 

SSRI’s

            Selective serotonin reuptake inhibitor antidepressants include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). In clients with profound and severe mental retardation, these medications are considered first line treatment for depressive symptoms. Agitation, compulsiveness, impulsiveness, anxiousness, aggression, self-injury, panic symptoms, changes in appetite and sleep problems may all suggest the need for an SSRI trial. Fluoxetine (Prozac) has been shown to be effective in reducing symptoms of autism.  Some of the more common side effects of SSRI’s are headache, nausea, nervousness, or sedaton, diarrhea or constipation and sexual dysfunction. If one SSRI trial fails or the side effects are intolerable, a different SSRI may succeed.

 

Miscellaneous Antidepressants

            Trazodone (Desyrel) and nefazodone (Serzone) are antidepressants that can have concomitant antianxiety effects. For this reason, these drugs may be beneficial in clients with agitated behaviors.   Both of these medications can also be useful for treating sleep problems. In fact, trazodone sometimes cannot be tolerated at the doses needed to treat depression due to the sedative effect. Nefazodone may be less sedating than trazodone and can actually improve sleep cycles and, thus, the quality of sleep. Notable side effects are daytime sedation, dizziness, orthostatic hypotension and alterations in heart rate.

            Mirtazpine (Remeron) is a relatively new antidepressant that may have antianxiety effects. It is useful for treating clients with depressive disorder who exhibit agitation, diminished appetite with weight loss, or have sleep disturbances. Sedation , dizziness, increased appetite and weight gain are the more common side effects of mirtazapine. It has minimal anticholinergic effects (eg dry mouth, blurred vision, urinary retention and constipation).

            Venlafaxine (Effexor) may be reserved for difficult to treat depressed clients or those with concomitant anxiety. Blood pressure should be monitored regularly for possible sustained increases especially in high doses or if the client has a history of hypertension. Common side effects are nausea, nervousness, somnolence, insomnia, dizziness, anorexia and sexual dysfunction.

            Bupropion (Wellbutrin) is available is available in an extended form with fewer side effects. It may increase the risk for seizures, so it may be contraindicated for use with clients who have known low seizure thresholds. Clients with profound and severe mental retardation have a higher incidence of seizures, so Wellbutrin would not be a first line option in their treatment.

            Antidepressant treatment, if tolerated by the client, should continue for 6-8 weeks after a therapeutic dose is reached. This provides sufficient time to collect data on target behaviors and determine if the medication is beneficial. Minimum effective doses do not apply to antidepressants, in that the maintenance dose is the initial effective dose.  If others perceive that the effect of an antidepressant has ameliorated over time, options include increasing the dose, switching to a different antidepressant agent or augmenting with buspirone.

 

Mood Stabilizers

            Current established mood stabilizers include lithium, valproate (eg valproic acid [Depakene] and divaproex sodium [Depakote]) and carbamazepine (Tegretol). Adjunct drug treatment might include an antipsychotic, a benzodiazepine or an antidepressant, depending on the symptoms. If traditional mood stabilizers are not well tolerated, second line mood stabilizing agents including gabapentin (Neurontin), calcium blockers (nerapamil) or trazadone may be used. Mood stabilizers can be very useful for treating bipolar disorder in individuals with profound and severe mental retardation. Treatable target behaviors may include agitation, irritability, aggression, decreased sleep, decreased appetite, self-injury, increased vocalizations, increased sexual displays, and decreased attention span. Mood swings are most easily recognized by graphing prevalent target behaviors on a chart over time. In appropriately aged females, if mood symptoms cycle monthly and are associated with their menses, the pharmacotherapy may be quite different for treating this premenstrual dysphoric disorder.

            Even though lithium has been the classic mood stabilizer since the ‘60’s, valproate is now considered a first line therapy and often produces fewer side effects than either lithium or carbamazeoine. It has a wider therapeutic range, less risk of toxicity and requires less laboratory monitoring. It can also be used to simultaneously treat seizure disorders (as can carbamazepine, whereas, lithium can lower the threshold. Additionally, carbamazine can be very difficult to use because of the multitude of drug interactions involved with the individuals on concomitant drug therapies.Clients with rapid cycling or mixed state mood disorders may be more likely to benefit from valproate.

            Acute manic episodes can also be effectively treated with valproate. Manic episodea with psychotic features can be treated with antipsychotics. Benzodiazepines are used to treat the insomnia and to decrease anxious symptoms.

            Treatment of bipolar disorder requires maintenance doses of mood stabilizers and sometimes requires mood stabilizers in combination to prevent recurring acute episodes. It is noteworthy that a minimum effective dose does not apply to mood stabilizers. Dosages are prescribed according to blood levels maintained within a therapeutic range.

 

Antianxiety Agents

            Antianxiety drugs include buspirone (Buspar), some of the antidepressants and benzodiazepines (eg, lorazepam [Ativan], clonazepam [Klonopin]). Treatable conditions in individuals with profound and severe mental retardation may be behaviorally defined nervous or anxious behaviors, panic-type behaviors, aggression or self-injurious behaviors.

            Benzodiazepines should be used only in the short term as they can be paradoxical disinhibitory effect on behavior, resulting in increased agitation and aggression. They can also cause considerable sedation and impair cognitive abilities; also, if used regularly, tolerance can occur where increasing doses may be needed. However, they can be effective in managing episodic agitation or sleep problems on an intermittent basis.

            Buspirone is a good first line treatment for anxiety symptoms, especially for generalized anxiety disorder. Agitation, aggression, self-injury, anxiousness or nervousness, hyperactivity and impulsiveness or compulsiveness are symptoms that might respond to buspirone treatment.

            SSRI’s can be effective for treating various anxiety disorders. Paroxetine and fluvoxamine are more sedating and less stimulating than fluoxetine, sertraline and citalopram. Citalopram (Celexa) is the most selective SSRI and may be associated with fewer side effects and drug interactions. SSRI’s have proven efficacy in anxiety associated with depression, panic disorder and obsessive compulsive disorder. Encouraging findings have been reported in social phobia, PTSD, and PDD.

 

Antipsychotics

            At this time, the atypical antipsychotics – clozapine (Clozaril), risperidone (Risperdal), olanzaoine (Zyprexa) and quetiapine (Seroquel) – are considered first line treatment as antipsychotic agents, except clozapine  because of the weekly blood testing. Chlorpromazine[Thorazine], thioridazine [Mellaril], haloperidol [Haldol]  are the older typical antipsychotics and are used much less. The first line antipsychotics are more effective, particularly in terms of treating the negative symptoms of schizophrenia (blunted affect, apathy, social and emotional withdrawal and anhedonia). They have less risk for extrapyramidal  symptoms (akathasia, dystonias, tremors, and cogwheel rigidity). The incidence of extrapyramidal effects does increase with increased dosages.

            It can be difficult at times to assess whether psychotic symptoms exist in a person with profound or severe mental retardation. When an antipsychotic is administered, orthostatic hypotension and sedation can be early side effects, but these generally subside over time. Risperidone is more likely than olanzapine or quetiapine to cause increases in prolactin levels and amenorrhea in females. Other reasons for increased levels of prolactin should be ruled out as there may be medical causes.

            Some individuals, especially older clients tend to be very sensitive to therapeutic response and side effects. In individuals with severe behavioral problem, major medication changes may involve risk of increased self-injury or aggression to others.

            Other medications used in combination with antipsychotics to treat side effects may be antcholinerics (eg, benztropine[Cogentin], diphenhydramine [Benadryl], trihexiphenidyl [Artane] for extrapyramidal effects or a beta-adrenergic blocker (eg, propranolol [Inderal]) for akathisia or restlessness. Benzodiazepines (eg, lorazepam [Ativan]) can be used in combination with antipsychotics for treating comorbid sleep or anxiety disorders or an antidepressant or mood stabilizer can also be used for affective disorders.

 

Adverse Behavioral Effects of Antiepileptic Medications in People with Developmental Disabilities

            The association of epilepsy with cognitive impairment is significant. When cerebral palsy and mental retardation coexist, seizure risk is higher. Both are indicators of neurologic abnormalities. Adding antiepileptic drugs to the equation, it becomes more complicated. The idiosyncratic reactions are of the greatest concerns because they are potentially life threatening. The additive effects of combination therapy can result in toxicity for almost half of the patients receiving three concurrent antiepileptic drugs.

            The inherent side effects include phenomena such as lethargy, decreased attention span, sleep pattern changes, impotency, and leukopenia. These side effects can produce their own behavioral consequences. Similarly, the dose-related adverse affects of sedation, mental dullness, ataxia, diplopia, and headache can produce behavioral effects. The ability of the cognitively impaired, mentally ill patient to articulate these concerns may be severely limited. A change in behavior may be the only way the patients have to express their concerns.

 

Phenytoin

            Phenytoin (Dilantin) appears essentially devoid of any significant general behavioral impact. However, in the case of people with mental retardation, phenytoin can cause significant dose-related cognitive impairment, as well as ataxia, poor coordination and dyskinesia that can consist principally of choreiform disturbances. Non-dose related effects can include significant cosmetic affects(darkening or increasing of body hair, coarsening of facial features, worsening of acne or gingival hyperplasia), which may have significant behavioral consequences. With chronic use, a consideration can be osteopenia (thinning of bones) as well as folic acid deficiency.

            Significant drug interactions can also occur because of pheytoin’s significant protein binding. Drug interactions with psychotropic medications, antibiotics, or other antiepileptic drugs can result insignificant change in the level due to this saturation kinetic interaction, resulting in toxicity that may manifest only as a behavior change.

 

Carbamazepine

            Carbamazepine (Tegretol) has resulted in many reports of favorable change. The most commonly reported changes are decreased anxiety, depression, and aggression with increased cooperation and generally improved behavior. Side effects include, double vision, cognitive viscosity, lethargy and movement disorders. Non-dose related side effects include hyponatremia, which when pronounced, can cause an exacerbation of seizures or behavioral consequences of its own. A few isolate reports of discontinuation as precipitating mania.

 

Valproic Acid

            Valproic acid (Depakene) has demonstrated a positive behavioral effect.. Side effects include gastrointestinal upset, tremor, elevation of ammonia, some somnolence, cognitive viscosity and thrombocytopenia. Non-dose related effects include weight gain, nausea and a change in hair texture loss. From a behavioral aspect, the most pertinent concern is the confusional state that can progress to coma or stupor. There has been evidence of brain atrophy which reversed when medication was discontinued.

 

Phenobarbitol

            The barbiturates are the drugs most clearly associated with negative behavioral changes. Several studies have demonstrated increased depression, irritability, unhappiness, argumentativeness, stubbornness, or aggression. The barbiturates have also been associated with the most negative cognitive effects among the antiepileptic drugs. Other side effects of barbiturates in cognitively impaired people are self-injury, disruptive vocalizations and temper tantrums. The possibility exists of allergic dermatitis, Stevens Johnson syndrome, hepatic failure and dupytrens contractures.

 

Gabapentin

            Gabapentin (Neurontin) ia s new antiepileptic medication that is designed as a gammaaminobutyric mimetic. Its non dose related side effects include somnambulence, cognitive impairment hyperactivity and aggression which makes it necessary to use it cautiously with cognitively impaired people especially with a history of previous irritable or aggressive behavior.

 

Felbamate

            Felbamate (Felbatol) was distributed in 1993 and used widely. Then it was discovered that this medicine has an irreversible idiosyncratic side effect, aplastic anemia. There is also possible behavioral exacerbations in patients with cognitive impairment and a past history of medicine induced behavioral exacerbations.

            Other newly developed antiepileptic drugs include lamotrigine (Lamictal), topramate (Topamax), tiagabine (Gabitril).

            Every anticonvulsnat medicine has behavioral consequences. The balance is between seizure control and side effects so choosing the appropriate medicine for the seizure type and epilepsy syndrome. It is prudent to avoid the barbiturates in the cognitively impaired, behaviorally challenged. Other medicines should each be considered as appropriate given their possible behavioral side effects.

 

Psychotropic Medications and Destructive Behavior

            The purpose of administering psychotropic treatments is to improve a person’s functioning by modifying the way that he typically responds to naturally occurring events in the environment. By doing so, challenging behavior is made unnecessary and improbable.

 

Functional Interpretations of Destructive Behavior

            A functional approach to behavioral assessment and treatment identifies factors associated with and controlling the person’s destructive behavior. These factors typically include environmental events immediately preceding or following the behavior problem as well as features of specific settings in which the behavior problem occurs.

            Many of our most effective environmentally-based treatments therefore, are designed to change the way we interact with individuals with behavior problems. Knowing the function of a problem behavior is important in designing habilitative or educational program s to promote alternative adaptive behaviors while reducing problem behaviors.

Biochemical Interpretations of Destructive Behavior

            There are cases, however, in which destructive behavior is neither attention nor escape motivated. There are three main neurochemical theories related to destructive behaviors – opioid receptor theory, serotonin receptor theory, and the dopamine theory.

 

Psychopathology, Dual Diagnosis and Functional Analysis of Behavior

            Major mental illness occurs among people with mental retardation with a higher incidence than among the non-developmentally disabled comparison group. A behavioral analysis of environmental variables can extend our understanding of the way in which biological brain disorders alter people’s ability to mange their daily transactions with the world around them.  In question are the primary presenting behavioral problems and learned adjustments to the environmental circumstances.

 

Neurobehavioral Pharmacology of Destructive Behavior

            A functional diagnostic approach attempts to evaluate the most probable behavioral and biological variables that may be contributing to the behavior of concern. A behavioral function may involve a consistent pattern of staff attention to head banging which maintains the problem behavior whereas a biological function may be related tot the release of endogenous opioids when the client strikes her head. The same form of destructive behavior may be influenced and controlled by different mechanisms. Self-injury that is pain-elicited or dopaminergically-driven may appear the same (eg, hand biting), but the neurochemical mechanisms regulating each type can be very different. Problem behavior that is positively reinforced (attention from the staff) or negatively reinforced (removal of an aversive task) may respond differently to pharmacological treatments.

            Therapeutic drugs influence a person’s health by modulating normal or abnormal physiological or biochemical processes.  If a person prone to hypertension walks too rapidly up the stairs, it may result in his blood pressure increasing to dangerous levels. A specific medication, clonidine, increases the diameter of peripheral blood vessels and therefore reduces the degree to which blood pressure increases when the person again takes the stairs two steps at a time. In comparison, the manner in which psychotropic drugs are often prescribed to alter the destructive behavior of people with developmental disabilities seldom reflects foregoing reasoning. Instead, practitioners and family members often act as though a medication can produce a qualitatively different patient outcome independent of the cause. Inappropriate prescriptions often arise from a prevalent theoretical misconception that drugs alter brain chemicals or physiological processes and cause behavior to change independent of the environmental circumstances within which the person functions. It is true that the brain’s neurochemistry and the body’s physiology set the limits at which external environmental processes and events exert their effects, but this does not happen in a vacuum. Sometimes there is a differential effect because part of what determines a drug’s effect is the person’s current and previous environmental circumstances ( their reinforcement history). Behavioral and medical history, and current circumstances influencing their behavior are variables that create the foundations upon which drugs are able to produce their effects. By adopting a functional approach, influential behavior and environmental factors are identified that may interact with a behaviorally active medication to improve a person’s ability to function independently and adaptively in addition to reducing a person’s destructive responses to the aversive environmental stimuli and stressors. The goal is to treat the underlying behavioral and biological mechanisms, not just the appearance of the behavior problem.

           

Psychotropic Medications and Contextual Control of Destructive Behavior

            Although different forms of destructive behavior can be influenced by discrete environmental events, such as staff demands placed on the individual, crowding, staff change, task repetition, and even stimulation arising from certain items of clothing, it is important to evaluate a broader range of environmental  setting factors including the typical physical  and social context setting the occasion for problem behavior, as well as events occurring within the individuals involved. This assessment would consider numerous factors including the health and physical discomfort of the individual (eg, menstrual cramps or pain from an inner ear infection), time since last meal or presence of a particular staff member.

 

Internal cues: rage, anxiety and panic attacks

            Environmental conditions that are provocative, demanding, or otherwise, stressful can often elicit internal stimulus changes. People with mental retardation often have difficulty learning socially acceptable ways to behave to internal emotional cues. Some of these feelings, such as anger, rage, anxiety or hostility may be ameliorated after an outburst of aggressive behavior.

