Tip Sheets

1
Tip Sheets

• Keys
• To
• Success

2
HCBMRDD Gives Special Thanks to the Following
Individuals

• Julie Holzderer, OVRS
• Lance Jordan, RHC
• Carolee Kamlager, UCP
• Eileen Kempf, UCP
• Steve Koons, Goodwill
• Lori Linville, UCP
• Stephanie Miller, Talbert House
• Lisa Schneider, Goodwill
• Victor Strunk, VV
• Barbara Sweeney, OVRS
• Traci Williams, UCP

3
SEVERELY MENTALLY DISABLED

• A person diagnosed with a severe mental
  disability must have one of the following Axis I
  diagnoses
• Psychotic Disorder
• Schizophrenia
• Schizoaffective Disorder
• Bipolar Disorder
• Major Depression

• Axis I Category also includes
• Adjustment Disorders of Childhood
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Oppositional Defiant Disorder
• Eating Disorders
• Impulse Control Disorders
• Substance Abuse Disorder

4
A PERSON CAN GET HALLUCINATIONS FROM

• A Blow to the head
• Schizophrenia
• Taking a drug
• Sensory Deprivation

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BEHAVIORAL OVERSHADOWING

• Identifying psychopathology as learned behavior
  rather than a sign or symptom of mental illness

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DIAGNOSTIC OVERSHADOWING

• Assuming behaviors or concerns are inherent to
  the condition of mental retardation

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DIAGNOSTIC OVEREMPHASIS

• Attributing most or all maladaptive behavior to a
  specific disorder subsequent to the diagnosis

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DEFINITION OF MENTAL RETARDATION

• Mental Retardation is characterized by
  significantly sub-average intellectual
  functioning and related limitations in two or
  more of the following skill areas communication
  self-care home living social skills community
  use self-direction health and safety
  functional academics leisure work. Mental
  Retardation manifests before age 18.

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DEVELOPMENTAL DISABILITY

• A condition that manifests itself prior to age
  22 is chronic and life long. It results in
  substantial functional limitations in three or
  more areas self-care receptive and expressive
  language learning mobility self-direction
  capacity for independent living
  self-sufficiency. It reflects the persons need
  for a combination and sequencing of special
  interdisciplinary or generic care, treatment, or
  other services. Autism, Cerebral Palsy,
  Epilepsy, Mental Retardation, and Acquired Brain
  Injury are examples.

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ANOTHER WAY TO LOOK AT MENTAL RETARDATION

• Intellectual Disability is not something you
  have such as blue eyes or a bad heart. It is not
  something you are such as short or tall. It is
  not a medical or mental condition.
• It is a particular state of functioning that
  begins in childhood and is characterized by
  differences in intelligence and adaptive skills.
• Intellectual Disability reflects the fit
  between the capabilities of the individual and
  the structure and expectations of their
  environment.

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ANOTHER WAY

• MENTAL RETARDATION IS OUT
• AND
• INTELLECTUAL DISABILITIES IS IN

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MY FRIEND ROBIN

• My friend Robin has cognitive differences.
  She tells me her IQ is 67. She and I were
  talking about her being able to predict the
  future. I said that she appears to have mental
  telepathy. She became very upset and told me in
  no uncertain terms, not to call her mental!

13
DEFINITION OF A CO OCCURING CONDITION

• The presence of Mental Retardation (Intellectual
  Disability) and Mental Illness
• Individuals with Mental Retardation experience
  the full range of mental health disorders (once
  they were thought to be immune)
• Now it is likely that individuals with Mental
  Retardation have a higher occurrence of mental
  illness than the general population

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DUANE LIVES IN A SMALL GROUP HOME

• One day, Duane was at his home and became
  visibly and verbally upset. He was threatening
  to hang himself. He indicated this by
  gesturing with his hand and arm, moving it across
  his neck and holding his arm above his head.
• He was transported to a local hospital
  emergency room. He continued to verbalize and
  gesture his intent to hurt himself. The staff
  who accompanied Duane were told to take him home,
  that it was just behavior.

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WHY IS THIS SO ???????

