assessment of dd new 7

Clinical Assessment of Clinical Assessment of Developmental DisordersDevelopmental Disorders

Dr Khalid MansourDr Khalid MansourLocum Consultant Psychiatrist Locum Consultant Psychiatrist

Al-Amal HospitalAl-Amal HospitalRiyadh – SARiyadh – SA

20112011

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Introduction 1:Introduction 1: In psychiatry > two main categories: In psychiatry > two main categories:

Specific DD (e.g. dyslexia, dyscalculia,Specific DD (e.g. dyslexia, dyscalculia, speech disorders, etc.speech disorders, etc.

Pervasive DD (e.g. Mental Retardation Pervasive DD (e.g. Mental Retardation ((Learning DifficultiesLearning Difficulties) or Autistic Spectrum ) or Autistic Spectrum Disorders)Disorders)

Specific DD are largely under other specialities Specific DD are largely under other specialities e.g. educational psychology, speech therapy, e.g. educational psychology, speech therapy, neurology, etc perhaps except ADHD.neurology, etc perhaps except ADHD.

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Introduction 2:Introduction 2: For Pervasive DD;For Pervasive DD;

Apparently there are no standard clinical assessment Apparently there are no standard clinical assessment format or sheets other than the classical psychiatric format or sheets other than the classical psychiatric assessment sheet of mental disorders (PH, FH, PPH, assessment sheet of mental disorders (PH, FH, PPH, etc).etc).

Most assessments are psychometric > not enoughMost assessments are psychometric > not enough Expensive, time consuming and hard to find Expensive, time consuming and hard to find Heavily dependent on client cooperation (less Heavily dependent on client cooperation (less

objective than clinical assessment)objective than clinical assessment) Relatively of limited specificity and low sensitivity Relatively of limited specificity and low sensitivity

(↑ False +ve and False –ve)(↑ False +ve and False –ve) Not as good in suggesting differential diagnosisNot as good in suggesting differential diagnosis Most services demand confirmations via clinical Most services demand confirmations via clinical

assessment especially by a doctor assessment especially by a doctor 33

Introduction 3:Introduction 3: For Pervasive DDFor Pervasive DD

Some clinicians develop their own elective Some clinicians develop their own elective assessment sheets.assessment sheets. Developmental HistoryDevelopmental History: (more detailed : (more detailed

Personal History)Personal History) Assessment of basic abilitiesAssessment of basic abilities Assessment of developmentAssessment of development / / maturitymaturity

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Assessment of Developmental Disorders: Assessment of Developmental Disorders:

MethodsMethods Interviews: Interviews:

History taking (client History taking (client and carers)and carers)

Cross-sectional Cross-sectional examinationexamination

Other:Other: Observation Observation Psychometric toolsPsychometric tools Group / team thinkingGroup / team thinking Trials of therapy Trials of therapy Monitoring Monitoring

Common Common problems: poorly problems: poorly communicating communicating clients and poor clients and poor informantsinformants

More emphasis More emphasis on “Other” on “Other” methods.methods.

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Assessment of Developmental Disorders: Assessment of Developmental Disorders: StructuresStructures

Two main parts of assessment:Two main parts of assessment: Basic AbilitiesBasic Abilities + + MaturityMaturity

Abilities are usually called “Intelligence” Abilities are usually called “Intelligence” Maturity is usually called “development”Maturity is usually called “development”

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DevelopmentDevelopment

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Intelligence 1: Intelligence 1: Multiple Intelligence not single Intelligence Multiple Intelligence not single Intelligence

(Gardner, 1993)(Gardner, 1993) General (core) Intelligence (Spearman, General (core) Intelligence (Spearman,

1927) and other specific Intelligences 1927) and other specific Intelligences (Cattell, 1941; Horn 1965; Gardner, 1993).(Cattell, 1941; Horn 1965; Gardner, 1993).

In this scheme: 3 types of general In this scheme: 3 types of general intelligences relevant to psychiatry:intelligences relevant to psychiatry: Physical Intelligence (PI) as in IQ Physical Intelligence (PI) as in IQ Emotional Intelligence (EI)Emotional Intelligence (EI) Social Intelligence (SI)Social Intelligence (SI)

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Why Three Intelligences?Why Three Intelligences? Clinical:Clinical:

Wide clinical use of terms like general Wide clinical use of terms like general (IQ) intelligence, emotional intelligence (IQ) intelligence, emotional intelligence and social intelligences (usually and social intelligences (usually separately). separately).

Wide Clinical applications of the 3 Wide Clinical applications of the 3 intelligences model.intelligences model.