 

 

Monitoring Psychotropic Medication

Development of psychotropic medication:

laudanum (opium in alcohol)

chloral hydrate 1869 [sedative hypnotic]

paraldehyde 1882

barbiturtates 1903

rauwolfia serpentina 1931 [the natural basis for reserpine used to treat psychosis]

amphetamine 1937 (Adderall) [stimulant]

phentoin 1940

lithium 1949 (Lithobid, Eskalith) [antimania]

chlorpromazine 1952 (Thorazine) [antipsychotic]

meprobamate 1954 (Miltown) [antianxiety]

chlordiazepoxide 1957 (Librium)[benzodiazepine antianxiolitic]

imipramil 1958 (Tofranil) [tricyclic antidepressants]

haloperidol 1958 (Haldol) [development of antipsychotics other than phenothiazines]

sertraline (Zoloft) SSRI antidepressant

clozapine (Clozaril) [antipsychotic for treatment resistant group]

 

In the mid ‘70’s, it became routine to have an “annual drug holiday”. It should be remembered that the original drug holiday requirement occurred because in numerous situations, psychotropic drugs had been given in large doses for years for unknown, vague or forgotten reasons and little or no data or monitoring existed.

This has been replaced by an in-depth psychotropic review conducted at least annually in relation to the underlying condition or hypothesis, treatment stage, risk factors, dose, side effects, index behavior data, quality of life, and concurrent non-

pharmacological interventions. If reduction is deemed possible, a gradual reduction plan is developed to determine the lowest maintenance dose, which may be, but no necessarily is, zero medication.

 

Psychotropic Medication Definition

            A psychopharamacologic medication is any drug prescribed to stabilize or improve mood, mental status or behavior. Some drugs typically classified as psychotropics may have other indications. The antianxiety agent diazepam (Valium) may be prescribed for spasticity and the stimulant methylphenidate (Ritalin) may be prescribed for narcolepsy. Similarly, drugs not typically classified as psychotropic may have psychiatric indications; such as the antiepileptic, carbamazepine (Tegretol) may be prescribed for certain affective diagnoses.

 

Biopsychosocial Model: postulates that biological, psychological and sociological aspects of care are interdependent and each must be acknowledged and addressed in order to provide optimal patient care.

 

Rational Empirical Model: the use of psychotropic medications must be based upon a psychiatric diagnosis or a specific behavioral-pharmacological hypothesis resulting from a full diagnostic and functional assessment. Specific index behaviors and quality of life outcomes must be objectively defined, quantified and tracked using recognized empirical measurement methods in order to evaluate the efficacy of psychotropic medication.

 

Coordinated Multidisciplinary Care Plan: psychotropic medication must be used within a coordinated multidisciplinary care plan designed to improve the individual’s quality of life. Psychotropic medication in and of itself is not a care plan. Behaviors or symptoms may worsen or improve and may do so in different settings. Behavior problems may not be entirely eliminated or may only return to previous levels, meaning that behavior or condition will still need to be addressed by the 9individual or others. Medications do not teach new skills or cognitive strategies; psychotropic medication does not prevent psychiatric relapse, it lowers the probability of relapse. A coordinated multidisciplinary care plan is important to address the interactive nature of biochemical, psychological and sociological aspects of care.

 

Short Term Versus Long Term Use

            The length of time a person is prescribed psychotropic medication and the dose level depend on a number of factors such as the diagnosis or condition itself, treatment phase and relapse history.

            Acute use:

            Generally 3-6 months or less: the key consideration is whether the problem (and resulting diagnosis or hypothesis and treatment plan) is of a short-term nature. In this case it is considered a short-term aid while adjustment occurs or educational strategies are taught to address a situation.

            Continuation (chronic use):

            Generally 4-24 months depending on the condition. An initial episode of a psychiatric condition may require a longer period of treatment in order to lower the probability of relapse.

            In any of these situations it is important to ensure a gradual dose reduction to ensure that any side effects are not the result of extraneous factors such as withdrawal effects, the environment, poor active treatment, other medical conditions or an undiagnosed psychiatric condition.

            Maintenance (extended use):

            Maintenance use is generally more than 12 – 24 months with expectation of extended or lifelong treatment.

 

Dose levels:

            It must be remembered that acute crisis doses or regimens are not necessarily maintenance drug and dose regimens.

 

Informed consent:

            The individual, if competent, or the individual’s guardian must provide written informed consent before the non-emergency initiation of any psychotropic medication and must be periodically renewed. Information should be provided orally, in writing and educationally.

 

Index Behaviors

            They are indicative of and serve as an observable index of the underlying condition of hypothesis. Specific index behaviors are important to assist in arriving at the diagnosis, evaluating progress and the psychotropic medication efficacy over time. It is the behavior that should improve over time. Tracking objective index behaviors over time is important to determine clinical status.

 

Baseline:

            A baseline is a period of time that an index behavior is measured in order to establish the frequency or severity of the index behavior. The most important aspect of a baseline is that it serves as a standard against which the efficacy of subsequent psychotropic medication is evaluated. A baseline is a mandatory part of an assessment.

 

Index Behaviors:

            Otherwise known as target behaviors. An observable index of the underlying condition or hypothesis; used to assist the prescriber of medications in diagnosis and to evaluate progress and psychotropic medication efficacy over time. As this applies to non-verbal people, clinical data collecting from behavioral observations and reports rather than traditional interviewing which has limitations. Over frequency, duration and time.

 

Side Effects: secondary effects of a drug that are undesirable and/or different from the therapeutic effect. ADR: any response to a drug that is noxious and unintended and that occurs at doses used in humans for prophylaxis, diagnosis, or therapy, excluding the failure to accomplish the intended purpose.

            ADR classifications are: hypersensitivity – reactions related to the patient’s immunologic response; idiosyncratic – reactions manifesting themselves as an inordinate response to o a usual drug (intolerance or hyperreactivity); side effects – reactions that are unintended and unwanted, yet are known pharmacologic effects of the drug; toxic reactions – reactions that are unintended, unwanted, and are not related to the drug’s pharmacologic effects; adverse drug interactions – reactions that are due to the in vivo interaction of two or more drugs. ADR’s are usually listed in standardized pharmacy and nursing references by body areas or systems. Categories include autonomic, cardiovascular, drug interactions, endocrine, gastrointestinal, hematological, hepatic, central nervous system, neurological, ocular, respiratory, dermatological, ocular, and urinary. Side effects scales can be general or specific and they address the side effects for all medications, or specific ones, depending on which is used.

           

 

Treatment for Challenging Behaviors or Mental Health Disorders: A False Dichotomy

 

Psychiatric disorders occur in persons with developmental disabilities at more than four times the rate observed in the intellectually unimpaired. The incidence of psychiatric disorders increases in relation to the severity of retardation. No major psychiatric diagnoses are peculiar to certain levels of intellectual functioning.

 

Functional analysis of behavior: the antecedent, the behavior, and the consequences. Target behaviors can be identified, but it should be understood that target behaviors can have transitory functions.

 

Describing the relationship between problem behavior and maintaining functions that it serves.

 

Six basic functions that problem behavior may serve, organized into two classes each motivated by either social or nonsocial outcomes.

            The desire to secure or maintain conditions of positive reinforcement

            The desire to secure negative reinforcement associated with escape and avoidance of aversive events.

  • an individual encounters a desirable item that she cannot obtain by herself, she may produce problem behavior to influence a social partner in a way that would result in obtaining the item.
  • problem behavior may be produced when a person wishes to secure or maintain the attention of the social partner.
  • – both presume that that the desired items and attention serve as positive reinforcers.; the probability increases that problem behavior will be used in the future to obtain these outcomes because they were delivered contingently.
  • Other situations may arise that an individual is expected to engage in an activity or interact with an aversive item; in this case an individual may engage in problem behavior to escape and avoid negative reinforcement.
  • The behavior may occur in an effort to obtain the contingent removal of discomfort.
  • If soothing comfort results as a consequence for a tantrum that was originally to relieve pain, the individual may generalize his problem behavior to situations in which he would like comforting affection, but does not have pain.

 

Problem behaviors may begin for different reasons, but are maintained by their social effect (positive; negative reinforcement).

 

Considerations in the Design of Effective Treatment

            Basic features of the living environment: a safe, humane environment that encourages the development and use of functional skills and likewise effectively addresses problems.

            The engagement of individuals in meaningful and enjoyable interactions and activities.

            Orderliness in the environment: predictability and structure of environment.

            Promoting independence and competence which is supported and maintained. Effective Treatment:

           

 

Diagnosis and treatment for the biological factors and medical conditions that may be contributing to the problem, including the appropriate use of pharmacotherapy for identified psychopathology directly or indirectly associated with the challenging behavior.

 

Assessment and analysis of the environmental conditions and contingencies that are functional in maintaining the challenging behavior and explicit inclusion of this information in all therapeutic and living arrangements.

 

Alteration of environmental conditions that provoke problems are altered or removed and circumstances that set the occasion for appropriate alternative behaviors predominate in the person’s day and life.

 

Use of instructional methods and reinforcement systems to strengthen behavior that will functionally replace the problems and to strengthen adaptive skills that will allow the individual to function in the environments in which the problem will be less

 

Reduction of reinforcement for the problem, specially decreasing the magnitude and frequency of reinforcement that the challenging behavior previously produced. The decrease is a relative one, involving the differential shift of reinforcement from problem behavior to alternative elements of the individuals’ repertoire that are more benign and adaptive in a conventionally desirable way.

 

Arrangement of specific consequences for the problem itself if the behavior remains dangerous or disruptive despite reasonable attempts to treat it.

 

Systematic programming for generalization and maintenance, ensuring that the arrangements that effectively resulted in improvements in the first [place are sufficiently in place in all the settings and times to enhance the likelihood that improvement will be pervasive and durable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

           

 

 

 

 

                       

           

 

Challenging Behavior of Persons with Mental Health Disorders and Severe Developmental Disabilities

Wiesler and Hanson

1999 American Association on Mental Retardation

 

Depressive symptoms – a dysphoric or irritable mood and/or a markedly diminished interest or pleasure in most or almost all activities.

            May be associated with a combination of the following:

•1.      significant weight loss or gain

•2.      insomnia or hypersomnia

•3.      psychomotor agitation or retardation

•4.      fatigue or loss of energy

•5.      feelings of worthlessness or excessive guilt

•6.      diminished ability to become or remain involved in an activity requiring concentrations

•7.      recurrent thoughts of death

 

Depressive Episode: a cluster of emotional and somatic signs and symptoms comprises a depressive episode. A major depressive episode is diagnosed when the individual experiences at least 5 of the above symptoms with one of the primary features and these symptoms represent change from previous functioning – during two consecutive weeks. These symptoms are out of proportion in intensity and duration to particular stressors and thus interfere with the individuals overall functioning.

 

Depressive Disorder: the diagnosis of major depressive disorder is made whenever the criteria for one or more major depressive episodes are met in the absence of any of the following that could account for the symptoms or represent other mental disorders:

  • 1. mood disorder due to a general medical condition
  • 2. substance induced mood disorder
  • 3. dysthymic disorder
  • 4. schizoaffective disorder
  • 5. mood features associated with schizophrenia
  • 6. bereavement
  • 7. previous manic or hypomanic episode

 

Dysthymic Disorder: this is a chronic condition characterized by a sad, depressed mood most of the day, more days than not, for at least two years ( irritable mood for a minimum 1 year duration for children and adolescents. The depressed mood is followed by at least two of the following: problems involving appetite, sleep patterns, energy level, concentration,, low self-esteem and feelings of helplessness.

 

Given the presence of a negative mood state, distinguishing factors are particular predisposing situation and the resulting type, range, intensity and duration of symptoms.

Behavioral Equivalents of Depressive Symptoms

Because the presence of severe to profound mental retardation often makes it difficult to detect these classic criteria, symptoms of depression are detected through close attention to various behavioral equivalents, which are changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences.

Depressed Mood, Irritability, Agitation:

            Rarely or never smiles

            Sad expressions

            Cries easily

            Tearful for no apparent reason

            Easily annoyed, provoked or angered

Increased difficulty in tolerating usual aggravations or disruptions in routine

            Easily provoked to disruptive outbursts

If verbal, may repeatedly express desire to return to former residential setting

 

 

Decreased Interest or Pleasure

            Usual activities are refused

            Typical events serving as reinforcers lose their effectiveness

            Social withdrawal

            Spends excessive time alone

            Minimal response to environmental stimuli

            Minimal eye contact

Rarely initiates activity or interactions

 

 

Self-Care Skills

            Toileting and grooming skills may deteriorate

In severe cases of loss of interest and withdrawal, may soil self, become incontinent, and lose interest in grooming such as bathing and changing clothes

 

Cognitive Performances

            Lowered performances in programs such as work activities

            Increased difficulty in maintaining attention to tasks, even routines

Appears confused in attempts to complete routines requiring concentration, focus and span of attention

 

Sleep Patterns

            Hypersomnia: sleep becomes a preferred activity

            Gets upset when attempts are made to awake and direct into usual activities

            Takes excessive naps during the day

            Insomnia: reduction in number of hours spent in sleep during the night

            Difficulty falling asleep

            Repeatedly awakes in middle of night

Awakes one or more hours before time to get up and then remains awake for the rest of the day

May present new or more severe behavior problems at bedtime, during the night or early hours

 

Weight / Appetite

            Increase: significant weight gain (5% of body weight over 1 month)

If free access is not available, may begin or increase frequency of food stealing and/or pica

Decrease: significant weight loss (5% body weight over 1 month)

Decreased food intake

Rejects favorite foods

Resists prompts to attend or complete meals

 

Psychomotor Retardation/Low Energy

Remains in one location with minimal motor activity for lengthy periods of time

            Passive

            Rarely initiates activity or interactions

            Spends excessive time lying or sitting

            May actively resist activities

            May present catatonic signs

            Extremely slow body movements

            Stops talking/communicating

 

Feelings of Worthlessness

In person with verbal skills, uses self-derogatory remarks – “I’m retarded”, “I’m ugly”

 

Excessive Concern for Death and Self-Harm

In person with verbal skills, excessive expression of concern over death of family or friends, funerals, or dying

In more severely impaired, suicidal ideation may take the form of increased fearfulness, clinging dependency, mimicry of a suicidal act, or drawings suggestive of death and burial

Threats or attempts to harm self

 

Nonspecific Behavioral Symptoms

Occurrence/increased occurrence and severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums out of proportion to social or environmental changes or events

            Repeated complaints of aches, pains or physical ailments

 

 

Mania

 

Manic Symptoms

            A distinct period of abnormally and persistently elevated, expansive or irritable mood.

            Related symptoms:

                        Inflated self-esteem or grandiosity

                        Decreased need for sleep

                        Increased talkativeness

                        Flights of ideas or subjective experience that thoughts are racing

                        Distractibility

                        Psychomotor agitation

Increased goal-directed activity (may be social, work, school or sexual)

Excessive involvement in pleasurable activities that have a likelihood of painful consequences

 

Manic Episode

A period of persistent and abnormally elevated, expansive or irritable mood lasting a minimum of 1 week (less if hospitalization is required)

This abnormal mood occurs in the presence of at least three of the above symptoms of mania (4 symptoms if the mood is only irritable)

The mood disturbance must be sufficiently severe to produce marked impairment in the person’s functioning

 

Hypomanic Episode

            A period as above that lasts for at least 4 days.

Must be different from the person’s usual demeanor, be clearly a change in functioning, and not due to the direct physiological effects of a substance or general medical condition

 

Mixed Episode

When symptom patterns for both a manic episode and a major depressive episode are present for at least one week

Experiences of rapidly alternating moods of sadness, irritability and euphoria along with the symptom patterns of both conditions

 

Bipolar I; Bipolar II; Rapid Cycling Bipolar Disorder; Cyclothymic Disorder – see DSM_IV for detail

 

Behavioral Equivalents of Mania

Presence of symptoms reflect changes from previous level of functioning or status and are not a result of other current biomedical or psychosocial influences

 

 

Euphoric/Elated/Irritable Mood

Appears boisterous, excited; easily provoked to disruptive outbursts; periods of acute and excessive anger

 

            Inflated Self-Esteem/Grandiosity

                        Has unrealistic notions of own skills

                        Views self as peer to staff or bosses

 

            Sleep

                        Decrease in total sleep time

Behavior problems occur at night when prompted to go to and remain in bed

 

Cognitive

                        Flights of ideas

                        Racing thoughts

                        Jumps from one topic to another in a frantic manner

 

            Speech

                        Pressured speech

                        Increased rate of verbalization/babbling

                        Nonstop vocalizations/does not seem to be able to stop

 

            Attention Span/Focus

                        Distractibility

                        Unable to stay on task when other activities occur

 

            Psychomotor

                        Psychomotor agitation

                        Seems wired

                        Unable to stop an activity

 

            Interests/Pleasures

                        Excessive involvement in pleasurable activities

Masturbates excessively or at inappropriate times/locations

                        Sexually provocative

                        Excessive teasing

                        Persistently requests reinforcers

 

            Self-Care Skills

                        Loss of skills

                        May become incontinent of urine and feces during day or night

                        Decrease in daily living skills

                       

            Nonspecific Behavioral Symptom

Occurrence or increased occurrence, severity or occurrence in new settings of various behavior problems such as aggression, self-injury, and tantrums that are out of proportion to social or environmental changes or events

                        Repeated complaints of aches, pains, or physical ailments

 

Diagnostic Protocol for Detection of Mood Disorders

            Individual clinical contact may reveal some impressions

Interviews with others who have knowledge of the person’s affect, social and problem behavior responsiveness through daily contact

Should be supplemented by direct observation of the person being assessed in selected residential, work, and related settings and conditions

Graphic display of behavioral data may be helpful

 

Structured interviews with informants, rating scales, and checklists of potential value in identification of mood disorder symptoms:

            Aberrant Behavior Checklist

            Children’s Depression Inventory

            Emotional Disorders Rating Scale for Developmental Disabilities

            Diagnostic Assessment for the Severely Handicapped

            Psycopathology Instrument for Mentally Retarded Adults

            Reiss Scale for Maladaptive Behavior

 

Integrative Psychosocial Model of Depression in People with Severe Mental Retardation : this model views the occurrence of depression as a product of both environmental events and personal vulnerability features.