• Biological Risk Factors
• CNS Damage (Prader-Willi Syndrome and Pervasive
  Developmental Disorder)
• Genetic predisposition to mental illness in
  family
• Environmental Stressors
• Major life changes and losses and family support
  problems
• Stigmatization
• Illnesses
• Frustrations of own limitations
• Insufficient social and coping skills
• Lack of social support/network
• Not being allowed to make own decisions
• Limited communication skills

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WHAT I HEAR THE MOST

• Consumers with Mental Retardation are too low
  functioning for counseling
• Mental Health professionals are best skilled to
  do counseling
• Mental Retardation professionals know best how to
  deal with behavior problems

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PITFALLS ?

• Psychiatrists sometimes admit they would prefer
  NOT to treat persons with Mental retardation
• Individuals who have borderline intelligence
  may fall between the cracks
• There may be difficulty coordinating services
  from both systems
• There may be a lack of professionals well versed
  in MR and MI

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ALL IS NOT LOST ?

• Complete a Functional Behavior Assessment
• If behavior comes on quickly, consider a possible
  medical issue
• If behavior occurs across settings, consider a
  possible psychiatric issue
• If behaviors only happen in one setting consider
  a possible learned behavior
• If you implement a Behavior Plan with out
  success, consider a possible mental health issue
• Look at side effects of medication influencing
  behaviors

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OTHER FACTS

• MENTAL ILLINESS HAS NOTHING TO DO WITH IQ
• INTELLECTUAL DISABILITY OCCURS DURING THE
  DEVELOPMENTAL PERIOD
• MENTAL ILLNESS MAY STRIKE AT ANY TIME

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MORE FACTS .

• A PERSON WITH MENTAL RETARDATION WILL NOT BE
  VIOLENT EXCEPT IN SITUATIONS THAT CAUSE VIOLENCE
  IN A PERSON WITHOUT MENTAL RETARDATION
• A PERSON WITH MENTAL ILLNESS MAY BEHAVE
  ERRATICALLY, OR EVEN VIOLENTLY, AND IRRATIONALLY
• INTELLECTUAL DISABILITIES CANNOT BE CURED

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EVEN MORE FACTS

• IF PERSONS WITH MENTAL ILLNESS ARE TREATED AND
  TREATMENT IS SUCCESSFUL, THE ILLNESS CAN GO AWAY
  AND THE PERSON WILL RETURN TO NORMAL
• THE MAIN TREATMENT OF PERSONS WITH INTELLECTUAL
  DISABILITIES CENTERS AROUND EDUCATION AND
  TRAINING OPPORTUNITIES
• THE MAIN TREATMENT OF MENTAL ILLNESS CENTERS
  AROUND MEDICATIONS AND THERAPY

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WHAT WILL HELP

• Systems (MR DD and MH) need to come together
  and learn the language
• Systems need to look at the whole person and the
  whole picture
• Systems need to put the pieces together to form
  the whole treatment puzzle for the person

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TIP SHEETS

• ATTENTION DEFICIT DISORDER
• ASPERGER SYNDROME
• AUTISM SPECTRUM DISORDER
• BIPOLAR DISORDER
• FETAL ALCOHOL SPECTRUM DISORDER
• OPPOSITIONAL DEFIANT DISORDER
• CONDUCT DISORDER
• DOWN SYNDROME
• INTERMITTENT EXPLOSIVE DISORDER
• PICA
• TRAUMATIC BRAIN INJURY
• CENTRAL NERVOUS SYSTEM DYSFUNCTION
• AGGRESSIVE BEHAVIOR

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ATTENTION DEFICIT DISORDER

• The fundamental deficit associated with ADHD/ADD
  is one of self-control, NOT attention.
  Self-control means controlling ones behavior by
  internal rules and standards. Self-control is
  referred to as self-regulation. This is due to
  biological reasons, and not because of parenting.
  

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ADD/ADHD

• CHARACTERISTICS
• Impulsiveness
• Inappropriate or excessive activity
• Lack of attending
• Easily distracted
• Shuts down with change
• Unable to learn from mistakes

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ADD/ADHD Continued

• Difficulty following directions
• Lacks motivation for solving problems
• Difficulty planning behavior over time
• Lack of recognition how behavior impacts others
• Lack of social adaptability
• Lack of ability in censoring emotions

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THINGS TO TRY ?

