Tag Archives: Mental Retardation

Roles of the Counselor with Learning Disabled Clients and Families


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Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  It’s a complex question regarding a complex disorder; there are no simple solutions.  Within the context of learning disabilities (LD) and mental retardation, there are a number of different roles we, as human services or mental health professionals, can fill in the multidisciplinary model of treatment for clients with LD.   Our expertise is needed not only by the clients themselves, but also by the families who endeavor to provide support for special needs individuals.  Finally, we should not discount our role in supporting other professionals, as we can have an impact, even if indirect, by allowing them to continue to function effectively in those sometimes challenging roles.

Direct treatments of clients with LD are most often focused on adaptation skills “since problems in adaptation are more likely to improve with remedial efforts than is the cognitive IQ, which tends to remain a more stable attribute.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 42)  Traditional interventions for children with learning and coordination disorders include: (1) general educational management of learning-disabled children eligible for special education services in the public schools; (2) specific methods of instruction; (3) cognitive-behavioral techniques to teach efficient problem strategies and to improve attitudinal/motivational problems, and (4) mental health approaches with children who have co-occurring social-emotional disorders.  (Netherton, Holmes, & Walker, 1999, p. 40)

A contemporary program that extends the boundaries of more traditional interventions is the “treatment mall.”  The programming (in the treatment mall model) is the result of a collaborative process involving the patient, his or her treatment team, a program design team (which has participant representation), and group facilitators from the many disciplines that practice in the treatment mall.  The emphasis of psychosocial rehabilitation programming is improving functional level, increasing capacity for recovery, and instilling hope.  Psychosocial rehabilitation treatment malls use a multidisciplinary team approach.  Nurses, psychologists, rehabilitation therapists, social workers, nutritionists, physical therapists, physicians, community college educators, and community support providers work together to teach patients with serious mental illness or mental retardation and developmental disabilities the skills and adaptive behaviors needed to live successfully in a community setting following discharge from the hospital.  (Ballard, 2008, expression Program Description)  The sidebar of the Ballard article specifically recognizes psychology staff as contributing to courses designed for short stay participants, including courses titled Legal Issues/Focus, Understanding Your Illness, Competency Restoration, Building Your Brainpower, and Building the Life You Want.  (Ballard, 2008, expression Sidebar)

Our contributions to the learning disabled community as mental health professionals are not confined to treatment malls.  High levels of frustration, with associated performance anxiety and depression, are not uncommon in LD children.  (Netherton, Holmes, & Walker, 1999, p. 45)  Accurate diagnosis provides a clear direction for interventions.  (Costello & Bouras, 2006, expression abstract)  Although substantially increased in recent years, research evidence about the prevalence of mental health problems in individuals with intellectual disabilities and the risk factors for developing specific psychiatric disorders is limited and often conflicting.  Most estimates of the prevalence of psychiatric illness in people with intellectual disabilities range from 10-39%.  (Costello & Bouras, 2006, expression Prevalence)  This suggests that our role isn’t simply confined to teaching problem solving techniques and life skills, but more importantly, addressing the underlying psychological issues that impact the learning disabled community as a whole.  Large numbers of individuals with intellectual disabilities living in the community exhibit psychiatric or behavioral problems arising from mental health problems.  Together the joint contributions of mental illness and intellectual disabilities indicate a group of individuals whose needs are considerable, and whose quality of life will be seriously impaired if the illness is not effectively identified and treated.  (Costello & Bouras, 2006, expression Implications)

So, to answer the question… Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  Yes, all of the above.  As we continue to define our roles, inevitably we will continue to develop new models of treatment and rehabilitation for our LD clients.  I contend that mental health professionals play a critical role at every point of entry, and should continue to play a significant role into the foreseeable future.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Ballard, F. A. (2008, Feb). Benefits of psychosocial rehabilitation programming in a treatment mall. Journal of Psychosocial Nursing & Mental Health Services, 46(2), 26-33. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1422243211&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Costello, H., & Bouras, N. (2006). Assessment of mental health problems in people with intellectual disabilities. The Israel Journal of Psychiatry and Related Sciences, 43(4), 241-252. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1254155791&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Definition of Intellectual Disability


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What two (2) major elements are necessary for a diagnosis of mental retardation?

Intellectual disability is a disability characterized by significant limitations both in (1) intellectual functioning and in (2) adaptive behavior, which covers many everyday social and practical skills.  (American Association on Intellectual and Developmental Disabilities [AAIDD], 2010 , para. 1)

What are the limitations of this definition?