            Immediate Disruptive Effects

            The process begins with stressors or life events that serve as onset instigators. For people with severe impairments, these stressors may represent a wide range of events or changes may be somewhat idiosyncratic and personal. Seemingly minor losses may have considerable meaning to a person who may also lack alternative skills in accommodating the losses.

            The antecedent life events are of significance to the extent that they disrupt substantial important and relatively automatic behavior patterns. Predictable and expected valued daily patterned behaviors are no longer possible.

           

Reduction of Positive Reinforcers

This creates a loss of meaningful reinforcers and reduction in positive affective experiences. Interactions with the environment become balanced in a negative direction. Often these people have a limited number of alternative behavior patterns that consistently provide predictable and valuable positive consequences.

 

Emotional Consequences

The disruption of patterned behaviors and the loss of valued reinforcers result in an immediate negative emotional reaction, the intensity and the pervasiveness of which is related to the importance of the loss to the person, the availability of the alternative sources of valued reinforcement and the person’s skill in obtaining these.

The aversiveness of the unpleasant event and the number of major stressors represent the best predictor of depressive onset. For people with severe impairments, limiting coping skills, a relatively impoverished motivational structure and a limited number of valued personal relationships, a hospitalization, separation from a friend or roommate, removal from a familiar environment with a structured familiar routine may represent huge stressors, especially if they are concurrent.

 

Turning Inward

Following limited or unsuccessful attempts to gain replacements for the losses or to reduce the stressors, the person begins to focus excessively on the current state of emotional distress produced by the change. This excessive self-focus on the internal distress interferes with alternative attempts to gain environmentally based experiences that will replace the loss of the reinforcers. This results in intensification of the distressing dysphoric affective reactions; increasing withdrawal from social and program participation; a downward cycle is perpetuated. The limited cognitive and associated internal speech of severely impaired people become unduly influenced by the internal state of distress.

 

Appearance of Multiple Depressive Symptoms

The self-focus and dysphoria reduce the person’s social competency and render the person less attractive to others, further perpetuating the social isolation and dysphoria. A state of irritability or exaggerated need for emotional support evolves. Excessively dysphoric or irritable mood correlates with regression in basic self-care and bodily functions.

 

Vulnerability Influences

Personal characteristic may serve as a significant vulnerability influence. Personal histories that include experiences with rejection, restricted opportunities, segregation, inadequate social supports, victimizations, and infantilization are not uncommon in this population. Such personal features as learned helplessness, limited behavioral repertoires, limited skills of coping with negative emotional stress and an aberrant motivational structure may reflect the effects of the damaging histories. Additionally, current socioenvironmental factors such as a lack of or inconsistent social supports and limited access to a range of reinforcing events and associated emotionally enhancing experiences are vulnerability influences. All of this can contribute to intense emotional consequences when individuals lack the means of gaining valuable alternatives.

Learned helplessness: a helpless and inactive state produced whenever a person is unable to escape from or avoid punishing conditions. The experiences of many individuals with severe impairments especially of those with lengthy placement in institutional settings, are consistent with the development of a general characteristic of learned helplessness.

 

Social and Coping Skill Deficits

Limitations in the range and complexity of interpersonal and pother socially related skills such as those involving leisure and work as well as the skills of effectively coping with unfamiliar and emotionally laden incidents are inherent in the definition of severe and profound mental retardation. Limited social skills, excessive attachment and dependency on a small number of significant others, activities and objects, and limited leisure and work skills that restrict opportunities for obtaining significant sources of positive feedback all serve as significant psychosocial vulnerabilities.

 

Limited Range of Affective Attachments

Affective attachments are, in general, limited and with the continued loss of these attachments, people are a high risk for depressive responding upon loss of the objects of attachments. The person has limited replacement alternatives and thus, is without sources of valued social support. Observations suggest that some people with developmental disabilities may become emotionally blunted after a series of losses involving valued peers or caregivers and excessively cautious in developing further attachments.

 

Emotional lability and generalized irritability

Emotional lability related either to a pathological psychological history or to neurological and neurochemical abnormalities may represent a further vulnerability for development of depression. Without skills to cope and calm, the person would be increasingly likely to be influenced in daily activities by the internal distress produced by losses.

 

Additional motivational limitations

The life experiences of the people with severe and profound cognitive impairments frequently result in a highly constricted motivational structure. Due to limited exposure, the person does not learn to value a variety of activities and objects. The person is prone to become very dependent upon a limited number of reinforcers and may appear to be insatiable relative to them. When these are lost or greatly restricted, the person becomes vulnerable to depressive responding due to the lack of responsiveness to alternative sources of reinforcement.

           

 

Implications for treatment

            Treatment for depression from a psychosocial perspective entails two major objectives. Therapeutic efforts initially address the current depressive symptoms with the objective of reducing or eliminating these as a means of returning the person to the level of functioning present prior to the current episode. The second objective involves the therapeutic efforts to reduce the psychosocial vulnerabilities that place the person at continued risk for future development of oppressive symptoms. Drug treatment may alleviate depressive symptoms but does not change the underlying pathophysiology or psychological or environmental vulnerabilities responsible for the disorder. As psychosocial therapies are designed to teach new coping strategies and to change other critical personal and socioenvironmental vulnerability features, they offer unique opportunities for increasing a person’s immunities that should mitigate the impact of the future psychological losses or disappointments.

            Treatment strategies for meeting the initial therapy objective of regaining the predepression functional status:

•1.      Whenever possible, prepare the person for major change or loss when these can be anticipated. Develop substitute or alternative personal relationships and routines that will be available on occurrence of the loss or change. If such preparation is not possible, or if ineffective, intervene as early as possible in the depressogenic process. Identify the losses that the person has experienced, the resulting behavioral routines that became nonfunctional and the range and types of interpersonal and activity reinforcing experiences that are lost. Develop alternatives to these valued routines.

•2.      Provide frequent and consistent emotional support during the grieving and adaptation period. Remove excess demands and minimize additional aversive experiences. Recall, however, that depressive behaviors attract positive social reinforcement (sympathy, assurance, physical presence) and may be strengthened if the focus of the depressive behaviors is prolonged. Minimize attention to dependency and helplessness.

•3.      Concurrently, expose the person to people, activities, and environments that offer suitable replacements. Provide a variety of social stimulation offered by a number of favored caregivers and peers. Expose to social models who predominately demonstrate positive affective behaviors. Identify activities (eating out, dancing, bowling) and objects (pictures, jewelry, miniature cars) that are valuable to the person and make these available. Use the necessary verbal and physical assistance needed to insure that the person does not withdraw into unresponsiveness.

 

Following resolution of a depressive episode, the range of personal and socioenvironmental vulnerabilities present with any specific person would become the focus of longer term therapeutic endeavors. The specific approaches selected would be determined by the particular constellation of psychosocial risk factors present for that individual.

 

Affective Disorders and Disruptive Behavioral Symptoms

            Noted an increase in:

            Aggression

            Self-injury

            Self-injury

            Property damage

            Pica

            Difficulties of:

            Mood and irritability

            Appetite changes

            Sleep disturbances

            Following a diagnosis of depression and successful pharmacological treatment, pica became a minimal problem.

           

A diagnostic case formulation model that accounts for the occurrence as well as the persistent recurrence of nonspecific behavioral symptoms should thus consider:

•1.      The complete stimulus complex that precedes and serves to instigate these symptoms

•2.      the persons biopsychosocial vulnerabilities or risk factors for engaging in these nonspecific symptoms when confronted with this instigating stimulus complex as well as,

•3.      those proximate consequences that follow behavioral occurrences and may contribute to their functionality and strength

 

The instigating stimulus complex may include the arousing/activating features of various components of a mood disorder. In these instances, the objective of a comprehensive diagnostic assessment is to “see past” the mood disorder and to ascertain the specific role served by the features of this condition in contributing to the occurrence, severity, fluctuation, and chronic recurrence of the behavioral symptoms. In this manner, informed speculation can be made about the extent of the reduction in critical features of the nonspecific symptom to be expected following effective treatment of the mood disorder.  

           

Multimodal Contextual Behavioral Analytic Model

            A multimodal(bio-, psycho-, and socioenvironmental modalities of influences) contextual ( contexts of instigating, vulnerability, and maintaining conditions) behavior analytic model is offered  as a representation of this broader diagnostic-treatment case formulation process. (Holistic assessment).

            Mood disorder features as instigating conditions – preceding events that, when present, influence the occurrence of nonspecific behavioral symptoms. These instigating conditions may serve either:

•1.      A sufficient role

•2.      or a contributing role

in influencing occurrence of these symptoms.

            The sufficient role may sometimes represent the internal psychological condition such as a profoundly mentally retarded person without verbal skills communicating his needs by autoaggressive ear slapping associated with a dysphoric mood. The internal painful distress serves as a sufficient instigating stimulus condition for the auto aggression independent of any additional provocation from social or physical sources.

            Whenever a persons nonspecific behavioral symptoms occur only in the presence of a critical level of discomfort produced by a dysphoric mood, a state dependent relationship is present. In this instance, effective treatment of the underlying stimulus condition (eg dysphoric mood) should remove or eliminate the instigating aversive internal state and the associated behavioral symptoms.

            In other cases, a person’s behavioral symptoms, such as aggression or self-injury, may also be instigated by antecedent stimulus conditions unrelated to features of the person’s depression. In this instance, as the behavioral symptoms may appear in the absence of the mood disorder, a state-dependent relationship would not be present; interventions addressing both sets of instigating conditions would be necessary.

 

Contributing instigating events reflecting mood disorders.

            In individuals with mental retardation diagnosed with rapid cycling disorder, occurrence of the behavioral symptoms was dependent on the psychological state associated with the psychiatric disorder plus occurrence of various staff prompts, even though different external prompts served as the instigating events during the different phases ( depression or mania) of the disorder. During the depressive episodes, the staff prompts intended to get the person involved in an activity, produced the problem behavior. During manic episodes, prompts to slow the person down or focus attention produced the behavioral symptom.

            Those prompts, even though necessary conditions, were not sufficient in the absence of the mood state to instigate the nonspecific behavior. Both the staff prompts and the mood state formed the stimulus complex that represented the necessary precursors for the nonspecific behavior symptoms. Neither was sufficient, independent of the other, to produce the behavioral symptoms.

            In this state dependent role, interventions resulting in removal of either of the contributing and necessary components of the stimulus complex (mood states or the prompt) would effectively manage the occurrence of the nonspecific behavior problem. The obvious focus of intervention, nonetheless, would be that of eliminating the aberrant mood states that rendered the staff prompts as aversive conditions to be removed or avoided through use of aggression or autoaggression. Following successful medication treatment of the bipolar disorder and removal of the associated instigating stimulus conditions (ie aberrant mood states), reduction or elimination of the nonspecific behavioral symptom would coincide with the concurrent reduction of the aversiveness  of the staff reduction.

            In state exacerbated relationship, the behavioral symptoms predate the mood disorder and increase in frequency and/or severity on occasion of the disorder. Instigating features of the mood disorder combine with other sources of provocation to increase the frequency and/or intensity of the behavioral symptoms but in isolation are neither necessary nor sufficient to produce these. In this instance, effective treatment of the mood disorder would result in reduction of the nonspecific behavioral symptoms related to the instigating features of the disorder.

            Mood disorder features serve various roles as instigating conditions for nonspecific behavioral symptoms. On some occasions, various aberrant stimulus components resulting from the disorder may serve as contributing instigating conditions. These conditions may occasionally serve as necessary conditions for the occurrence of the behavioral symptoms.

Treatment of a person’s mood disorder may indeed be effective in reducing or eliminating the primary symptoms of the disorder but be ineffective in reducing the person’s nonspecific behavioral symptoms unless features of these mood disorders do contribute to the stimulus complex producing these behaviors.

 

Vulnerability Influences

            Some personal; features associated with mod disorder may put a person at risk for engaging in nonspecific behavioral symptoms due to stress:

•1.      The fluctuating intensity of mood states

•2.      the mood lability

•3.      increased likelihood of physical fatigue associated with sleep disturbances

•4.      energy loss associated with eating difficulties

•5.      and the aberrant activity levels

These states may either produce nonspecific behavioral symptoms or may increased the likelihood of these behaviors when the person is exposed to other sources of provocation. Add to that the deficits of coping skills, and an increase is likely in the occurrence of nonspecific symptoms.

 

Mood Influences on Functionality of Nonspecific Symptoms

            Occurrence of nonspecific behavioral symptoms may result in changes in the internal affective states associated with a mood disorder. These changes may contribute to the strength and functionality of the behavioral symptoms. For instance, responding aggressively may remove a staff directive to attend a scheduled training program rendered aversive by a dysphoric mood state. As a result, aggressive responding is strengthened. Self-injurious face slapping may become functional as it results in frequent personal attention in a person who becomes excessively emotionally needy during periods of sadness. In these instances, the nonspecific behavioral symptoms become more likely under similar instigating conditions as these result in consequences valuable to the person.

 

Facts and Fiction About Behavior and MR/DD

Myth: Behavior always has functional significance and is under the control of the affected individual.

Premise: Behavior is an adaptive response to an external or internal stimulus.

Reality: Some behavior is involuntary and nonadaptive (eg, tics, and vocalizations of Tourette’s disorder)

Treatment implications: involuntary behavior may not respond to psychological interventions.

Myth: If a behavior has functional significance, it is unlikely to be related to a psychiatric disorder.

Premise: Determining the “meaning of the behavior” means that it can be explained in behavioral terms.

Reality: Behavior may represent an adaptive response to stress associated with a psychiatric disorder. (The onset of the illness may reproduce state-dependent behavior or result in an increase in state exacerbated behavior.

Treatment Implications: State-dependent and state-exacerbated behavior should be managed with treatment directed toward the underlying psychiatric disorder.

           

Myth: A person with severe or profound disabilities is too impaired to develop classic psychiatric disorders.

Premise: Because impairments in communication and functional skills preclude obtaining information about psychiatric symptoms (eg, suicidal ideation), people with severe impairments cannot manifest psychiatric disorders such as major depression.

Reality: DSM IV diagnostic criteria represent only approximations of syndromes, many of which have biochemical underpinnings. Criteria are based on the assumption that the diagnostically relevant behaviors and emotional experiences are highly associated.

Treatment implications: All patients, irrespective of the severity of their disabilities, who are treated with psychotropic drug therapy should have a DSM IV diagnostic formulation.

 

Myth: Bizarre behaviors, such as talking to yourself out loud, fantasy play or talking to an imaginary friend, represent manifestations of psychosis.

Premise: Bizarre behaviors indicate the presence of delusions or hallucinations.

Reality: Talking to yourself out loud, fantasy play and imaginary friends are best considered to be normal developmental behaviors that have persisted.

Treatment implications: These behaviors do not respond to antipsychotic drug therapy.

                       

Myth: Drug therapy is a restrictive form of behavioral control. All regimens must, therefore, include a behavior plan and a timetable for discontinuing treatment.

            Premise: Drug therapy directly affects behavior.

Reality: Behavior such as self-injury and aggression are too nonspecific to be considered as direct targets for drug therapy.

Treatment implications: The appropriate targets for drug therapy are the changes in neurophysiological function that mediate behavior associated with psychiatric disorders and central nervous system dysfunction.