• Plan ahead
• Have a schedule
• Use visual teaching tools
• Break things down
• Use immediate rewards
• Dont plant the seed for negative behavior
• Use Grandmas Law
• State rules in a positive way
• Reinforce often
• Remind often
• Do not use physical punishment

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AUTISM SPECTRUM DISORDER

• Autism Spectrum Disorder falls under the umbrella
  of Pervasive Developmental Disorders. This
  disorder may cause severe and pervasive
  impairment in thinking, feeling, language, and
  the ability to relate to others.

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ASD/PDD

• CHARACTERISTICS
• Difficulty in verbal and non-verbal communication
  
• Rigidity in thought processes
• Highly resistant to change
• Lack of recognition of how other person feels
• Difficulty with social interaction
• Intense desire for sameness

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ASD/PDD Continued

• Scattered skills and areas of strength
• Lack of space recognition
• May have restricted areas of interests

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THINGS TO TRY ?

• Have a planned routine but build in safe
  choices
• Teach and model emotions
• Be aware of hypersensitivity
• Teach turn taking
• Use social stories
• Use visual supports
• Use instrumental gestures
• When in trouble lessen verbal input
• Teach waiting skills
• Consider sensory integration
• Consequences to behaviors dont work

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ASPERGERS SYNDROME

• Individuals with Aspergers Syndrome are
  characterized by social isolation and eccentric
  behavior in childhood. There are impairments in
  two-sided social interaction and non-verbal
  communication. Though grammatical, speech may
  sound peculiar due to differences in inflection
  and a repetitive pattern.

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AS Continued

• CHARACTERISITICS
• Lack of emotional give and take and empathy
• Attached to own routines and rituals
• Repetitive motor mannerisms
• May be very neat and orderly
• May develop social anxiety
• Difficulty in making appropriate/relevant
  comments
• Difficulty in reading social cues
• Difficulty judging timing of conversation
  (end/start)
• Displays minimal facial expressions
• Difficulty making generalizations

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THINGS TO TRY ?

• Build on strong memory visual memory skills
• Tends to display rule governed behavior
• Use social stories
• Build on measurable information
• Usually rational learners
• Do not stop repetitive behavior (try to channel
  fixations)
• Be concrete NOT abstract
• Plan ahead for change
• Teach self-talk

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HIGH FUNCTIONING AUTISM AND ASPERGER SYNDROME

• COUNSELING SUGGESTIONS
• Sit side by side (this avoids the eye contact
  issue)
• Permit individual to see your note pad and what
  is being written down (notes provide visual
  backup)
• Have a separate note pad or whiteboard for person
• Problems are often seen as black or white
• Draw a line down the center of note pad to
  develop pros and cons, unrealistic and realistic
  points
• Allow individual to keep notes in own folder (to
  bring to each session)
• Set tangible weekly goals with the individual
• Avoid metaphors, humor, and abstract concepts
• Help individual recognize feelings by identifying
  what is seen

36
BIPOLAR DISORDER

• Bipolar Disorder is a genetic disorder that
  affects a persons moods, sleep and awake cycles,
  and executive functions (reasoning, problem
  solving, strategizing, working memory, self
  control, and motor sequencing.) Bipolar can have
  accompanying disorders such as anxiety and ADHD.
  

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BIPOLAR DISORDER Continued

• CHARACTERISTICS
• Depressive Episodes
• Sadness, excessive crying, loss of pleasure, low
  energy, abnormal sleep, irritability, eating
  problems (too much)
• Restlessness
• Difficulty concentrating
• Feelings of hopelessness and worthlessness
• Thoughts of death or suicide

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CHARACTERISTIC Continued

• Manic Episodes
• Inappropriate sense of euphoria (extreme
  happiness)
• Racing thoughts
• Reckless behavior
• Extreme irritability
• Out of control behaviors
• Poor judgment
• Aggressive behavior
• Abnormal sleep

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THINGS TO TRY ?