The first and most objective limitation is the age of onset.  This disability originates before the age of 18.   (AAIDD, 2010 , para. 1)

A second quasi-objective limitation to a diagnosis of mental retardation is intelligence quotient (IQ).  One criterion to measure intellectual functioning is an IQ test.  Generally, an IQ test score of around 70 or as high as 75 indicates a limitation in intellectual functioning.  (AAIDD, 2010 , para. 3)

A third, more subjective measure, is the degree to which a disability limits adaptive behavior.  Standardized tests can be used to gain objectivity in the areas of conceptual, social, and practical skills.

Fourth and finally, the AAIDD takes qualitative differences in environmental, cultural, socioeconomic, and other normative factors (language) into consideration.  They acknowledge that limitations often coexist with strengths, and that outcomes can be positive with sustained personalized supports.

How does this definition compare to the DSM-IV TR?

The DSM-IV-TR criterion(s) for a mental retardation diagnosis are as follows… (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 41)

A)    Significantly sub-average general intellectual functioning accompanied by;

B)    Significant limitations in adaptive functioning in at least two of the following skill areas:

  1. Communication
  2. Self-Care
  3. Home Living
  4. Social/Interpersonal Skills
  5. Use of Community Resources
  6. Self-Direction
  7. Functional Academic Skills
  8. Work
  9. Leisure
  10. Heath
  11. Safety

C)    The onset must occur before age 18.

The DSM authors make more formal recommendations on which IQ tests should be used to measure IQ and acknowledge differences of measurement between them.  They share commonality with the AAIDD definition in the regard to the arbitrary IQ cutoff (approximately 70-75 or below).  The DSM also shares concern with AAIDD in that they “take into account factors that may limit test performance (e.g., the individual’s socio-cultural background, native language, and associated communicative, motor, and sensory handicaps). (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 42)  Like the AAIDD, the DSM posits a dimensional assessment of strengths and weaknesses when the nature of the disability skews IQ scores.

Although I think the variance in severity is implied by the AAIDD, the DSM authors codified the broad differences between individuals with mental retardation.  On the whole, my impression is that the AAIDD definition was written and based on the DSM-IV-TR.


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References

American Association on Intellectual and Developmental Disabilities. (2010 ). Definition of intellectual disability. Retrieved March 26, 2010, from http://www.aamr.org/content_100.cfm?navID=21

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Reflections on Mental Retardation


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Although it is not the most politically correct term for the condition, mental retardation (MR) is still has significant presence in the populations we counselors intend to serve.  It is well documented that individuals with MR are at higher risk for comorbid mental illness of virtually all flavors…

Despite our best efforts to serve this needy population, interdisciplinary approaches that are considered ideal are still infrequently deployed due to cost and time constraints.   I am surprised and disappointed that this kind of consideration isn’t arranged for everyone dually diagnosed with MR and a comorbid mental illness.  I believe if we engaged TEAMS of psychologists, social workers, teachers, and communities agencies at every level of care and integrated it into a cohesive whole, the individuals we serve would receive a higher level of care for a LOWER COST!

A natural extension of the interdisciplinary approach is the involvement of the family in the decision-making process.  (Netherton, Holmes, & Walker, 1999, p. 19)  The importance of the family can not be overstated… absolutely critical and nothing less. I think this approach is too often implied and too rarely explicit.  Three key tenets to working with families are not to be overlooked:

1)      The team must be receptive to including families in the decision making process.

2)      The team must consider the level of knowledge and understanding of the family related to the disability of the child and/or the service and treatment options.

3)      Once the family has an adequate understanding of the condition and service and treatment alternatives, they may need to be nurtured through the team decision making process.  (Netherton et al., 1999, p. 21)

We, as practicing clinicians and psychotherapists, could take a number of different roles in the team environment.  As facilitators, we should frequently be asking parents what their perspective is, constantly seeking feedback and nurturing their freedom of autonomy.   It is absolutely critical that the family “buys in.”  I believe that if we nurture their ability to participate, that “buy in” is much more likely.  As educators, we can also serve parents by helping them making informed decisions regarding every phase of the plan.

I think every expectant parent comes to the table with hopes, dreams, and expectations of who their child will become.  Because many of these children will never grow up and meet the expectations of their parents, we can play a role in assisting them in coping, or simply modifying or altering those expectations to coincide with the realities of raising a child who may never be cured of mental retardation.

As the plan unfolds, we as councilors can play a role not only in the development of the primary client, but we can play a developmental role in the lives of the family members.  If the family experiences feelings of shame, guilt, or even a certain sense of grief can be dealt with in a variety of different formats; including group therapy, family therapy, individual therapy, or even couples therapy for parents.

In summary, I hope we can come to consensus that psychologists should play a significant role in the planning and execution of any developmental plan involving a child with mental retardation.  I would advocate that, aside from the primary care givers and family, our ability to offer assistance at different points of entry uniquely positions us to fill the much needed gaps in the overall individual treatment plan.

Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

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