 

 

            The traditional view that all behavior is functionally defined is limiting. The traditional view was that people with MR/DD displayed maladaptive behavior because they lived in deprived environments and that the remedy to this situation was to provide an enriched lifestyle, value each person as an individual and enhance self-esteem. If problems persisted, a behavioral program would help retrain the person to a more adaptive behavior pattern. The belief was that these interventions would eliminate all the challenging behaviors; clinically, however, this is not always the case.

            The provision of psychosocial treatment implies that some functional purpose accounts for its etiology. For example, the assumption is that if a person is provided with more alternatives to communicate his needs, to respond in different ways, and to have more meaningful daily life experiences, he will not engage in challenging behaviors. This is true for some people (with MR/DD, or without); but for many it is not true. Manic overactivity, for example, is not a functional response to the environment, it is totally driven by biological neurochemical structures and pathways. In a manic state, individuals need little sleep. Once awakened, and feeling uncomfortable, the person in the manic state may begin to roam around the house, which may attract the attention of housemates or staff. In this situation, misguided caregivers have assumed that such behavior is attention-getting and that it will respond to a behavior program.

            The reality is that some behavior is involuntary. It is not under the control of the individual and may not respond to social consequences. Behavioral symptoms may be managed, but it is not the same as treating the underlying biological condition. Psychosocial and behavioral interventions may serve as containment that keeps the person safe, but only while the programmatic restrictions are in place. In many instances, pharmacological intervention may be the treatment of choice and may be the active and necessary component for healthy change.

 

            A dysfunctional behavior may have functional significance and it may be an adaptive response at the same level. The person with MR/DD may be able to moderate either internal or external stress in the case of a psychiatric disorder by performing a dysfunctional behavior. For example, a person suffering from a major depressive episode may avoid social contact because of the discomfort and negative self-thoughts generated by socialization. The social avoidance behavior serves to reduce the discomfort. This adaptive-maladaptive response has a strong functional relationship to the environment, but it is associated with major depression. Recommended treatment usually consists of cognitive-behavioral psychotherapy in concert with anti-depressant medication.

            If the target behavior is a manifestation of a psychiatric illness, then the active treatment should be directed to the underlying psychiatric illness, not just the behavioral manifestations. The treatment of first choice for a drug responsive psychiatric disorder is pharmacotherapy. Sometimes a disservice is performed by insisting that the behavior therapy is the active treatment and that the pharmacotherapy is just a containment measure necessary until the active treatment takes effect. In cases of severe depression, the person will generally be unable to initiate any self-correcting behavioral or other therapeutic measures. Once pharmacotherapy has lessened the physical symptoms associated with depression, the person will be more able to address difficulties in life and change any cognitive or behavioral habits that contribute to the depression.

            If service providers are not fully trained in mental health, consultations may be misguided. If a person with MR/DD has become irritable, disruptive, and aggressive, a behavioral consultation may be sought. During the assessment, it may become apparent that the individual reacts negatively with aggression in response to task demands. Rather than jump immediately to a purely behavioral plan, a more comprehensive assessment would ask about sleep patterns, eating patterns and general mood change to assess for depression or mania. Physical symptoms could be present suggesting a medical disorder. Physical and psychiatric disorders need to be fully explored.

 

            Cognitive limitations do not preclude psychiatric diagnosis. The problem with diagnosing criteria for mental illness is that it is based on self-reported information from people with normal intelligence. This does not imply the disorder is a function of intelligence, but the person who is non-verbal with MR/DD cannot describe negative feelings or will not express them in the typical manner.

            Research has shown that self-injury is associated with depressive disorders in people with MR/DD. Self-injury, assaultive behavior and tantrums were more prominent in people with severe developmental disabilities. This prominence suggests that the greater the intellectual disability, the more undifferentiated are responses to life, perhaps because of a limited repertoire of responding.

            Psychiatric disorders can be diagnosed in people with severe or profound disabilities, but they may not display the full syndrome – meet all the necessary criteria – because many of the criteria require the ability to verbalize and self-report symptoms. Partial criteria may be met and a diagnosis given. A person should not receive psychoactive medications without a DSM IV formulation Axis I – IV, even if they are severely disabled.

 

Bizarre behavior and psychosis

            Developmental delay, limited cognitive organization, stress, and prior traumatic experiences can result in behaviors that are regularly misdiagnosed as psychotic. Behavior must be considered in a neurodevelopmental perspective prior to being diagnosed as psychotic and other possible precipitating factors must be examined.  Considerations for: how organized the person’s behavior appears given latitude for the person’s developmental disabilities.

            In stressful situations, people with MR/DD often become overwhelmed and suffer cognitive deterioration. A similar situation called pseudodementia, is well known in the geriatric psychiatry. Memory problems may be seen, as well as apathy and loss of hygiene or adaptive daily living skills. In these cases, an elderly person suffering from a major depressive episode shows dramatic deterioration and may frequently be diagnosed with dementia, thought to occur because of neurobiological changes in the aging brain. People with MR/DD suffer the same cognitive disintegration under stress or when suffering from a mental illness, but mental health clinicians are not all as aware of this situation, frequently misdiagnosing psychotic conditions.

            From a developmental viewpoint, talking to oneself, having an imaginary friend, fantasy play and to some extent, hallucinations are not necessarily psychotic, but should be considered within the context of the person’s developmental level and present quality of life. Based on past history, a person may be having flashbacks to a former traumatic situation. Post traumatic stress may be revisited under extreme stress.

 

Behavioral Therapy and Pharmacotherapy

            For some, pharmacotherapy is seen as a restrictive form of treatment and that there must be a behavioral plan and a timetable for discontinuing the medication. Pharmacotherapy is therapeutic and may be the first line of treatment for some mental illnesses. For major depression, manic states, and schizophrenia, pharmacotherapy must be offered and encouraged as the first treatment. For people with MR/DD, problematic behavior may be secondary to the psychiatric disorder. If this is the case, the treatment of the psychiatric disorder is the primary consideration while the behavior program focuses primarily on the containment.

            For people of normal intelligence, no timetable to end medication is mandated. They can voice there opinions on options to continue or not, on side effects. If the person is tapered off from medications and begins to feel depressed again, they can tell the physician. Most people with MR/DD cannot do this and must wait until their symptoms are so difficult that they have serious decompensation. In the meantime, they may have to endure treatment aimed at making their behavior more adaptive. Such an approach is a form of disability discrimination.

            Because of the advances in biological psychiatry and neurobiology, it is now understood that mental illness is strongly influenced by brain neurochemistry. Many and perhaps the vast majority of people with MR/DD may have neurobiological brain abnormalities as the cause of their disability, either due to prenatal or perinatal difficulties, the effects of toxins, illness, accidents or genetic factors. Therefore, it is more likely that these abnormalities would contribute to an increased incidence of mental illness.

            Because people with MR/DD have received inadequate general habilitative care in this country until recent years, advocates have erroneously focused on pharmacotherapy as a treatment to be avoided. Today, pharmacotherapy is among the most effective treatments available for mental illness and it should be available for all individuals with intellectual disabilities.

 

Psychopharmacology for People With Profound and Severe Mental retardation and Mental Disorders

            All classes of psychotropic medications have been shown to be useful in treating psychiatric disorders in clients with profound and severe mental retardation, but drug response tends to be more unpredictable in this population than in the general population.

            Psychotropic medication classes include antidepressants, mood stabilizers, antipsychotics, anxiolytics, stimulants, and others ( eg, opiate antagonists and antihypertensives). Antiepileptic medications may also have pronounced behavioral effects.

            Because diagnosis is difficult, selection of psychotropic drug treatment in clients with profound and severe mental retardation is complicated. Generally, diagnosis is based on target behaviors and symptoms, which are interrelated and guide treatment toward reasonable drug choices. Defining the meaning of the target behavior is challenging. If the client is agitated, does this stem from depression, agitated mania, agitation because of sleep disorder or psychosis, or perhaps an anxiety disorder? Drug trials are utilized because of this unclear origin of symptoms. If a drug trial is effective, it often assists in clarifying the diagnosis.

            Drug history information is extremely important in developing medication trials because it can provide information that increases the possibility of success. Every effort should be made to acquire information relating to previous effective and ineffective treatments, along with the adverse effects that have occurred. Repeating ineffective drug trials needs to be avoided. In some cases, adverse effects can be minimized by using newer drugs with fewer side effects.

            Due to some amount of genetic linkage, family history of mental disorders may provide beneficial information. For example, the diagnostic history of family members treated effectively for mood disorders or schizophrenia can provide insight into drug trial development for the client.

            Target behaviors are identified and prioritized, baseline behavior data are collected and the client is treated symptomatically. Behaviorally defined target behaviors and qualified severity levels are extremely useful for assessing treatments. Drugs that can treat an array of symptoms are likely to be primary choices. The goals of pharmacological treatment are:

•1.      keep the drug treatment as simple as possible

•2.      provide the client with the greatest chance of success early in therapy

•3.      use the safest drug available to avoid side effects.

 

Initiating Drug Treatment

            Psychotropic drugs should be initiated at low doses and slowly titrated to avoid side effects. Clients with profound and severe mental retardation are frequently found to be especially sensitive to the effects of medications. Toxicity may occur at the typical dosage range used for psychiatric clients without cognitive disabilities. Additionally, drug response can be observed at lower than usual doses. If the drug is well tolerated, the drug trial may last 1 to 6 months or longer, depending on the specific drug. This period allows for an evaluation of the drug response based on the empirical data on index behaviors.

 

Side Effects Versus Disorders

            Once a drug is initiated, it is often difficult or impossible to determine whether a client is having side effects from the medication. Clients with profound or severe retardation are not able to communicate information directly about the side effect discomfort. Staff need to be aware of the common side effects of the psychotropic medication and consider how these might affect behaviors. Regular and frequent monitoring of drug specific effects is very important in this population. Baseline laboratory values and vital signs before and after the initiation of some medications are also helpful.

            Side effects may manifest as increases in target behaviors. This may occur with antipsychotic drugs that cause akathisia ( a subjective feeling of restlessness). In a client who otherwise has anxious symptoms, or becomes easily agitated, akathisia would likely cause increased rates of target behaviors. The selective seratonin reuptake inhibitors like fluoxetine (Prozac), can cause some nervousness or agitation, but this is more often observed at higher doses as can buspirone (Buspar), an anxiolytic. A client with mood symptoms and target behaviors of screaming and crying may display more if experiencing a headache as a medication side effect. Side effects may cause a person with self-injurious biting to begin banging his head because the medication is causing headaches.

            Side effects of medications can also result in decreased behaviors. Sedation and fatigue are effects of many psychotropic drugs, including antipsychotics, antidepressants, mood stabilizers, anxiolytics and antihypertensives (eg beta blockers). The resultant chemical restraint from sedation is not an acceptable outcome of drug treatment.

            When mild side effects occur, tolerance of them can develop over time. Common side effects like nausea, sedation, agitation and blood pressure changes often subside over time. In some cases, the doses can be decreased to lessen the adverse effect or the medication may need to be discontinued. If a drug is effective, but the side effects are a concern, another drug in the same class may be substituted.

 

Psychotropic drug Classes and Specific Drugs

            Drugs may be used in combinations in cases of comorbidity or as augmentation treatment. It is important to remember that psychotropic medications have the potential to interact with one another, with nonpsychotropic drugs, and both prescription and nonprescription drugs. When a drug interaction is significant, it may result in treatment failure or toxic effects.

 

Antidepressants

            Antidepressant medications include selective serotonin reuptake inhibitors (SSRI’s), tricyclic antidepressants (TCS’s), monoamine oxidase inhibitors (MAO’s), and other miscellaneous agents. Antidepressants can be useful in treating depression, anxiety, panic, obsessive-compulsive disorders, eating disorders and sleep disturbances. TCA’s and MAO’s are not use as first line treatment due to their  many side effects and interaction with foods and because they require more monitoring than the newer antidepressants.

 

SSRI’s

            Selective serotonin reuptake inhibitor antidepressants include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). In clients with profound and severe mental retardation, these medications are considered first line treatment for depressive symptoms. Agitation, compulsiveness, impulsiveness, anxiousness, aggression, self-injury, panic symptoms, changes in appetite and sleep problems may all suggest the need for an SSRI trial. Fluoxetine (Prozac) has been shown to be effective in reducing symptoms of autism.  Some of the more common side effects of SSRI’s are headache, nausea, nervousness, or sedaton, diarrhea or constipation and sexual dysfunction. If one SSRI trial fails or the side effects are intolerable, a different SSRI may succeed.

 

Miscellaneous Antidepressants

            Trazodone (Desyrel) and nefazodone (Serzone) are antidepressants that can have concomitant antianxiety effects. For this reason, these drugs may be beneficial in clients with agitated behaviors.   Both of these medications can also be useful for treating sleep problems. In fact, trazodone sometimes cannot be tolerated at the doses needed to treat depression due to the sedative effect. Nefazodone may be less sedating than trazodone and can actually improve sleep cycles and, thus, the quality of sleep. Notable side effects are daytime sedation, dizziness, orthostatic hypotension and alterations in heart rate.

            Mirtazpine (Remeron) is a relatively new antidepressant that may have antianxiety effects. It is useful for treating clients with depressive disorder who exhibit agitation, diminished appetite with weight loss, or have sleep disturbances. Sedation , dizziness, increased appetite and weight gain are the more common side effects of mirtazapine. It has minimal anticholinergic effects (eg dry mouth, blurred vision, urinary retention and constipation).

            Venlafaxine (Effexor) may be reserved for difficult to treat depressed clients or those with concomitant anxiety. Blood pressure should be monitored regularly for possible sustained increases especially in high doses or if the client has a history of hypertension. Common side effects are nausea, nervousness, somnolence, insomnia, dizziness, anorexia and sexual dysfunction.

            Bupropion (Wellbutrin) is available is available in an extended form with fewer side effects. It may increase the risk for seizures, so it may be contraindicated for use with clients who have known low seizure thresholds. Clients with profound and severe mental retardation have a higher incidence of seizures, so Wellbutrin would not be a first line option in their treatment.

            Antidepressant treatment, if tolerated by the client, should continue for 6-8 weeks after a therapeutic dose is reached. This provides sufficient time to collect data on target behaviors and determine if the medication is beneficial. Minimum effective doses do not apply to antidepressants, in that the maintenance dose is the initial effective dose.  If others perceive that the effect of an antidepressant has ameliorated over time, options include increasing the dose, switching to a different antidepressant agent or augmenting with buspirone.

 

Mood Stabilizers

            Current established mood stabilizers include lithium, valproate (eg valproic acid [Depakene] and divaproex sodium [Depakote]) and carbamazepine (Tegretol). Adjunct drug treatment might include an antipsychotic, a benzodiazepine or an antidepressant, depending on the symptoms. If traditional mood stabilizers are not well tolerated, second line mood stabilizing agents including gabapentin (Neurontin), calcium blockers (nerapamil) or trazadone may be used. Mood stabilizers can be very useful for treating bipolar disorder in individuals with profound and severe mental retardation. Treatable target behaviors may include agitation, irritability, aggression, decreased sleep, decreased appetite, self-injury, increased vocalizations, increased sexual displays, and decreased attention span. Mood swings are most easily recognized by graphing prevalent target behaviors on a chart over time. In appropriately aged females, if mood symptoms cycle monthly and are associated with their menses, the pharmacotherapy may be quite different for treating this premenstrual dysphoric disorder.

            Even though lithium has been the classic mood stabilizer since the ‘60’s, valproate is now considered a first line therapy and often produces fewer side effects than either lithium or carbamazeoine. It has a wider therapeutic range, less risk of toxicity and requires less laboratory monitoring. It can also be used to simultaneously treat seizure disorders (as can carbamazepine, whereas, lithium can lower the threshold. Additionally, carbamazine can be very difficult to use because of the multitude of drug interactions involved with the individuals on concomitant drug therapies.Clients with rapid cycling or mixed state mood disorders may be more likely to benefit from valproate.

            Acute manic episodes can also be effectively treated with valproate. Manic episodea with psychotic features can be treated with antipsychotics. Benzodiazepines are used to treat the insomnia and to decrease anxious symptoms.

            Treatment of bipolar disorder requires maintenance doses of mood stabilizers and sometimes requires mood stabilizers in combination to prevent recurring acute episodes. It is noteworthy that a minimum effective dose does not apply to mood stabilizers. Dosages are prescribed according to blood levels maintained within a therapeutic range.