• Prevention Strategies
• Involve the person
• Be consistent and supportive
• Develop a safe place
• Reinforce the positive (self worth and self
  control)
• Break day up and limit free time periods
• Identify a cool down spot
• Allow movement
• Have a calm environment

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THINGS TO TRY Continued

• Venting Strategies
• Drawing
• Writing (put feelings into words)
• Exercise
• Put head down briefly
• Wall push ups
• Squeeze hands together and release

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THINGS TO TRY Continued

• Reacting Strategies
• Maintain a neutral stance
• Be supportive and kind
• Use a cognitive redirect to get person unstuck
• Wait until emotions settle and process outburst
  and seek alternatives
• Use Active Listening Skills
• Speak in short phrases and make no promises
• Recognize all positive efforts and participatory
  behaviors

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FETAL ACOHOL SPECTRUM DISORDER

• Fetal Alcohol Syndrome is the manifestation of
  specific growth, mental, and physical birth
  defects associated with the mothers high levels
  of alcohol during pregnancy. Resulting
  abnormalities may include growth deficiency in
  weight, height, head circumference delays
  development with decreased mental functioning
  (mild to severe) facial abnormalities heart
  defects limb abnormalities.

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FASD

• CHARACTERISITICS
• INFANTS CHILDREN
• Poor sleep patterns
• Poor weight gain
• Chronic ear infections
• Speech delays
• Delays in rolling over, crawling, and walking
• Easily distracted
• Small appetites
• Continued motor delays

44
FASD Continued

• CHARACTERISTICS
• ADULTS
• Difficulty with focusing
• Difficulty sitting still
• Poor judgment and impulse control
• Lack of maturity

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THINGS TO TRY ?

• INFANTS CHILDREN
• Soft music and singing
• Low lights
• Nutritional consult
• Evaluate and treat ear infections
• Seek assistance from OT/PT
• Consult a Speech Therapist
• Establish a routine
• Simplify rooms and reduce noise and stimulation
• Serve small portions of food (lukewarm or cool
  and with texture)

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THINGS TO TRY Continued

• ADULTS
• Keep distractions to a minimum
• Keep décor calm
• Assist with Anger Management Skill Training
• Teach self-talk
• Alert person before you touch him/her
• Review guidelines

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THINGS TO TRY Continued

• IN THE CLASSROOM
• Use text or notes to accompany lectures
• Do not overly decorate the classroom
• Bulletin boards that change more than every other
  month can be over-stimulating
• Use headphones during lessons with other students
  are talking
• Introduce concepts and information, then move on
  to quiet work time

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OPPOSITIONAL DEFIANT DISORDER

• This is a disorder where a pattern of
  negativistic, hostile, and defiant behavior is
  present and lasts at least 6 months. Behaviors
  include the following loss of temper argues
  with adults defies rules refuses to comply
  deliberately annoys others blames others for own
  mistakes is angry and resentful is often
  spiteful or vindictive.

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ODD

• CHARACTERISTICS
• May have a bad temper
• May have a scowl on face (look angry)
• May have problems calming down
• Argues with those in authority
• Refuses to follow directions (no-mode)
• A need to have the last word!

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THINGS TO TRY ?

• Prescribe self-control by having a daily
  calendar/routine to follow
• If there is an issue with the schedule, it will
  be taken with the schedule
• Use a self-management approach
• Be consistent
• Use walk by reinforcement
• Admire what is good about the person
• Behavior rehearse rules

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MORE THINGS TO TRY

• Put individual in charge of something (positive
  self control)
• Implement a Contract
• DO NOT get into a power struggle
• Offer pre-determined choices, not an open ended
  selection
• Outline consequences
• Use Active Listening Skills
• Implement motivating activities such as field
  trips, building and drawing, collecting, carrying
  out independent projects

52
MORE THINGS.

• Create a win-win situation
• Stick to the rules
• DO NOT have a blending of rules
• Avoid argumentsDO NOT fuel the fire but rather
  disengage quickly

53
CONDUCT DISORDER

• Conduct Disorder (considered the most serious
  of childhood psychiatric disorders), refers to a
  group of behavioral and emotional problems in
  youngsters. Children and adolescents with this
  disorder have great difficulty following rules
  and behaving in a socially acceptable way. They
  are often viewed as delinquent rather than
  mentally ill. Many factors contribute to a child
  developing conduct disorder including brain
  damage child abuse genetic vulnerability
  school failure traumatic life experiences.