AutismAutism:: a good example of separation a good example of separation of General (Physical) Intelligence from of General (Physical) Intelligence from Emotional Intelligence and Social Emotional Intelligence and Social Intelligences Intelligences

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Why Three Intelligences:Why Three Intelligences:Kim Peek: The Rain ManKim Peek: The Rain Man

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Why Three Intelligences?Why Three Intelligences? Psychological:Psychological: ↑ numbers of tools assessing the ↑ numbers of tools assessing the

3 intelligences (usually separately). 3 intelligences (usually separately). Physical Intelligence: IQ toolsPhysical Intelligence: IQ tools Emotional intelligence: (Leuner,1966; Payne, Emotional intelligence: (Leuner,1966; Payne,

1985; Greenspan, 1989; Salovey and 1985; Greenspan, 1989; Salovey and Mayer,1990; Goleman, 1995). Mayer,1990; Goleman, 1995).

Social Intelligence: (Cohen, 2000; Goleman, Social Intelligence: (Cohen, 2000; Goleman, 2006) 2006)

Other theories: Other theories: (e.g. Judith Rich Harris’s (e.g. Judith Rich Harris’s Modular Theory of Social Development, Modular Theory of Social Development, 2006)2006)

Triune Brain TheoryTriune Brain Theory: (MacLean, 1993) : (MacLean, 1993) 1111

Triune Brain Triune Brain TheoryTheory 1: 1: A model by Paul D. MacLean (1993) > functional structures A model by Paul D. MacLean (1993) > functional structures

of the brain > compared brain structures & functions in of the brain > compared brain structures & functions in different animals: different animals: Reptiles and fish: Reptiles and fish: R-complexR-complex (spinal cord, brain stem, (spinal cord, brain stem,

basal ganglia and cerebellum) > survival skills; motor basal ganglia and cerebellum) > survival skills; motor routines, territorial behaviour, aggression & copulation. routines, territorial behaviour, aggression & copulation.

Small mammals (dogs, cats, rats): Small mammals (dogs, cats, rats): R-complex & Limbic R-complex & Limbic SystemSystem > as above + Parenting, Play & Vocalisation > as above + Parenting, Play & Vocalisation

Large mammals (apes and humans): Large mammals (apes and humans): R-complex, R-complex, Limbic System & NeocortexLimbic System & Neocortex > as above + Problem > as above + Problem Solving Skills and Mentation. Solving Skills and Mentation.

Human brain > three brains, each has independent Human brain > three brains, each has independent intelligence but functionally integrated.intelligence but functionally integrated.

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Triune Brain Theory: 2Triune Brain Theory: 2

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Triune Brain Theory: 3Triune Brain Theory: 3

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Triune Brain Theory > Triune Brain Theory > Triune IntelligenceTriune Intelligence

Physical IntelligencePhysical Intelligence (general intelligence - IQ): (general intelligence - IQ): managing material world (not emotionalised – not managing material world (not emotionalised – not socialised) e.g. budgeting and travelling > survival socialised) e.g. budgeting and travelling > survival in the environment in the environment

Emotional IntelligenceEmotional Intelligence:: managing managing emotional/personalised environment e.g. insight emotional/personalised environment e.g. insight and empathy > emotional bonding (that allows us and empathy > emotional bonding (that allows us to tell individuals apart).to tell individuals apart).

Social IntelligenceSocial Intelligence:: managing social managing social environment e.g. fitting and functioning in social environment e.g. fitting and functioning in social group > ability of creating society / civilisation.group > ability of creating society / civilisation.

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:Normal IntelligenceNormal Intelligence

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:Mental RetardationMental Retardation

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:AutismAutism

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:MR and AutismMR and Autism

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:Antisocial PersoanlityAntisocial Persoanlity

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:Schizoid or Dependant PersonalitiesSchizoid or Dependant Personalities

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Clinical Variations of the Triune Intelligence:Clinical Variations of the Triune Intelligence:LD (MR) with Challenging BehaviourLD (MR) with Challenging Behaviour

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Clinical Assessment of Physical Clinical Assessment of Physical Intelligence:Intelligence:

1.1. Conversation (executive) skills: Conversation (executive) skills: Attention and concentration, switching between Attention and concentration, switching between

topics, comprehension, naming, abstract thinkingtopics, comprehension, naming, abstract thinking2.2. General knowledge of environment (territorial General knowledge of environment (territorial

knowledge):knowledge): Significant events, Significant characters, Cause Significant events, Significant characters, Cause

relationship between events and ability to predict relationship between events and ability to predict changeschanges