 

Antianxiety Agents

            Antianxiety drugs include buspirone (Buspar), some of the antidepressants and benzodiazepines (eg, lorazepam [Ativan], clonazepam [Klonopin]). Treatable conditions in individuals with profound and severe mental retardation may be behaviorally defined nervous or anxious behaviors, panic-type behaviors, aggression or self-injurious behaviors.

            Benzodiazepines should be used only in the short term as they can be paradoxical disinhibitory effect on behavior, resulting in increased agitation and aggression. They can also cause considerable sedation and impair cognitive abilities; also, if used regularly, tolerance can occur where increasing doses may be needed. However, they can be effective in managing episodic agitation or sleep problems on an intermittent basis.

            Buspirone is a good first line treatment for anxiety symptoms, especially for generalized anxiety disorder. Agitation, aggression, self-injury, anxiousness or nervousness, hyperactivity and impulsiveness or compulsiveness are symptoms that might respond to buspirone treatment.

            SSRI’s can be effective for treating various anxiety disorders. Paroxetine and fluvoxamine are more sedating and less stimulating than fluoxetine, sertraline and citalopram. Citalopram (Celexa) is the most selective SSRI and may be associated with fewer side effects and drug interactions. SSRI’s have proven efficacy in anxiety associated with depression, panic disorder and obsessive compulsive disorder. Encouraging findings have been reported in social phobia, PTSD, and PDD.

 

Antipsychotics

            At this time, the atypical antipsychotics – clozapine (Clozaril), risperidone (Risperdal), olanzaoine (Zyprexa) and quetiapine (Seroquel) – are considered first line treatment as antipsychotic agents, except clozapine  because of the weekly blood testing. Chlorpromazine[Thorazine], thioridazine [Mellaril], haloperidol [Haldol]  are the older typical antipsychotics and are used much less. The first line antipsychotics are more effective, particularly in terms of treating the negative symptoms of schizophrenia (blunted affect, apathy, social and emotional withdrawal and anhedonia). They have less risk for extrapyramidal  symptoms (akathasia, dystonias, tremors, and cogwheel rigidity). The incidence of extrapyramidal effects does increase with increased dosages.

            It can be difficult at times to assess whether psychotic symptoms exist in a person with profound or severe mental retardation. When an antipsychotic is administered, orthostatic hypotension and sedation can be early side effects, but these generally subside over time. Risperidone is more likely than olanzapine or quetiapine to cause increases in prolactin levels and amenorrhea in females. Other reasons for increased levels of prolactin should be ruled out as there may be medical causes.

            Some individuals, especially older clients tend to be very sensitive to therapeutic response and side effects. In individuals with severe behavioral problem, major medication changes may involve risk of increased self-injury or aggression to others.

            Other medications used in combination with antipsychotics to treat side effects may be antcholinerics (eg, benztropine[Cogentin], diphenhydramine [Benadryl], trihexiphenidyl [Artane] for extrapyramidal effects or a beta-adrenergic blocker (eg, propranolol [Inderal]) for akathisia or restlessness. Benzodiazepines (eg, lorazepam [Ativan]) can be used in combination with antipsychotics for treating comorbid sleep or anxiety disorders or an antidepressant or mood stabilizer can also be used for affective disorders.

 

Adverse Behavioral Effects of Antiepileptic Medications in People with Developmental Disabilities

            The association of epilepsy with cognitive impairment is significant. When cerebral palsy and mental retardation coexist, seizure risk is higher. Both are indicators of neurologic abnormalities. Adding antiepileptic drugs to the equation, it becomes more complicated. The idiosyncratic reactions are of the greatest concerns because they are potentially life threatening. The additive effects of combination therapy can result in toxicity for almost half of the patients receiving three concurrent antiepileptic drugs.

            The inherent side effects include phenomena such as lethargy, decreased attention span, sleep pattern changes, impotency, and leukopenia. These side effects can produce their own behavioral consequences. Similarly, the dose-related adverse affects of sedation, mental dullness, ataxia, diplopia, and headache can produce behavioral effects. The ability of the cognitively impaired, mentally ill patient to articulate these concerns may be severely limited. A change in behavior may be the only way the patients have to express their concerns.

 

Phenytoin

            Phenytoin (Dilantin) appears essentially devoid of any significant general behavioral impact. However, in the case of people with mental retardation, phenytoin can cause significant dose-related cognitive impairment, as well as ataxia, poor coordination and dyskinesia that can consist principally of choreiform disturbances. Non-dose related effects can include significant cosmetic affects(darkening or increasing of body hair, coarsening of facial features, worsening of acne or gingival hyperplasia), which may have significant behavioral consequences. With chronic use, a consideration can be osteopenia (thinning of bones) as well as folic acid deficiency.

            Significant drug interactions can also occur because of pheytoin’s significant protein binding. Drug interactions with psychotropic medications, antibiotics, or other antiepileptic drugs can result insignificant change in the level due to this saturation kinetic interaction, resulting in toxicity that may manifest only as a behavior change.

 

Carbamazepine

            Carbamazepine (Tegretol) has resulted in many reports of favorable change. The most commonly reported changes are decreased anxiety, depression, and aggression with increased cooperation and generally improved behavior. Side effects include, double vision, cognitive viscosity, lethargy and movement disorders. Non-dose related side effects include hyponatremia, which when pronounced, can cause an exacerbation of seizures or behavioral consequences of its own. A few isolate reports of discontinuation as precipitating mania.

 

Valproic Acid

            Valproic acid (Depakene) has demonstrated a positive behavioral effect.. Side effects include gastrointestinal upset, tremor, elevation of ammonia, some somnolence, cognitive viscosity and thrombocytopenia. Non-dose related effects include weight gain, nausea and a change in hair texture loss. From a behavioral aspect, the most pertinent concern is the confusional state that can progress to coma or stupor. There has been evidence of brain atrophy which reversed when medication was discontinued.

 

Phenobarbitol

            The barbiturates are the drugs most clearly associated with negative behavioral changes. Several studies have demonstrated increased depression, irritability, unhappiness, argumentativeness, stubbornness, or aggression. The barbiturates have also been associated with the most negative cognitive effects among the antiepileptic drugs. Other side effects of barbiturates in cognitively impaired people are self-injury, disruptive vocalizations and temper tantrums. The possibility exists of allergic dermatitis, Stevens Johnson syndrome, hepatic failure and dupytrens contractures.

 

Gabapentin

            Gabapentin (Neurontin) ia s new antiepileptic medication that is designed as a gammaaminobutyric mimetic. Its non dose related side effects include somnambulence, cognitive impairment hyperactivity and aggression which makes it necessary to use it cautiously with cognitively impaired people especially with a history of previous irritable or aggressive behavior.

 

Felbamate

            Felbamate (Felbatol) was distributed in 1993 and used widely. Then it was discovered that this medicine has an irreversible idiosyncratic side effect, aplastic anemia. There is also possible behavioral exacerbations in patients with cognitive impairment and a past history of medicine induced behavioral exacerbations.

            Other newly developed antiepileptic drugs include lamotrigine (Lamictal), topramate (Topamax), tiagabine (Gabitril).

            Every anticonvulsnat medicine has behavioral consequences. The balance is between seizure control and side effects so choosing the appropriate medicine for the seizure type and epilepsy syndrome. It is prudent to avoid the barbiturates in the cognitively impaired, behaviorally challenged. Other medicines should each be considered as appropriate given their possible behavioral side effects.

 

Psychotropic Medications and Destructive Behavior

            The purpose of administering psychotropic treatments is to improve a person’s functioning by modifying the way that he typically responds to naturally occurring events in the environment. By doing so, challenging behavior is made unnecessary and improbable.

 

Functional Interpretations of Destructive Behavior

            A functional approach to behavioral assessment and treatment identifies factors associated with and controlling the person’s destructive behavior. These factors typically include environmental events immediately preceding or following the behavior problem as well as features of specific settings in which the behavior problem occurs.

            Many of our most effective environmentally-based treatments therefore, are designed to change the way we interact with individuals with behavior problems. Knowing the function of a problem behavior is important in designing habilitative or educational program s to promote alternative adaptive behaviors while reducing problem behaviors.

Biochemical Interpretations of Destructive Behavior

            There are cases, however, in which destructive behavior is neither attention nor escape motivated. There are three main neurochemical theories related to destructive behaviors – opioid receptor theory, serotonin receptor theory, and the dopamine theory.

 

Psychopathology, Dual Diagnosis and Functional Analysis of Behavior

            Major mental illness occurs among people with mental retardation with a higher incidence than among the non-developmentally disabled comparison group. A behavioral analysis of environmental variables can extend our understanding of the way in which biological brain disorders alter people’s ability to mange their daily transactions with the world around them.  In question are the primary presenting behavioral problems and learned adjustments to the environmental circumstances.

 

Neurobehavioral Pharmacology of Destructive Behavior

            A functional diagnostic approach attempts to evaluate the most probable behavioral and biological variables that may be contributing to the behavior of concern. A behavioral function may involve a consistent pattern of staff attention to head banging which maintains the problem behavior whereas a biological function may be related tot the release of endogenous opioids when the client strikes her head. The same form of destructive behavior may be influenced and controlled by different mechanisms. Self-injury that is pain-elicited or dopaminergically-driven may appear the same (eg, hand biting), but the neurochemical mechanisms regulating each type can be very different. Problem behavior that is positively reinforced (attention from the staff) or negatively reinforced (removal of an aversive task) may respond differently to pharmacological treatments.

            Therapeutic drugs influence a person’s health by modulating normal or abnormal physiological or biochemical processes.  If a person prone to hypertension walks too rapidly up the stairs, it may result in his blood pressure increasing to dangerous levels. A specific medication, clonidine, increases the diameter of peripheral blood vessels and therefore reduces the degree to which blood pressure increases when the person again takes the stairs two steps at a time. In comparison, the manner in which psychotropic drugs are often prescribed to alter the destructive behavior of people with developmental disabilities seldom reflects foregoing reasoning. Instead, practitioners and family members often act as though a medication can produce a qualitatively different patient outcome independent of the cause. Inappropriate prescriptions often arise from a prevalent theoretical misconception that drugs alter brain chemicals or physiological processes and cause behavior to change independent of the environmental circumstances within which the person functions. It is true that the brain’s neurochemistry and the body’s physiology set the limits at which external environmental processes and events exert their effects, but this does not happen in a vacuum. Sometimes there is a differential effect because part of what determines a drug’s effect is the person’s current and previous environmental circumstances ( their reinforcement history). Behavioral and medical history, and current circumstances influencing their behavior are variables that create the foundations upon which drugs are able to produce their effects. By adopting a functional approach, influential behavior and environmental factors are identified that may interact with a behaviorally active medication to improve a person’s ability to function independently and adaptively in addition to reducing a person’s destructive responses to the aversive environmental stimuli and stressors. The goal is to treat the underlying behavioral and biological mechanisms, not just the appearance of the behavior problem.

           

Psychotropic Medications and Contextual Control of Destructive Behavior

            Although different forms of destructive behavior can be influenced by discrete environmental events, such as staff demands placed on the individual, crowding, staff change, task repetition, and even stimulation arising from certain items of clothing, it is important to evaluate a broader range of environmental  setting factors including the typical physical  and social context setting the occasion for problem behavior, as well as events occurring within the individuals involved. This assessment would consider numerous factors including the health and physical discomfort of the individual (eg, menstrual cramps or pain from an inner ear infection), time since last meal or presence of a particular staff member.

 

Internal cues: rage, anxiety and panic attacks

            Environmental conditions that are provocative, demanding, or otherwise, stressful can often elicit internal stimulus changes. People with mental retardation often have difficulty learning socially acceptable ways to behave to internal emotional cues. Some of these feelings, such as anger, rage, anxiety or hostility may be ameliorated after an outburst of aggressive behavior.

 

 

Monitoring Psychotropic Medication

Development of psychotropic medication:

laudanum (opium in alcohol)

chloral hydrate 1869 [sedative hypnotic]

paraldehyde 1882

barbiturtates 1903

rauwolfia serpentina 1931 [the natural basis for reserpine used to treat psychosis]

amphetamine 1937 (Adderall) [stimulant]

phentoin 1940

lithium 1949 (Lithobid, Eskalith) [antimania]

chlorpromazine 1952 (Thorazine) [antipsychotic]

meprobamate 1954 (Miltown) [antianxiety]

chlordiazepoxide 1957 (Librium)[benzodiazepine antianxiolitic]

imipramil 1958 (Tofranil) [tricyclic antidepressants]

haloperidol 1958 (Haldol) [development of antipsychotics other than phenothiazines]

sertraline (Zoloft) SSRI antidepressant

clozapine (Clozaril) [antipsychotic for treatment resistant group]

 

In the mid ‘70’s, it became routine to have an “annual drug holiday”. It should be remembered that the original drug holiday requirement occurred because in numerous situations, psychotropic drugs had been given in large doses for years for unknown, vague or forgotten reasons and little or no data or monitoring existed.

This has been replaced by an in-depth psychotropic review conducted at least annually in relation to the underlying condition or hypothesis, treatment stage, risk factors, dose, side effects, index behavior data, quality of life, and concurrent non-

pharmacological interventions. If reduction is deemed possible, a gradual reduction plan is developed to determine the lowest maintenance dose, which may be, but no necessarily is, zero medication.

 

Psychotropic Medication Definition

            A psychopharamacologic medication is any drug prescribed to stabilize or improve mood, mental status or behavior. Some drugs typically classified as psychotropics may have other indications. The antianxiety agent diazepam (Valium) may be prescribed for spasticity and the stimulant methylphenidate (Ritalin) may be prescribed for narcolepsy. Similarly, drugs not typically classified as psychotropic may have psychiatric indications; such as the antiepileptic, carbamazepine (Tegretol) may be prescribed for certain affective diagnoses.

 

Biopsychosocial Model: postulates that biological, psychological and sociological aspects of care are interdependent and each must be acknowledged and addressed in order to provide optimal patient care.

 

Rational Empirical Model: the use of psychotropic medications must be based upon a psychiatric diagnosis or a specific behavioral-pharmacological hypothesis resulting from a full diagnostic and functional assessment. Specific index behaviors and quality of life outcomes must be objectively defined, quantified and tracked using recognized empirical measurement methods in order to evaluate the efficacy of psychotropic medication.

 

Coordinated Multidisciplinary Care Plan: psychotropic medication must be used within a coordinated multidisciplinary care plan designed to improve the individual’s quality of life. Psychotropic medication in and of itself is not a care plan. Behaviors or symptoms may worsen or improve and may do so in different settings. Behavior problems may not be entirely eliminated or may only return to previous levels, meaning that behavior or condition will still need to be addressed by the 9individual or others. Medications do not teach new skills or cognitive strategies; psychotropic medication does not prevent psychiatric relapse, it lowers the probability of relapse. A coordinated multidisciplinary care plan is important to address the interactive nature of biochemical, psychological and sociological aspects of care.

 

Short Term Versus Long Term Use

            The length of time a person is prescribed psychotropic medication and the dose level depend on a number of factors such as the diagnosis or condition itself, treatment phase and relapse history.

            Acute use:

            Generally 3-6 months or less: the key consideration is whether the problem (and resulting diagnosis or hypothesis and treatment plan) is of a short-term nature. In this case it is considered a short-term aid while adjustment occurs or educational strategies are taught to address a situation.

            Continuation (chronic use):

            Generally 4-24 months depending on the condition. An initial episode of a psychiatric condition may require a longer period of treatment in order to lower the probability of relapse.

            In any of these situations it is important to ensure a gradual dose reduction to ensure that any side effects are not the result of extraneous factors such as withdrawal effects, the environment, poor active treatment, other medical conditions or an undiagnosed psychiatric condition.

            Maintenance (extended use):

            Maintenance use is generally more than 12 – 24 months with expectation of extended or lifelong treatment.

 

Dose levels:

            It must be remembered that acute crisis doses or regimens are not necessarily maintenance drug and dose regimens.

 

Informed consent:

            The individual, if competent, or the individual’s guardian must provide written informed consent before the non-emergency initiation of any psychotropic medication and must be periodically renewed. Information should be provided orally, in writing and educationally.

 

Index Behaviors

            They are indicative of and serve as an observable index of the underlying condition of hypothesis. Specific index behaviors are important to assist in arriving at the diagnosis, evaluating progress and the psychotropic medication efficacy over time. It is the behavior that should improve over time. Tracking objective index behaviors over time is important to determine clinical status.

 

Baseline:

            A baseline is a period of time that an index behavior is measured in order to establish the frequency or severity of the index behavior. The most important aspect of a baseline is that it serves as a standard against which the efficacy of subsequent psychotropic medication is evaluated. A baseline is a mandatory part of an assessment.