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CD

• CHARACTERISTICS
• Aggression to people and animals (bully, frighten
  and intimidate others initiate physical fights
  may use weapon)
• Destruction of property (deliberately engage in
  fire setting with the intention of causing
  serious harm)
• Being deceitful (lying and stealing)
• Serious violation of rules (runs away from home
  violates curfew prior to 13 years of age skips
  school prior to age 13 years)

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THINGS TO TRY ?

• Provide tight supervision
• Provide empathy training
• Work closely with families
• Provide helping projects
• Give a little, get a little (building a
  relationship)
• Multi-system therapy may be the most effective
  (involves doing many different things at the same
  time)

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DOWN SYNDROME

• Down Syndrome is a set of mental and physical
  symptoms that result from having an extra copy of
  chromosome 21. Usually, mental development and
  physical development are slower in people with
  Down Syndrome than in those without it.

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DOWN SYNDROME

• CHARACTERISTICS
• May have heart disease
• May have hearing problems
• May have problems with intestines, eyes, and
  thyroid glands
• May have language and auditory processing
  concerns
• May have sleep apnea
• May have lack of emotional maturity
• May have high tolerance for pain
• May come across as being defiant or oppositional
• May display aggression to self or others

58
THINGS TO TRY ?

• Develop a positive relationship and connection
• Rule out medical concerns prior to looking at
  behavior concerns
• Create a predictable environment
• Use visual supports
• Use social stories
• Teach positive self-control by offering choices
• Allow processing time
• Consider sensory calming techniques
• State the positive NOT the negative!

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INTERMITTENT EXPLOSIVE DISORDER

• Intermittent explosive disorder is a mental
  disturbance that is characterized by specific
  episodes of violent and aggressive behavior that
  may involve harm to others or destruction of
  property. Usually, these episodes follow minor
  incidents and are out of proportion to the
  trigger. These behaviors are not caused by
  another mental disorder (e.g., Antisocial
  Personality Disorder, ADHD, or ASD.) These
  impulsive acts are not caused by substance abuse
  or medical condition (head trauma or Alzheimers
  Disease).

60
THINGS TO TRY ?

• Have appropriate ways to vent and release anger
  (counting, deep breathing, muscle relaxation)
• Establish a plan to be called upon when things
  begin to go wrong
• Write plan in understandable words and/or use
  pictures in a visual sequence
• Use guided visualization
• Listen to relaxing music
• Have a quiet spot to go to focus and calm down

61
PICA

• Pica is an appetite for non-nutritive
  substances (e.g., coal, soil, chalk, paper, etc.)
  Also, it can be an abnormal appetite for some
  things that may be considered foods such as food
  ingredients (e.g., flour, raw potatoes, starch).
  The conditions name comes from the Latin word
  for magpie, a bird which is reputed to eat almost
  anything. Pica is seen in all ages and
  especially in children who are developmentally
  disabled, where it is the most common eating
  disorder.

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PICA

• THEORIES
• Accompanies profound intellectual disabilities
• More prevalent in institutional settings
• Aberrant behavior due to family stress
• An addictive behavior
• A self-injurious behavior

63
RISKS OF PICA

• Eating painted plaster containing lead may lead
  to brain damage
• Eating dirt near roads that existed prior to
  phase out of tetra-ethyl lead in gasoline or
  prior to the cessation of the use of contaminated
  oil to settle dust
• Gastro-intestinal obstruction or tearing of the
  stomach
• Eating dirt containing animal feces and parasites
  

64
THINGS TO TRY ?

• Complete a physical exam
• Assess for symptoms of Anxiety Disorder, OCD,
  Impulse Control Disorder
• Provide close supervision
• Complete a Functional Behavior Assessment
• Implement a reinforcement-based intervention
• Consider the environment
• Consider medication

65
TRAUMATIC BRAIN INJURY

• A traumatic brain injury is usually the result of
  a sudden, violent blow to the head. A brain
  injury may also occur when a projectile, such as
  a bullet, rock or fragment of a fractured skull
  actually penetrates the brain.
• There are two stages of brain injury (1) the
  original impact may bruise a portion of the brain
  or directly sever nerve connections (2) the
  second stage occurs when the tissue at the injury
  site begins to swell.