3.3. Basic Living skills:Basic Living skills: Budgeting, (money, math) Budgeting, (money, math) Travelling (roads, geography)Travelling (roads, geography)

4.4. Planning skillsPlanning skills5.5. Problem solvingProblem solving IQ test and Adaptive Behaviour Assessment testsAdaptive Behaviour Assessment tests 2323

Clinical Assessment of Clinical Assessment of Emotional Intelligence:Emotional Intelligence:

Main Clinical Assessment: ability to see him Main Clinical Assessment: ability to see him self and others as unique individuals self and others as unique individuals (Cortical (Cortical blindness analogy) blindness analogy) Empathy (Theory of Mind Empathy (Theory of Mind ((Baron-Cohen et al, 1985), Baron-Cohen et al, 1985),

Mirror neurons Mirror neurons ((Rizzolatti et al, 2004)Rizzolatti et al, 2004))) Insight (Self Awareness)Insight (Self Awareness)

Other Clinical Forms: Other Clinical Forms: Attachment, Bonding, Sympathy, Guilt, Care, Attachment, Bonding, Sympathy, Guilt, Care,

Remorse, Facial Emotional Recognition,Remorse, Facial Emotional Recognition, etc. etc.

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Clinical Assessment of Clinical Assessment of Social Intelligence:Social Intelligence:

Social appropriatenessSocial appropriateness Ability of Ability of mixing and fitting-inmixing and fitting-in social groups social groups Appreciation of Appreciation of Social NormsSocial Norms e.g. Social e.g. Social

identities, Social roles and Social Dynamics identities, Social roles and Social Dynamics Social appropriatenessSocial appropriateness:: Ability to respond Ability to respond

well to social eventswell to social events Social functioning: e.g. Social functioning: e.g. work in groupswork in groups to to

achieve common goalsachieve common goals

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Maturity Stages 1Maturity Stages 1 ““Many schools: e.g.Many schools: e.g.

Jean Piaget's theory of cognitive development Jean Piaget's theory of cognitive development Erik Erikson's stages of psychosocial developmentErik Erikson's stages of psychosocial development Freud's psychosexual stages, Freud's psychosexual stages, Lawrence Kohlberg's stages of moral development Lawrence Kohlberg's stages of moral development Jane Loevinger, Stages of ego development.Jane Loevinger, Stages of ego development. Margaret Mahler's separation-individuation theory Margaret Mahler's separation-individuation theory Judith Rich Harris' Modular theory of social Judith Rich Harris' Modular theory of social

development.development.

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Proposed Stages of Development:Proposed Stages of Development:1.1. Autistic Stage:Autistic Stage:

Autonomic Stage: 0 - 1Autonomic Stage: 0 - 1 Object Centred Stage: 1 - 2Object Centred Stage: 1 - 2

2.2. Narcissistic Stage:Narcissistic Stage: Narcissistic Emotional Stage: 3 - 5Narcissistic Emotional Stage: 3 - 5

3.3. Social (Altruistic) Stages: Social (Altruistic) Stages: Concrete Social Stage: 6 - 11Concrete Social Stage: 6 - 11 Narcissistic Social Stage: 12 - 18Narcissistic Social Stage: 12 - 18 Altruistic Social Stage: 16 – 20sAltruistic Social Stage: 16 – 20s Expansive Social Stage:Expansive Social Stage: > 18> 18

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Stages of Development: Internal MechanismsStages of Development: Internal Mechanisms

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Stages of Development: External MechanismsStages of Development: External Mechanisms

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Immaturity 2: Immature PersonalitiesImmaturity 2: Immature PersonalitiesFailing to Cross the BridgeFailing to Cross the Bridge

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Immaturity 3: Immaturity Related Disorders Immaturity 3: Immaturity Related Disorders Stuck in the Mud under the BridgeStuck in the Mud under the Bridge

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Immaturity 4: Understanding Regression in Immaturity 4: Understanding Regression in Some Chronic Mental IllnessesSome Chronic Mental Illnesses

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Immaturity 4: Immaturity 4: Indirect Maturity DisordersIndirect Maturity Disorders

Environmental factors: Environmental factors: Child Abuse (may be Borderline Personality Child Abuse (may be Borderline Personality

Disorder < Chronic severe traumas + Social Disorder < Chronic severe traumas + Social rejections). rejections).