 

Index Behaviors:

            Otherwise known as target behaviors. An observable index of the underlying condition or hypothesis; used to assist the prescriber of medications in diagnosis and to evaluate progress and psychotropic medication efficacy over time. As this applies to non-verbal people, clinical data collecting from behavioral observations and reports rather than traditional interviewing which has limitations. Over frequency, duration and time.

 

Side Effects: secondary effects of a drug that are undesirable and/or different from the therapeutic effect. ADR: any response to a drug that is noxious and unintended and that occurs at doses used in humans for prophylaxis, diagnosis, or therapy, excluding the failure to accomplish the intended purpose.

            ADR classifications are: hypersensitivity – reactions related to the patient’s immunologic response; idiosyncratic – reactions manifesting themselves as an inordinate response to o a usual drug (intolerance or hyperreactivity); side effects – reactions that are unintended and unwanted, yet are known pharmacologic effects of the drug; toxic reactions – reactions that are unintended, unwanted, and are not related to the drug’s pharmacologic effects; adverse drug interactions – reactions that are due to the in vivo interaction of two or more drugs. ADR’s are usually listed in standardized pharmacy and nursing references by body areas or systems. Categories include autonomic, cardiovascular, drug interactions, endocrine, gastrointestinal, hematological, hepatic, central nervous system, neurological, ocular, respiratory, dermatological, ocular, and urinary. Side effects scales can be general or specific and they address the side effects for all medications, or specific ones, depending on which is used.

           

 

Treatment for Challenging Behaviors or Mental Health Disorders: A False Dichotomy

 

Psychiatric disorders occur in persons with developmental disabilities at more than four times the rate observed in the intellectually unimpaired. The incidence of psychiatric disorders increases in relation to the severity of retardation. No major psychiatric diagnoses are peculiar to certain levels of intellectual functioning.

 

Functional analysis of behavior: the antecedent, the behavior, and the consequences. Target behaviors can be identified, but it should be understood that target behaviors can have transitory functions.

 

Describing the relationship between problem behavior and maintaining functions that it serves.

 

Six basic functions that problem behavior may serve, organized into two classes each motivated by either social or nonsocial outcomes.

            The desire to secure or maintain conditions of positive reinforcement

            The desire to secure negative reinforcement associated with escape and avoidance of aversive events.

  • an individual encounters a desirable item that she cannot obtain by herself, she may produce problem behavior to influence a social partner in a way that would result in obtaining the item.
  • problem behavior may be produced when a person wishes to secure or maintain the attention of the social partner.
  • – both presume that that the desired items and attention serve as positive reinforcers.; the probability increases that problem behavior will be used in the future to obtain these outcomes because they were delivered contingently.
  • Other situations may arise that an individual is expected to engage in an activity or interact with an aversive item; in this case an individual may engage in problem behavior to escape and avoid negative reinforcement.
  • The behavior may occur in an effort to obtain the contingent removal of discomfort.
  • If soothing comfort results as a consequence for a tantrum that was originally to relieve pain, the individual may generalize his problem behavior to situations in which he would like comforting affection, but does not have pain.

 

Problem behaviors may begin for different reasons, but are maintained by their social effect (positive; negative reinforcement).

 

Considerations in the Design of Effective Treatment

            Basic features of the living environment: a safe, humane environment that encourages the development and use of functional skills and likewise effectively addresses problems.

            The engagement of individuals in meaningful and enjoyable interactions and activities.

            Orderliness in the environment: predictability and structure of environment.

            Promoting independence and competence which is supported and maintained. Effective Treatment:

           

 

Diagnosis and treatment for the biological factors and medical conditions that may be contributing to the problem, including the appropriate use of pharmacotherapy for identified psychopathology directly or indirectly associated with the challenging behavior.

 

Assessment and analysis of the environmental conditions and contingencies that are functional in maintaining the challenging behavior and explicit inclusion of this information in all therapeutic and living arrangements.

 

Alteration of environmental conditions that provoke problems are altered or removed and circumstances that set the occasion for appropriate alternative behaviors predominate in the person’s day and life.

 

Use of instructional methods and reinforcement systems to strengthen behavior that will functionally replace the problems and to strengthen adaptive skills that will allow the individual to function in the environments in which the problem will be less

 

Reduction of reinforcement for the problem, specially decreasing the magnitude and frequency of reinforcement that the challenging behavior previously produced. The decrease is a relative one, involving the differential shift of reinforcement from problem behavior to alternative elements of the individuals’ repertoire that are more benign and adaptive in a conventionally desirable way.

 

Arrangement of specific consequences for the problem itself if the behavior remains dangerous or disruptive despite reasonable attempts to treat it.

 

Systematic programming for generalization and maintenance, ensuring that the arrangements that effectively resulted in improvements in the first [place are sufficiently in place in all the settings and times to enhance the likelihood that improvement will be pervasive and durable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

           

 

 

 

 

                       

           

 

     

PARADOX

Digging into Your Personal Past

What early memories tell us about who we are today

       by Robert Needlman, M.D., F.A.A.P.       reviewed by Laura Jana, M.D., F.A.A.P.

      Try as you might, you simply cannot remember everything that you have experienced–not yesterday, not a week ago, and certainly not when you were a child. In fact, very few of us remember much at all from our first three or four years. What memories we do hold on to are like the broken bits of ancient pottery, long buried in the sand. Yet, these fragments of memory can give us precious clues about our personalities.

       Shifting sands

      We rely on our memories to tell ourselves who we are, to anchor us. People who have lost their memories through brain damage are condemned to drift through life. But efore taking a closer look at your earliest memories, consider for a moment the puzzle that is memory. Autobiographical memories–the memories of what we have experienced and done in our lives–are at once indispensable and notoriously untrustworthy.

       We believe in our memories, and yet many of them are partial or complete fabrications. In one famous experiment, adults were told by relatives about how they got lost in a department store as a child–an incident that never happened. But after listening to the story several times, they developed memories of the event, complete with details that were entirely made up. And they persisted in believing these memories even after the researchers told them how they had been tricked.

       In another experiment, on the day the space shuttle Challenger exploded, college students were asked to write down how they had first heard about the disaster. Three years later, the same students were asked to recall the day. About a quarter of their remembered accounts were completely different from the original journal entries.

       These experiments, and many like them, have convinced researchers that memory cannot be thought of as a “bank” where people deposit their experiences and withdraw them unchanged years later. Rather, memories are creations of the moment, weaving together bits of stored experience with later-acquired knowledge and thoughts. In the process some elements are dropped and others elaborated on.

       The value of earliest memories

      Paradoxically, it is this very fluid nature of memory that makes early childhood memories so valuable. The fact that memories are always changing means that memories that have lasted for years and years must be meaningful–otherwise they would have faded out like the millions of other memories and impressions that disappeared without a trace. The very earliest memories, it follows, must be the most meaningful.

      Psychologists have pondered early memories for the past century. Sigmund Freud, wondering why “the earliest recollection of a person often seemed to preserve the unimportant and accidental,” suggested that seemingly trivial early memories might be “screens” hiding memories that were unacceptable to the conscious mind.  Alfred Adler, a key figure in ego       psychology who also stressed the importance of birth order, wrote that a person’s earliest memories are “the reminders he carries about with him of his own limits…a story he repeats to himself to warn or comfort him, to keep him concentrated on his goal.”

       More recently, several psychologists have developed systems for analyzing early memories as a form of personality assessment. None of these lend themselves to easy “how to” instructions, but there are some general principles which can help to guide your explorations of your earliest       recollections:

          Memories from early childhood are rare. Few people have more than a handful of them, and more than 90 percent of early memories are memories not of events themselves, but of accounts by other people of those events. How can you tell if yours is a secondhand memory? If you can see yourself in your memory, as though you were looking from across a room or down from the ceiling, then the memory cannot be an actual replay of your experience. But just because a memory is secondhand does not make it any less meaningful for you. After all, it is a memory that you have chosen to hang on to!

          Think about the role you play. Are you a passive observer in your memories, or are you active? Are you exploring, taking physical action, communicating? How you portray yourself to yourself in your earliest memories may give you insights into your character that weren’t obvious before.

      Think about relationships. In your memory, are you alone or with others? Are they helpful, caring, and supportive, or hostile and frightening? Earliest memories may shed light on the way you habitually perceive other people, a critical aspect of what Adler called your “style of life.”

       Think about emotions. In your memory, do you feel happy, sad, scared, angry, or confused? In daily life, emotions change from day to day and from moment to moment. The emotional tone of your early memories may be telling you something about a more fundamental, underlying emotional response to the world. If nothing else, the emotional flavor of your earliest memories raises a question: Is this how you feel most of the time?

       In addition to your earliest memory, consider a larger set of first memories: first memory of parents or siblings, going to school, playing with a friend, getting into an argument, being frightened, and so on.

      Write your memories down and look for patterns. The process of remembering and pondering won’t necessarily lead to a sudden revelation about your deepest nature, but it will make you a more introspective, self-aware individual.

       Traumatic memories 

      The topic of traumatic memories–memories of physical or sexual abuse–is       tremendously controversial. You may find that thinking about your earliest memories is fascinating or perhaps confusing. But if you find it to be upsetting, let that be a signal to you to stop. If you feel, however, that you need to explore this area of yourself further, please do so with the guidance of a qualified professional.

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      THIS SITE DOES NOT PROVIDE MEDICAL ADVICE. The information drSpock.com provides is for educational purposes only and is not a substitute for professional medical advice. Always seek the advice of your health care professional if you have a specific health concern. Mention or      advertisement of any product, service, or brand does not constitute endorsement, guarantee, or recommendation by The Dr. Spock Company. Please read our full Terms of Service.

Code of EthicsAMHCA members follow the highest professional standards and pledge to abide by this code.

Code of Ethics of the American Mental Health Counselors Association
2000 Revision

Preamble

Mental health counselors believe in the dignity and worth of the individual. They are committed to
increasing knowledge of human behavior and understanding of themselves and others. While
pursuing these endeavors, they make every reasonable effort to protect the welfare of those who
seek their services, or of any subject that may be the object of study. They use their skills only for
purposes consistent with these values and do not knowingly permit their misuse by others. While
demanding for themselves freedom of inquiry and community, mental health counselors accept
the responsibility this freedom confers: competence, objectivity in the application of skills, and
concern for the best interest of clients, colleagues, and society in general. In the pursuit of these
ideals, mental health counselors subscribe to the following principles:

Principle 1 Welfare of the Consumer

Principle 2 Clients’ Rights

Principle 3 Confidentiality

Principle 4 Utilization of Assessment Techniques

Principle 5 Pursuit of Research Activities

Principle 6 Consulting

Principle 7 Competence

Principle 8 Professional Relationships

Principle 9 Supervisee, Student and Employee Relationships

Principle 10 Moral and Legal Standards

Principle 11 Professional Responsibility

Principle 12 Private Practice

Principle 13 Public Statements

Principle 14 Internet On-Line Counseling

Principle 15 Resolution of Ethical Problems

Clinical Issues

Principle 1 Welfare of the Consumer

A) Primary Responsibility

1. The primary responsibility of the mental health counselor is to respect the dignity and
integrity of the client. Client growth and development are encouraged in ways that foster
the client’s interest and promote welfare.
2. Mental health counselors are aware of their influential position with respect to their
clients, and avoid exploiting the trust and fostering dependency of their clients.
3. Mental health counselors fully inform consumers as to the purpose and nature of any
evaluation, treatment, education or training procedure and they fully acknowledge that
the consumer has the freedom of choice with regard to participation.
B) Counseling Plans

Mental health counselors and their clients work jointly in devising integrated, individual counseling
plans that offer reasonable promise of success and are consistent with the abilities and
circumstances of the client. Counselors and clients regularly review counseling plans to ensure
their continued viability and effectiveness, respecting the client’s freedom of choice.

C) Freedom of Choice
Mental health counselors offer clients the freedom to choose whether to enter into a counseling
relationship and determine which professionals will provide the counseling. Restrictions that limit
clients’ choices are fully explained.

D) Clients Served by Others

1. If a client is receiving services from another mental health professional or counselor, the
mental health counselor secures consent from the client, informs that professional of the
arrangement, and develops a clear agreement to avoid confusion and conflicts for the
client.
2. Mental health counselors are aware of the intimacy and responsibilities inherent in the
counseling relationship. They maintain respect for the client and avoid actions that seek
to meet their personal needs at the expense of the client. Mental health counselors are
aware of their own values, attitudes, beliefs and behaviors, and how these apply in a
diverse society. They avoid imposing their values on the consumer.
E) Diversity

1. Mental health counselors do not condone or engage in any discrimination based on age,
color, culture, disability, ethnic group, gender, race, religion, sexual orientation, marital
status or socioeconomic status.
2. Mental health counselors will actively attempt to understand the diverse cultural
backgrounds of the clients with whom they work. This includes learning how the
counselor’s own cultural/ethical/racial/religious identity impacts his or her own values and
beliefs about the counseling process. When there is a conflict between the client’s goals,
identity and/or values and those of the mental health counselor, a referral to an
appropriate colleague must be arranged.
F) Dual Relationships
Mental health counselors are aware of their influential position with respect to their clients and
avoid exploiting the trust and fostering dependency of the client.

1. Mental health counselors make every effort to avoid dual relationships with clients that
could impair professional judgement or increase the risk of harm. Examples of such
relationships may include, but are not limited to: familial, social, financial, business, or
close personal relationships with the clients.
2. Mental health counselors do not accept as clients individuals with whom they are
involved in an administrative, supervisory, and evaluative nature. When acting as
supervisors, trainers, or employers, mental health counselors accord recipients informed
choice, confidentiality and protection from physical and mental harm.
3. When a dual relationship cannot be avoided, counselors take appropriate professional
precautions such as informed consent, consultation, supervision and documentation to
ensure that judgement is not impaired and no exploitation has occurred.
G) Sexual Relationships
Sexual relationships with clients are strictly prohibited. Mental health counselors do not counsel
persons with whom they have had a previous sexual relationship.

H) Former Clients
Counselors do not engage in sexual intimacies with former clients within a minimum of two years
after terminating the counseling relationship. The mental health counselor has the responsibility
to examine and document thoroughly that such relations did not have an exploitative nature
based on factors such as duration of counseling, amount of time since counseling, termination
circumstances, the client’s personal history and mental status, adverse impact on the client, and
actions by the counselor suggesting a plan to initiate a sexual relationship with the client after
termination.

I) Multiple Clients
When mental health counselors agree to provide counseling services to two or more persons who
have a relationship (such as husband and wife, or parents and children), counselors clarify at the
outset which person or persons are clients, and the nature of the relationship they will have with
each involved person. If it becomes apparent that counselors may be called upon to perform
potentially conflicting roles, they clarify, adjust, or withdraw from roles appropriately.

J) Informed Consent
Mental health counselors are responsible for making their services readily accessible to clients in
a manner that facilitates the clients’ abilities to make an informed choice when selecting a
provider. This responsibility includes a clear description of what the client can expect in the way
of tests, reports, billing, therapeutic regime and schedules, and the use of the mental health
counselor’s statement of professional disclosure. In the event that a client is a minor or
possesses disabilities that would prohibit informed consent, the mental health counselor acts in
the client’s best interest.

K) Conflict of Interest
Mental health counselors are aware of possible conflicts of interests that may involve the
organization in which they are employed and their client. When conflicts occur, mental health
counselors clarify the nature of the conflict and inform all parties of the nature and direction of
their loyalties and responsibilities, and keep all parties informed of their commitments.

L) Fees and Bartering

1. Mental health counselors clearly explain to clients, prior to entering the counseling
relationship, all financial arrangements related to professional services, including the use
of collection agencies or legal measures for nonpayment.
2. In establishing fees for professional counseling services, mental health counselors
consider the financial status of their clients and locality. In the event that the payment of
the mental health counselor’s usual fees would create undue hardship for the client,
assistance is provided in attempting to find comparable services at an acceptable cost.
3. Mental health counselors ordinarily refrain from accepting goods or services from clients
in return for counseling service because such arrangements create inherent potential for
conflicts, exploitation and distortion of the professional relationship. Participation in
bartering is only used when there is no exploitation, if the client requests it, if a clear
written contract is established, and if such an arrangement is an accepted practice
among professionals in the community.
M) Pro Bono Service
Mental health counselors contribute to society by devoting a portion of their professional activity
to services for which there is little or no financial return.

N) Consulting
Mental health counselors may choose to consult with any other professionally competent person
about a client. In choosing a consultant, the mental health counselor should avoid placing the
consultant in a conflict of interest situation that would preclude the consultant from being a proper
party to the mental health counselor’s effort to help the client.