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TBI

• CHARACTERSITICS
• Difficulty drawing on knowledge and skills or
  learning new information
• Unable to plan actions and foresee consequences
• Short term memory problems
• Difficulty with organization
• Difficulty following directions
• Decreased attention span
• Difficulty concentrating

67
THINGS TO TRY ?

• Use written directions, maps, schedules,
  appointment books, calendars
• Practice asking for clarification of information
• Practice in writing information down
• Practice in note taking skills
• Use a watch alarm
• Use a routine sequence when planning activities

68
MORE THINGS TO TRY

• Be aware of fatigue level, dont over stimulate
• Avoid surprises
• Use positive feedback NOT criticism
• Respond to person in a neutral manner
• Provide a social coach
• Teach individual to chunk information
• Link new information to prior knowledge
• Use a schedule and reinforce person for referring
  to schedule
• Use checklists
• Use color-coding

69
AND MORE THINGS..

• Provide oral AND written instructions
• Ask person to repeat instructions
• Use an underliner or highlighter
• Give direction gtgtgt ask person to perform task gtgtgt
  check for accuracy gtgtgt provide immediate feedback
  
• Slow down the pace of instruction
• Reduce distractions
• Use a cue word to alert person to pay attention
  (i.e., Listen, Look, or call his/her name
• Establish a non verbal cueing system (eye
  contact, touch) to obtain attention

70
CENTRAL NERVOUS SYSTEM DYSFUNCTION

• The central nervous system is a complex system
  that consists of the brain and spinal cord. It
  also consists of the eyes ears sensory organs
  of taste, smell, skin, joints, muscles. Also,
  the CNS is vulnerable to many disorders such as
  Epilepsy, Parkinsons Disease, and psychiatric
  disorders (Anxiety, Bipolar disorder, and
  Depression).

71
CNS

• CHARACTERISITCS
• Individuals need to feel safe and protected
• Controlling and manipulative behaviors might be
  sensory
• Escape driven behaviors may have a sensory cause
• Individuals might have sensory processing
  problems

72
THINGS TO TRY ?

• Regulate emotions by using fidgeters, watching
  fish in a tank, playing background music,
  watching a lava lamp
• Use deep pressure
• Use heavy work
• Implement a Sensory Diet
• First calm, then alert
• Have simple routines
• Alternate sitting and standing activities/tasks/jo
  bs
• Use visual supports
• Give one directive at a time

73
AGGRESSIVE BEHAVIOR

• Aggressive behavior is reactionary and impulsive
  behavior that often results in breaking rules or
  the law. Aggressive behavior can be violent and
  unpredictable.
• There are four types of violent behavior
• Situational
• Relationship
• Predatory
• Psychopathological

74
AGGRESSIVE BEHAVIOR

• REASONS
• Limited ability to communicate
• Limitations in the area of feelings and emotions
• Limitation in problem solving skills
• Limitations in understanding ones own behavior
• Limited coping skills

75
AGGRESSIVE BEHAVIOR ..

• COMPREHENSIVE EVAUALTION
• Developmental history
• Environmental changes
• Medical reasons (genetic syndromes)
• Medication side effects
• Life stressors
• Behavioral variables
• Departure from baseline (increase/decrease)

76
THINGS TO TRY ?

• Look at antecedents
• Complete a Functional Behavior Assessment
• Teach replacement behaviors
• Create a safe environment
• Implement a daily routine
• Promote early success and gradually raise the
  bar
• Offer choices and set limits
• Create a positive behavior momentum
• Create a win-win situation

77
SUMMARY

• Questions
• Comments
• Feedback
• Other