Mental Retardation / Intellectual Disabilities:
“Main pitfalls in the current classification of mental retardation”.
Luis Salvador-Carulla University of Cadiz (Spain) Head. Section of MR, WPA. luis.salvador@telefonica.net
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Mental Retardation: Main points
Highest costs in Health Care High prevalence (1-4%)
High psych comorbidity (30%) Ignored as Mental Health Problem
Important contributions
Stigma and naming Health approach vs illness appr. Behavioral problems classif Behavioral phenotypes
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Mental Retardation: Main pitfalls
Name/Concept MR Classification of MR
Psychiatric disorders
Behavioral problems
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What is in a name?
Continuous name shift “Mental Retardation” and “Learning Disabilities” are outdated and unacceptable for users
“Intellectual Disabilities” adopted by
/ AAMR US President´s Commission DSM-IVTR 2005 Is it adequate?
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IASSID
American Association on Mental Retardation (AAMR). Ad hoc Committee on Terminology and Classification. AAMR News & Notes, 14 (5): 10-13, 2001.
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What is Mental Retardation?
A DEFICIT? (ICF- 2002) A DISABILITY? (AAMR -2002) A DISORDER? (ICD-10 & DSM- IV TR)
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The Concept of Mental Retardation
- MR is neither a disease nor a disability. MR a syndromic grouping similar to the construct of Dementia
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It includes a heterogeneous group of nosological entities characterised by a DEFICIT in cognitive functioning prior to skills acquisition through learning
Cognitive impairment diverge accross different conditions with MR
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The intensity of the deficit is such to interfere in a significant way with individual normal functioning (restriction in activities and limitation of participation CIF)
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What is Mental Retardation?
How should we name it? How should MR be defined and classified? How valid are the diagnostic criteria? What is Mental Retradation?
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Mental Retardation: ICD-10, DSM-IV-TR, AAMR
Low intellectual functioning (IQ 70) Impairment in basic adaptative skills Onset before 18 yrs old
The present concept based on IQ and age limit is imprecise and hampers research, needs assessment, and planning and provision of services for persons with MR
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CRITERION A: IQ Level
Complex construct with higher difficulties in the extremes Several domains of intelligence (lack of intnl. agreement)
IQ does not relate to specific cognitive impairment in diff. diseases with MR (Down vs William syndromes)
WAIS/WISC IQ was not developed for assessing MR
Confounding factors in measuring IQ (Flynn effect) IQ is culturally bound and international standarisation of instruments is limited Differences in cut-off points among classification systems Useful for classifying subtypes ?
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Criterion B: Adaptative behaviour & Skills
AAMR –2002: 3 domains, 16 types, 26 skills
Dimensional vs. Categorical Difficulties in operational use for identifying groups of individuals Heterogeneity in assessment instruments and content Defines a problem by its function (confusion between a pathological entity and its consequences)
Disease vs. Disability Interaction with environment Cultural variability
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New concept of MR
Criterion A Criterion B
Substitute Intelligence by a grouping of cognitive impairments Simplify, operationalise, and reach intnl. agreement on domains, types and assessment of adaptative skills Should be deleted Exclusion hierarchical criterion (i.e.
MR when generalised developmental disorder is absent)
Criterion C Criterion D
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MULTIAXIAL Changes in all axis
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New concept of MR
Metasyndromic condition as in Dementia Spectrum
Such as: MILD COGNITIVE IMPAIRMENT (MCI)
Multiple
Polynomious polysemic approach:
meanings of words
Scientific meaning Social meaning Policy-Administration meaning
INTELLECTUAL DISABILITY & EARLY COGNITIVE DEFICIT (ECD)
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Problems of Psych Diagnostic Systems in MR
Weighted towards verbal items Multiaxial System:
Axis
I: Psych crit. useful ONLY for high verbal skills & IQ Axis II:Pers. Dis.& MR in diff axis Axis III: Inadequate – Needs to be expanded Axis IV: Different Impact of Life Events Axis V: Cluster in few ranges due to previous disability
Diagnostic Categories : Higher error as more detailed (i.e. Non-affective psychoses vs Schizoph.) Diagnostic criteria have not been validated in MR
Different symptoms (equivalents) // Temporal course
Exclusion criteria (dd) // Functioning
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New Classification Systems
Royal
College of Psych UK-Ireland
(2001)
Royal College of Psychiatrists. Diagnostic Classification of Learning Disabilities (DC-LD). OP 48. Gaskell, 2001
Mild
Moderate
Severe
Profound
ICD-10 DC-LD
American
Psych Assoc / NADD (2005) DSM-IVTR ID
DIAGNOSTIC MANUAL OF PSYCHIATRIC DISORDERS FOR PEOPLE WITH INTELLECTUAL DISABILITIES R. Fletcher & M First
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MULTIAXIAL DC-LD SYSTEM
Axis I Level of MR Axis II Cause of MR Axis III Psychiatric Disorders
Level A: Developmental Dis. Level B: Psychiatric Illness Level C: Personality Disorders Level D: Problem Behaviors Level E: Other disorders
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Royal College of Psychiatrists. DC-LD. OP 48. Gaskell, 2001
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Behavioral Problems Assessment
Independent
Multiaxial
approach approach
Comprehensive
Ecological-topographic
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Multicausality: Behavioral Phenotypes Developmental-evolutional approach Standardised
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I would give my life for the simplicity on the other side of complexity.
Oliver Wendell Holmes
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DC-LD : Axis IIID
LEVEL D: Problem Behaviours • General diagnostic criteria • Verbally aggressive behaviour • Physically aggressive behaviour • Destructive behaviour • Self-injurious behaviour • Sexually inappropriate behaviour • Oppositional behaviour • Demanding behaviour • Wandering behaviour • Mixed problem behaviours
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Behavioral Phenotype
Behavioral pattern which characterises a
population group, is directly related to
genotype, appears at a given stage in the life cycle, and may vary for the defined group
through the life cycle
Behavioral
–
Phenotype
Disease related
• – Mental Retardation / ECD related
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