O) Group Work

1. Mental health counselors screen prospective group counseling/therapy participants.
Every effort is made to select members whose needs and goals are compatible with
goals of the group, who will not impede the group process, and whose well being will not
be jeopardized by the group experience.
2. In the group setting, mental health counselors take reasonable precautions to protect
clients from physical and psychological harm or trauma.
3. When the client is engaged in short term group treatment/training programs, i.e.
marathons and other encounter type or growth groups, the members ensure that there is
professional assistance available during and following the group experience.
P) Termination and Referral
Mental health counselors do not abandon or neglect their clients in counseling. Assistance is
given in making appropriate arrangements for the continuation of treatment, when necessary,
during interruptions such as vacation and following termination.

Q) Inability to assist clients
If the mental health counselor determines that their services are not beneficial to the client, they
avoid entering or terminate immediately a counseling relationship. Mental health counselors are
knowledgeable about referral sources and appropriate referrals are made. If clients decline the
suggested referral, mental health counselors discontinue the relationship.

R) Appropriate Termination
Mental health counselors terminate a counseling relationship, securing a client’s agreement when
possible, when it is reasonably clear that the client is no longer benefiting, when services are no
longer required, when counseling no longer serves the needs and interests of the client, when
clients do not pay fees charged, or when agency or institution limits do not allow provision of
further counseling services.

Principle 2 Clients’ Rights

The following apply to all consumers of mental health services, including both in- and out-patients
and all state, county, local, and private care mental health facilities, as well as clients of mental
health practitioners in private practice.

The client has the right:

A) To be treated with dignity, consideration and respect at all times;

B) To expect quality service provided by concerned, trained, professional and competent staff;

C) To expect complete confidentiality within the limits of the law, and to be informed about the
legal exceptions to confidentiality; and to expect that no information will be released without the
client’s knowledge and written consent;

D) To a clear working contract in which business items, such as time of sessions, payment
plans/fees, absences, access, emergency procedures, and third-party reimbursement procedures
are discussed;

E) To a clear statement of the purposes, goals, techniques, rules of procedure and limitations, as
well as the potential dangers of the services to be performed, and all other information related to
or likely to affect the ongoing mental health counseling relationship;

F) To appropriate information regarding the mental health counselor’s education, training, skills,
license and practice limitations and to request and receive referrals to other clinicians when
appropriate;

G) To full, knowledgeable, and responsible participation in the ongoing treatment plan to the
maximum extent feasible;

H) To obtain information about their case record and to have this information explained clearly
and directly;

I) To request information and/or consultation regarding the conduct and progress of their therapy;

J) To refuse any recommended services and to be advised of the consequences of this action;

K) To a safe environment free of emotional, physical and sexual abuse;

L) To a client grievance procedure, including requests for consultation and/or mediation; and to
file a complaint with the mental health counselor’s supervisor, and/or the appropriate
credentialing body; and

M) To a clearly defined ending process, and to discontinue therapy at any time.

Principle 3 Confidentiality

Mental health counselors have a primary obligation to safeguard information about individuals
obtained in the course of practice, teaching, or research. Personal information is communicated
to others only with the person’s written consent or in those circumstances where there is clear
and imminent danger to the client, to others or to society. Disclosure of counseling information is
restricted to what is necessary, relevant and verifiable.

A) At the outset of any counseling relationship, mental health counselors make their clients aware
of their rights in regard to the confidential nature of the counseling relationship. They fully disclose
the limits of, or exceptions to, confidentiality, and/or the existence of privileged communication, if
any.

B) All materials in the official record shall be shared with the client, who shall have the right to
decide what information may be shared with anyone beyond the immediate provider of service
and be informed of the implications of the materials to be shared.

C) Confidentiality belongs to the clients. They may direct the mental health counselor, in writing,
to release information to others. The release of information without the consent of the client may
only take place under the most extreme circumstances. The protection of life, as in the case of
suicidal or homicidal clients, exceeds the requirements of confidentiality. The protection of a child,
an elderly person, or a person not competent to care for themselves from physical or sexual
abuse or neglect requires that a report be made to a legally constituted authority. The mental
health counselor complies with all state and federal statutes concerning mandated reporting of
suicidality, homicidality, child abuse, incompetent person abuse and elder abuse. The protection
of the public or another individual from a contagious condition known to be fatal also requires
action that may include reporting the willful infection of another with the condition.

The mental health counselor (or staff member) does not release information by request unless
accompanied by a specific release of information or a valid court order. Mental health counselors
will comply with the order of a court to release information but they will inform the client of the
receipt of such an order. A subpoena is insufficient to release information. In such a case, the
counselor must inform his client of the situation and, if the client refuses release, coordinate
between the client’s attorney and the requesting attorney so as to protect client confidentiality and
one’s own legal welfare.

In the case of all of the above exceptions to confidentiality, the mental health counselor will
release only such information as is necessary to accomplish the action required by the exception.

D) The anonymity of clients served in public and other agencies is preserved, if at all possible, by
withholding names and personal identifying data. If external conditions require reporting such
information, the client shall be so informed.

E) Information received in confidence by one agency or person shall not be forwarded to another
person or agency without the client’s written permission.

F) Service providers have the responsibility to ensure the accuracy and to indicate the validity of
data shared with their parties.

G) Case reports presented in classes, professional meetings, or publications shall be so
disguised that no identification is possible unless the client or responsible authority has read the
report and agreed in writing to its presentation or publication.

H) Counseling reports and records are maintained under conditions of security, and provisions
are made for their destruction when they have outlived their usefulness. Mental health counselors
ensure that all persons in his or her employ, volunteers, and community aides maintain privacy
and confidentiality.

I) Mental health counselors who ask that an individual reveal personalinformation in the course of
interviewing, testing or evaluation, or who allow such information to be divulged, do so only after
making certain that the person or authorized representative is fully aware of the purposes of the
interview, testing or evaluation, and of the ways in which the information will be used.

J) Sessions with clients may be taped or otherwise recorded only with their written permission or
the written permission of a responsible guardian. Even with a guardian’s written consent, one
should not record a session against the expressed wishes of a client. Such tapes shall be
destroyed when they have outlived their usefulness.

K) Where a child or adolescent is the primary client, or the client is not competent to give consent,
the interests of the minor or the incompetent client shall be paramount. Where appropriate, a
parent(s) or guardian(s) may be included in the counseling process. The mental health counselor
must still take measures to safeguard the client’s confidentiality.

L) In work with families, the rights of each family member should be safeguarded. The provider of
service also has the responsibility to discuss the contents of the record with the parent and/or
child, as appropriate, and to keep separate those parts, which should remain the property of each
family member.

M) In work with groups, the rights of each group member should be safeguarded. The provider of
service also has the responsibility to discuss the need for each member to respect the
confidentiality of each other member of the group. He must also remind the group of the limits on
and risk to confidentiality inherent in the group process.

N) When using a computer to store confidential information, mental health counselors take
measures to control access to such information. When such information has outlived its
usefulness, it should be deleted from the system.

Principle 4 Utilization of Assessment Techniques

A) Test Selection

1. In choosing a particular test, mental health counselors should ascertain that there is
sufficient evidence in the test manual of its applicability in measuring a certain trait or
construct. The manual should fully describe the development of the test, the rationale,
and data pertaining to item selection and test construction. The manual should explicitly
state the purposes and applications for which the test is intended, and provide reliability
and validity data about the test. The manual should furthermore identify the qualifications
necessary to properly administer and interpret the test.
2. In selecting a particular combination of tests, mental health counselors need to be able to
justify the logic of those choices.
3. Mental health counselors should employ only those tests for which they judge themselves
competent by training, education, or experience. In familiarizing themselves with new
tests, counselors thoroughly read the manual and seek workshops, supervision, or other
forms of training.
4. Mental health counselors avoid using outdated or obsolete tests, and strive to remain
current regarding test publication and revision.
5. Tests selected for individual testing must be appropriate for that individual in that
appropriate norms exist for variables such as age, gender, and race. The test form must
fit the client. If the test must be used in the absence of available information regarding the
above subsamples, the limitations of generalizability should be duly noted.
B) Test Administration

1. Mental health counselors should faithfully follow instructions for administration of a test in
order to ensure standardization. Failure to consistently follow test instructions will result in
test error and incorrect estimates of the trait or behavior being measured.
2. Tests should only be employed in appropriate professional settings or as recommended
by instructors or supervisors for training purposes. It is best to avoid giving tests to
relatives, close friends or business associates, in that doing so constructs a dual
professional/personal relationship, which is to be avoided.
3. Mental health counselors should provide the test taker with appropriate information
regarding the reason for assessment, the approximate length of time required, and to
whom the report will be distributed. Issues of confidentiality must be addressed, and the
client must be given the opportunity to ask questions of the examiner prior to beginning
the procedure.
4. Care should be taken to provide an appropriate assessment environment in regard to
temperature, privacy, comfort, and freedom from distractions.

5. Information should be solicited regarding any possible handicaps, such as problems with
visual or auditory acuity, limitations of hand/eye coordination, illness, or other factors. If
the disabilities cannot be accommodated effectively, the test may need to be postponed
or the limitations of applicability of the test results noted in the test report.
6. Professionals who supervise others should ensure that their trainees have sufficient
knowledge and experience before utilizing the tests for clinical purposes.
7. Mental health counselors must be able to document appropriate education, training, and
experience in areas of assessment they perform.
C) Test Interpretation

1. Interpretation of test or test battery results should be based on multiple sources of
convergent data and an understanding of the tests’ foundations and limits.
2. Mental health counselors must be careful not to make conclusions unless empirical
evidence is present to justify the statement. If such evidence is lacking, one should not
make diagnostic or prognostic formulations.
3. Interpretation of test results should take into account the many qualitative influences on
test-taking behavior, such as health, energy, motivation, and the like. Description and
analysis of alternative explanations should be provided with the interpretations.
4. One should not make firm conclusions in the absence of published information that
establishes a satisfactory degree of test validity, particularly predictive validity.
5. Multicultural factors must be considered in test interpretation and diagnosis, and
formulation of prognosis and treatment recommendations.
6. Mental health counselors should avoid biased or incorrect interpretation by assuring that
the test norms reference the population taking the test.
7. Mental health counselors are responsible for evaluating the quality of computer software
interpretations of test data. Mental health counselors should obtain information regarding
validity of computerized test interpretation before utilizing such an approach.
8. Supervisors should ensure that their supervisees have had adequate training in
interpretation before entrusting them to evaluate tests in a semi-autonomous fashion.
9. Any individual or organization offering test scoring or interpretation services must be able
to demonstrate that their programs are based on sufficient and appropriate research to
establish the validity of the programs and procedures used in arriving at interpretations.
The public offering of an automated test interpretation service will be considered a
professional-to-professional consultation. The formal responsibility of the consultant is to
the consultee, but his or her ultimate and overriding responsibility is to the client.
10. Mental health counselors who have the responsibility for making decisions about clients
or policies based on test results should have a thorough understanding of counseling
theory, assessment techniques, and test research.
11. Mental health counselors do not represent computerized test interpretations as their own
and clearly designate such computerized results.
D) Test Reporting

1. Mental health counselors should write reports in a clear fashion, avoiding excessive
jargon or clinical terms that are likely to confuse the lay reader.
2. Mental health counselors should strive to provide test results in as positive and
nonjudgmental manner as possible.
3. Mindful that one’s report reflects on the reputation of oneself and one’s profession,
reports are carefully proofread so as to be free of spelling, style, and grammatical errors
as much as is possible.
4. Clients should be clearly informed about who will be allowed to review the report and, in
the absence of a valid court order, must sign appropriate releases of information
permitting such release. Mental health counselors must not release the report or findings
in the absence of the aforementioned releases or order.

5. Mental health counselors are responsible for ensuring the confidentiality and security of
test reports, test data, and test materials.
6. Mental health counselors must offer the client the opportunity to receive feedback about
the test results, interpretations, and the range of error for such data.
7. Transmissions of test data or test reports by fax or e-mail must be accomplished in a
secure manner, with guarantees that the receiving device is capable of providing a
confidential transmission only to the party who has been permitted to receive the
document.
8. Mental health counselors should train his or her staff to respect the confidentiality of test
reports in the context of typing, filing, or mailing them.
9. Mental health counselors (or staff members) do not release a psychological evaluation by
request unless accompanied by a specific release of information or a valid court order. A
subpoena is insufficient to release a report. In such a case, the counselor must inform
his/her client of the situation and, if the client refuses release, coordinate between the
client’s attorney and the requesting attorney so as to protect client confidentiality and
one’s own legal welfare.

Principle 5 Pursuit of Research Activities

Mental health counselors who conduct research must do so with regard to ethical principles. The
decision to undertake research should rest upon a considered judgment by the individual
counselor about how best to contribute to counseling and to human welfare. Mental health
counselors carry out their investigations with respect for the people who participate and with
concern for their dignity and welfare.

1. The ethical researcher seeks advice from other professionals if any plan of research
suggests a deviation from any ethical principle of research with human subjects. Such
deviation must still protect the dignity and welfare of the client and places on the
researcher a special burden to act in the subject’s interest.
2. The ethical researcher is open and honest in the relationship with research participants.
a) The ethical researcher informs the participant of all features of the research that might
be expected to influence willingness to participate and explains to the participant all other
aspects about which the participant inquires.
b) Where scientific or human values justify delaying or withholding information, the
investigator acquires a special responsibility to assure that there are no damaging
consequences for the participants.
c) Following the collection of the data, the ethical researcher must provide the participant
with a full clarification of the nature of the study to remove any misconceptions that may
have arisen.
d) As soon as possible, the participant is to be informed of the reasons for concealment
or deception that are part of the methodological requirements of a study.
e) Such misinformation must be minimized and full disclosure must be made at the
conclusion of all research studies.
f) The ethical researcher understands that failure to make full disclosure to a research
participant gives added emphasis to the researcher’s abiding responsibility to protect the
welfare and dignity of the participant.
3. The ethical researcher protects participants from physical and mental discomfort, harm
and danger. If the risks of such consequences exist, the investigator is required to inform
the participant of that fact, secure consent before proceeding, and take all possible
measures to minimize the distress.
4. The ethical researcher instructs research participants that they are free to withdraw their
consent and from participation at any time.
5. The ethical researcher understands that information obtained about research participants

during the course of an investigation is confidential. When the possibility exists that
others may obtain access to such information, the participant must be made aware of the
possibility and the plans for protecting confidentiality as a part of the procedure for
obtaining informed consent.
6. The ethical researcher gives sponsoring agencies, host institutions, and publication
channels the same respect and opportunity for informed consent that they accord to
individual research participants.
7. The ethical researcher is aware of his or her obligation to future research workers and
ensures that host institutions are given feedback information and proper
acknowledgement.

Principle 6 Consulting

A) Mental health counselors acting as consultants must have a high degree of self-awareness of
their own values, knowledge, skills and needs in entering a helping relationship that involves
human and/or organizational change. The focus of the consulting relationship should be on the
issues to be resolved and not on the personal characteristics of those presenting the consulting
issues.

B) Mental health counselors should develop an understanding of the problem presented by the
client and should secure an agreement with the consultation client, specifying the terms and
nature of the consulting relationship.

C) Mental health counselors must be reasonably certain that they and their clients have the
competencies and resources necessary to follow the consultation plan.

D) Mental health counselors should encourage adaptability and growth toward self-direction.
Mental health counselors should avoid becoming a decision-maker or substitute for the client.

E) When announcing consultant availability for services, mental health counselors conscientiously
adhere to professional standards.

F) Mental health counselors keep all proprietary information confidential.

G) Mental health counselors avoid conflicts of interest in selecting consultation clients.

Professional Issues

Principle 7 Competence

The maintenance of high standards of professional competence is a responsibility shared by all
mental health counselors in the best interests of the public and the profession. Mental health
counselors recognize the boundaries of their particular competencies and the limitations of their
expertise. Mental health counselors only provide those services and use only those techniques
for which they are qualified by education, techniques or experience. Mental health counselors
maintain knowledge of relevant scientific and professional information related to the services they
render, and they recognize the need for on-going education.
A) Mental health counselors accurately represent their competence, education, training and
experience.

B) As teaching professionals, mental health counselors perform their duties based on careful
preparation in order that their instruction is accurate, up to date and educational.

C) Mental health counselors recognize the need for continued education and training in the area
of cultural diversity and competency. Mental health counselors are open to new procedures and
sensitive to the diversity of varying populations and changes in expectations and values over
time.