Drug Addiction in ChildhoodDrug Addiction in Childhood Mental illnesses in childhood: Mental illnesses in childhood:

Organic: Epilepsy > ? Epileptic PersonalityOrganic: Epilepsy > ? Epileptic Personality or or Head Injuries > OPD / FLSHead Injuries > OPD / FLS

Functional: Grief, Phobia, anxiety, depression, Functional: Grief, Phobia, anxiety, depression, etcetc

Other Specific Developmental Disorders:Other Specific Developmental Disorders: E.g ADHD, Dyslexia E.g ADHD, Dyslexia

Combinations of factors Combinations of factors 3333

ADHDADHD ↑ ↑ awareness > ↑ prevalence figures (Faraone et awareness > ↑ prevalence figures (Faraone et

al, 2003; Polanczyk et al, 2007 (>5% worldwide). al, 2003; Polanczyk et al, 2007 (>5% worldwide). ↑ ↑ recognition of adult ADHD and how disabling it recognition of adult ADHD and how disabling it

can becan be Adult forms > Adult forms >

↓ ↓ hyperactivity hyperactivity ↑ ↑ hyper-excitability, impulsivity, distractibility & hyper-excitability, impulsivity, distractibility &

inattention. inattention. High association with other developmental High association with other developmental

disorders disorders Treating comorbidity of ADHD is highly essential Treating comorbidity of ADHD is highly essential

for treating other psychiatric disorders for treating other psychiatric disorders 3434

Developmental Disorders: Some Developmental Disorders: Some Aspects of Rehabilitation 1Aspects of Rehabilitation 1

Family model of care:Family model of care: Childhood development model Childhood development model

(developmental ladder): (developmental ladder): Identify current abilities and deficits Identify current abilities and deficits Identify current functional stage on the Identify current functional stage on the

developmental ladder developmental ladder Devise a Rehabilitation Programme to Devise a Rehabilitation Programme to

improve abilities to the next level and improve abilities to the next level and prevent deterioration towards the prevent deterioration towards the lower level.lower level.

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Rehabilitation Ladder Rehabilitation Ladder

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General roles (Family model of care):General roles (Family model of care): Home like environment: clear boundaries, Home like environment: clear boundaries,

supervision, support, care,, etcsupervision, support, care,, etc Significance of the human factor; consistency, Significance of the human factor; consistency,

predictability and positive therapeutic predictability and positive therapeutic relationship. relationship.

Individualisation of careIndividualisation of care Normalisation of care Normalisation of care

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General roles:General roles: Support of the client sometimes dictates Support of the client sometimes dictates

supporting the family too.supporting the family too. Other crucial parts of care include: Other crucial parts of care include:

“protection” of vulnerable clients“protection” of vulnerable clients Improving quality of life is an important part of Improving quality of life is an important part of

the carethe care Public need to be more aware of cost-Public need to be more aware of cost-

effectiveness of care for DD patients.effectiveness of care for DD patients.

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Bridging:Bridging: e.g. use physical intelligence to compensate e.g. use physical intelligence to compensate for lack of emotional intelligencefor lack of emotional intelligence

Modelling:Modelling: if client cannot develop appropriate response if client cannot develop appropriate response but can imitate it, staff need to provide models for such but can imitate it, staff need to provide models for such responses. responses.

Supervision:Supervision: if client can not develop appropriate if client can not develop appropriate response and cannot imitate: staff need to provide response and cannot imitate: staff need to provide constant reminding of appropriate responses > client constant reminding of appropriate responses > client needs to learn to engage with staff and accept their needs to learn to engage with staff and accept their guidanceguidance

Compensation:Compensation: poorly functional clients need especially poorly functional clients need especially designed environment to compensate for the client designed environment to compensate for the client needs and deficits (do not ask the patient to change but needs and deficits (do not ask the patient to change but instead change the environment and support system). instead change the environment and support system).

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Common Psychological Tests used in DDCommon Psychological Tests used in DD Wechsler Adult Intelligence Scale (WAIS-IV) Wechsler Adult Intelligence Scale (WAIS-IV) Adaptive Behaviour Assessment System (ABAS-II)Adaptive Behaviour Assessment System (ABAS-II)

Conners Rating Scales-Revised (CRS-R) Conners Rating Scales-Revised (CRS-R) The Swanson, Nolan and Pelham (SNAP-IV) The Swanson, Nolan and Pelham (SNAP-IV)

QuestionnaireQuestionnaire

Autism Diagnostic Observation Schedule (ADOS) Autism Diagnostic Observation Schedule (ADOS) Autism Diagnostic Interview, Revised (ADI-R) Autism Diagnostic Interview, Revised (ADI-R) The Diagnostic Interview for Social and The Diagnostic Interview for Social and

Communication Disorders (DISCO)Communication Disorders (DISCO) Sally-Anne Test Sally-Anne Test (Wimmer & Perner, 1983).

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Sally – Anne TestSally – Anne Test

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assessment of dd new 7

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