D) Mental health counselors and practitioners recognize that their effectiveness depends in part
upon their ability to maintain sound and healthy interpersonal relationships. They are aware that
any unhealthy activity would compromise sound professional judgement and competency. In the
event that personal problems arise and are affecting professional services, they will seek
competent professional assistance to determine whether they should limit, suspend or terminate
services to their clients.

E) Mental health counselors have a responsibility both to the individual who is served and to the
institution within which the service is performed to maintain high standards of professional
conduct. Mental health counselors strive to maintain the highest level of professional services
offered to the agency, organization or institution in providing the highest caliber of professional
services. The acceptance of employment in an institution implies that the mental health counselor
is in substantial agreement with the general policies and principles of the institution. If, despite
concerted efforts, the member cannot reach an agreement with the employer as to acceptable
standards of conduct that allows for changes in institutional policy conducive to the positive
growth and development of counselors, then terminating the affiliation should be seriously
considered.

G) Ethical behavior among professional associates, mental health counselors and non-mental
health counselors is expected at all times. When information is possessed that raises serious
doubts as to the ethical behavior of professional colleagues, whether association members or not,
the mental health counselor is obligated to take action to attemptto rectify such a condition. Such
action shall utilize the institution’s channels first and then utilize procedures established by the
state licensure board.

H) Mental health counselors are aware of the intimacy of the counseling relationship, maintain a
healthy respect for the integrity of the client, and avoid engaging in activities that seek to meet the
mental health counselor’s personal needs at the expense of the client. Through awareness of the
negative impact of both racial and sexual stereotyping and discrimination, the member strives to
ensure the individual rights and personal dignity of the client in the counseling relationship.

Principle 8 Professional Relationships

Mental health counselors act with due regard for the needs and feelings of their colleagues in
counseling and other professions. Mental health counselors respect the prerogatives and
obligations of the institutions or organizations with which they associate.

A) Mental health counselors understand how related professions complement their work and
make full use of other professional, technical, and administrative resources that best serve the
interests of consumers. The absence of formal relationships with other professional workers does
not relieve mental health counselors from the responsibility of securing for their clients the best
possible professional services; indeed, this circumstance presents a challenge to the professional
competence of mental health counselors, requiring special sensitivity to problems outside their
areas of training, and foresight, diligence, and tact in obtaining the professional assistance
needed by clients.

B) Mental health counselors know and take into account the traditions and practices of other
professional groups with which they work and cooperate fully with members of such groups when
research, services and other functions are shared, or in working for the benefit of public welfare.

C) Mental health counselors treat professional colleagues with the same dignity and respect
afforded to clients. Professional discourse should be free of personal attacks.

D) Mental health counselors strive to provide positive conditions for those they employ and to
spell out clearly the conditions of such employment. They encourage their employees to engage
in activities that facilitate their further professional development.

E) Mental health counselors respect the viability, reputation, and proprietary rights of
organizations that they serve. Mental health counselors show due regard for the interest of their
present or perspective employers. In those instances where they are critical of policies, they
attempt to effect change by constructive action within the organization.

F) In pursuit of research, mental health counselors are to give sponsoring agencies, host
institutions, and publication channels the same respect and opportunity for giving informed
consent that they accord to individual research participants. They are aware of their obligation to
future research workers and insure that host institutions are given feedback information and
proper acknowledgement.

G) Credit is assigned to those who have contributed to a publication, in proportion to their
contribution.

H) Mental health counselors do not accept or offer referral fees from other professionals.

I) When mental health counselors violate ethical standards, mental health counselors who know
firsthand of such activities should, if possible, attempt to rectify the situation. Failing an informal
solution, mental health counselors should bring such unethical activities to the attention of the
appropriate state licensure board committee on ethics and professional conduct. Only after all
professional alternatives have been utilized will mental health counselors begin legal action for
resolution.

Principle 9 Supervisee, Student and Employee Relationships

Mental health counselors have an ethical concern for the integrity and welfare of supervisees,
students, and employees. They maintain these relationships on a professional and confidential
basis. They recognize the influential position they have with regard to both current and former
supervisees, students and employees. They avoid exploiting their trust and dependency.

A) Mental health counselors do not engage in ongoing counseling relationships with current
supervisees, students and employees.

B) All forms of sexual behavior with supervisees, students and employees are unethical. Further,
mental health counselors do not engage in sexual or other harassment of supervisees, students,
employees or colleagues.

C) Mental health counselor supervisors advise their supervisees, students and employees
against offering or engaging in or holding themselves out as competent to engage in professional
services beyond their training, level of experience and competence.

D) Mental health counselors make every effort to avoid dual relationships with supervisees,
students and employees that could impair their judgment or increase the risk of personal or
financial exploitation. When a dual relationship can not be avoided, mental health counselors take
appropriate professional precautions to make sure that judgment is not impaired. Examples of
such dual relationships include, but are not limited to, a supervisee who receives supervision as a
benefit of employment, or a student in a small college where the only available counselor on
campus is an instructor.

E) Mental health counselors do not disclose supervisee confidences except:

1. To prevent clear and eminent danger to a person or persons.
2. As mandated by law.
a) As in mandated child or senior abuse reporting.
b) Where the counselor is a defendant in a civil, criminal or disciplinary action.
c) In educational or training settings where only other professionals who will share
responsibility for the training of the supervisee are present.
d) Where there is a waiver of confidentiality obtained in writing prior to such a release of
information.
F) Supervisees must make their clients aware in their informed consent statement that they are
under supervision and they must provide their clients with the name and credentials of their
supervisor.

G) Mental health counselors require their supervisees, students and employees to adhere to the
Code of Ethics. Students and supervisees have the same obligations to clients as those required
of mental health counselors.

Principle 10 Moral and Legal Standards

Mental health counselors recognize that they have a moral, legal and ethical responsibility to the
community and to the general public. Mental health counselors should be aware of the prevailing
community standards and the impact of professional standards on the community.

A) To protect students, mental health counselors/teachers will be aware of diverse backgrounds
of students and will see that material is treated objectively and fairly to reflect the multicultural
community in which they live.

B) Providers of counseling services conform to the statutes relating to such services as
established by their state and its regulating professional board(s).

C) As employees, mental health counselors refuse to participate in an employer’s practices that
are inconsistent with the moral and legal standards established by federal or state legislation
regarding the treatment of employees. In particular and for example, mental health counselors will
not condone practices that result in illegal or otherwise unjustified discrimination on the basis of
race, sex, religion or national origin in hiring, promotion or training.

D) In providing counseling services to clients, mental health counselors avoid any action that will
violate or diminish the legal and civil rights of clients or of others that may be effected by the
action.

E) Sexual conduct, not limited to sexual intercourse, between mental health counselors and
clients is specifically in violation of this Code of Ethics. This does not, however, prohibit the use of
explicit instructional aids including films and videotapes. Such use is within excepted practices of
trained and competent sex therapists.

Principle 11 Professional Responsibility

In their commitment to the understanding of human behavior, mental health counselors value
objectivity and integrity, and in providing services they maintain the highest standards. They
accept responsibility for the consequences of their work and make every effort to ensure that their
services are used appropriately.

A) Mental health counselors accept ultimate responsibility for selecting appropriate areas for
investigation and the methods relevant to minimize the possibility that their finding will be
misleading. They provide thorough discussion of the limitations of their data and alternative
hypotheses, especially where their work touches on social policy or might be misconstrued to the
detriment of specific age, sex, ethnic, socioeconomic, or other social categories. In publishing
reports of their work, they never discard observations that may modify the interpretation of
results. Mental health counselors take credit only for the work they have actually done. In
pursuing research, mental health counselors ascertain that their efforts will not lead to changes in
individuals or organizations unless such changes are part of the agreement at the time of
obtaining informed consent. Mental health counselors clarify in advance the expectations for
sharing and utilizing research data. They avoid dual relationships that may limit objectivity,
whether theoretical, political, or monetary, so that interference with data, subjects, and milieu is
kept to a minimum.

B) As employees of an institution or agency, mental health counselors have the responsibility to
remain alert to institutional pressures that may distort reports of counseling findings or use them
in ways counter to the promotion of human welfare.

C) When serving as members of governmental or other organizational bodies, mental health
counselors remain accountable as individuals to the Code of Ethics of the American Mental
Health Counselors Association.

D) As teachers, mental health counselors recognize their primary obligation to help others acquireknowledge and skill. They maintain high standards of scholarship and objectivity by presenting
counseling information fully and accurately, and by giving appropriate recognition to alternative
viewpoints.

E) As practitioners, mental health counselors know that they bear a heavy social responsibility
because their recommendations and professional actions may alter the lives of others. They
therefore remained fully cognizant of their impact and alert to personal, social, organizational,
financial or political situations or pressures that might lead to the misuse of their influence.

F) Mental health counselors provide reasonable and timely feedback to employees, trainees,
supervisors, students, clients, and others whose work they may evaluate.

Principle 12 Private Practice

A) A mental health counselor should assist, where permitted by legislation or judicial decision, the
profession in fulfilling its duty to make counseling services available in private settings.

B) In advertising services as a private practitioner, mental health counselors should advertise the
services in such a manner so as to accurately inform the public as to services, expertise,
profession, and techniques of counseling in a professional manner. Mental health counselors who
assume an executive leadership role in the organization shall not permit their name to be used in
professional notices during periods when not actively engaged in the private practice of
counseling. Mental health counselors advertise the following: highest relevant degree, type and
level of certification or license, and type and/or description of services or other relevant
information. Such information should not contain false, inaccurate, misleading, partial, out of
context, descriptive material or statements.

C) Mental health counselors may join in partnership/corporation with other mental health
counselors and/or other professionals provided that each mental health counselor of the
partnership or corporation makes clear his/her separate specialties, buying name in compliance
with the regulations of the locality.

D) Mental health counselors have an obligation to withdraw from an employment relationship or a
counseling relationship if it is believed that employment will result in violation of the Code of
Ethics, if their mental capacity or physical condition renders it difficult to carry out an effective
professional relationship, or if the mental health counselor is discharged by the client because the
counseling relationship is no longer productive for the client.

E) Mental health counselors should adhere and support the regulations for private practice in the
locality where the services are offered.

F) Mental health counselors refrain from attempts to utilize one’s institutional affiliation to recruit
clients for one’s private practice. Mental health counselors are to refrain from offering their
services in the private sector when they are employed by an institution in which this is prohibited
by stated policy that reflects conditions of employment.

Principle 13 Public Statements

Mental health counselors in their professional roles may be expected or required to make public
statements providing counseling information or professional opinions; or supply information about
the availability of counseling products and services. In making such statements, mental health
counselors take into full account the limits and uncertainties of present counseling knowledge and
techniques. They represent, as accurately and objectively as possible, their professional
qualifications, expertise, affiliations, and functions, as well as those of the institutions or
organizations with which the statements may be associated. All public statements,
announcements of services, and promotional activities should serve the purpose of providing
sufficient information to aid the consumer public in making informed judgements and choices on
matters that concern it. When announcing professional counseling services, mental health
counselors may describe or explain those services offered but may not evaluate as to their quality
or uniqueness and do not allow for testimonials by implication. All public statements should be
otherwise consistent with this Code of Ethics.

Principle 14 Internet On-Line Counseling

Mental health counselors engaged in delivery of services that involves the telephone,
teleconferencing and the Internet in which these areas are generally recognized, standards for
preparatory training do not yet exist. Mental health counselors take responsible steps to ensure
the competence of their work and protect patients, clients, students, research participants and
others from harm.

A) Confidentiality
Mental health counselors ensure that clients are provided sufficient information to adequately
address and explain the limitations of computer technology in the counseling process in general
and the difficulties of ensuring complete client confidentiality of information transmitted through
electronic communications over the Internet through on-line counseling. Professional counselors
inform clients of the limitations of confidentiality and identify foreseeable situations in which
confidentiality must be breached in light of the law in both the state in which the client is located
and the state in which the professional counselor is licensed. Mental health counselors shall
become aware of the means for reporting and protecting suicidal clients in their locale. Mental
health counselors shall become aware of the means for reporting homicidal clients in the client’s
jurisdiction.

B) Mental Health Counselor Identification
Mental health counselors provide a readily visible notice advising clients of the identities of all
professional counselor(s) who will have access to the information transmitted by the client. Mental
health counselors provide background information on all professional communications, including
education, licensing and certification, and practice information.

C) Client Identification
Professional counselors identify clients, verify identities of clients, and obtain alternative methods
of contacting clients in emergency situations.

D) Client Waiver
Mental health counselors require clients to execute client waiver agreements stating that the
client acknowledges the limitations inherent in ensuring client confidentiality of information
transmitted through on-line counseling and acknowledge the limitations that are inherent in a
counseling process that is not provided face-to-face. Limited training in the area of on-line
counseling must be explained and the client’s informed consent must be secured.

E) Electronic Transfer of Client Information
Mental health counselors electronically transfer client confidential information to authorized third-
party recipients only when both the professional counselor and the authorized recipient have
“secure” transfer and acceptance communication capabilities;the recipient is able to effectively
protect the confidentiality of the client’s confidential information to be transferred; and the
informed written consent of the client, acknowledging the limits of confidentiality, has been
obtained.

F) Establishing the On-Line Counseling Relationship

1. Appropriateness of On-line Counseling
Mental health counselors develop an appropriate in-take procedure for potential clients to

determine whether on-line counseling is appropriate for the needs of the client. Mental
health counselors warn potential clients that on-line counseling services may not be
appropriate in certain situations and, to the extent possible, inform the client of specific
limitations, potential risks, and/or potential benefits relevant to the client’s anticipated use
of on-line counseling services. Mental health counselors ensure that clients are
intellectually, emotionally, and physically capable of using on-line counseling services,
and of understanding the potential risks and/or limitations of such services.
2. Counseling Plans
Mental health counselors develop individual on-line counseling plans that are consistent
with both the client’s individual circumstances and the limitations of on-line counseling.
Mental health counselors who determine that on-line counseling is inappropriate for the
client should avoid entering into or immediately terminate the on-line counseling
relationship and encourage the client to continue the counseling relationship through a
traditional alternative method of counseling.
3. Boundaries of Competence
Mental health counselors provide on-line counseling services only in practice areas within
their expertise. Mental health counselors do not provide services to clients in states
where doing so would violate local licensure laws or regulations.
G) Legal Considerations
Mental health counselors confirm that the provision of on-line services are not prohibited by or
otherwise violate any applicable state or local statutes, rules, regulations or ordinances, codes of
professional membership organizations and certifying boards, and/or codes of state licensing
boards.

Principle 15 Resolution of Ethical Problems

Neither the American Mental Health Counselors Association, its Board of Directors, nor its
National Committee on Ethics investigate or adjudicate ethical complaints. In the event a member
has his or her license suspended or revoked by an appropriate state licensure board, the AMHCA
Board of Directors may then act in accordance with AMHCA’s National By-Laws to suspend or
revoke his or her membership.

Any member so suspended may apply for reinstatement upon the reinstatement of his or her
licensure.

Tips For Controlling Blood Alcohol Concentration (BAC):

 

Pace your drinking, allow time between drinks

 

Consider alternating non-alcoholic “decoy” drinks with those containing alcohol, ie. drinking plain orange juice every other drink.

 

Don’t drink on an empty stomach, foods with fats and/or proteins slow alcohol absorption.

 

Keep track of how much you are drinking; know how much alcohol is poured into every glass.

 

Dilute distilled beverages, don’t drink them straight.  After the first few drinks, reduce the amount of alcohol in each drink.(Your taste buds will be dulled and you won’t be able to tell the difference.)

 

Switch to “light beer” or “low alcohol” wines after the first few drinks.  (Again, your taste buds will be dulled and you won’t be able to tell the difference.)

 

Avoid possible interactions between alcohol and other drugs (including certain foods and over-the-counter medications).

 

Drink only if YOU want to, don’t let others dictate your choice.

 

Keep active.  Don’t just sit down and drink all night.  If you keep active you will drink less and will be more aware of your level of intoxication.

 

Keep out of “Chugging” contests or other drinking “games.”

 

Stop drinking before the party is over, to allow your liver time to burn off some of the alcohol.  Drink non-alcoholic beverages the last hour or so.

 

Keep in mind that an added ice cube, a slightly smaller glass, or a “decoy” drink will go undetected by others.  They may help you to resist the well-meaning efforts of others at the party who can’t stand to see someone without a drink in their hand.

 

Remember:  Careful planning of a party can increase the pleasure for both the guests and the hosts.  BAC’s are good measures of the amount of pleasure (or discomfort) that will result from a particular pattern of drinking.  BAC’s in excess of 0.125% will NOT increase the pleasure, only the discomfort.

 

Responsible alcohol use means that you won’t be sorry in the morning.