Post on 31-May-2018
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Dual diagnosis:
When there is apsychiatric disorder
on top of a
IEP Day April 11, 2008
Joshua D. Feder, MD
Faculty, Interdisciplinary Council on Developmental and LearningDisorders
Assistant Clinical Professor, Department of Psychiatry,
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There are no clean
patients in
Dual Diagnosis in education =
Intellectual Disability + MH disorder Dual Diagnosis in Mental Health =
Psychiatric + Substance Problem
Lumpers: It is all TS, or It is allAutism
Splitters: The person qualifies formulti le dia noses
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Practicalities:
List and prioritize target symptoms
Find the lynchpins e.g. alcohol,
inattention, depression its differentfor each individual
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What are the diagnoses?
And Depression
And Substance Abuse
And OCD
And Psychosis
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SOAPED Mnemonic:
Substance drugs, medicines, poisons,supplements, etc.
Organic brain trauma, seizures, tuberous
sclerosis, etc. Affective/anxiety/abuse includes bipolar,depression, OCD, simple phobias, PTSD,attachment problems
Psychosis that has its own mnemonic tooso
many types and causes, with schizophreniasthe big family here Eating/elimination anorexia, bulemia,
enuresis, encopresis, etc.
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Why does Diagnosis Matter?
Maybe a specific treatment (truebipolar disorder, seizures, ADHD,OCD, depression)
Maybe acceptance (genetic, PANDAS)
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Screening overall Function(HEADS)
Home/ discipline
Education/ occupation
Activities/ friends
Drugs/ medications
Sex/ close relationships
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Assessment Ia:
History of the PresentCondition
Chief complaint Why now? History of present illness often
chronic
The who, what, where, when, how,and why of the problem
List of target symptoms
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Assessment Ib:
Developmental History
Pregnancy, labor & delivery illnesses, toxins,APGAR scores, length & weight, complications,
e.g., fetal distress, meconium staining, jaundice Infancy & early childhood early regulation,
attachment, and relationships; simple babygames
Milestones: e.g., walking, talking & toilettraining
Common childhood illnesses ear infections,strep, asthma
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Assessment Ic:
Individual Differences inRegulation and Processing
Sensory processing and integrationdisorders Motor tone, function and planning
disorders
Central auditory processing disorders;receptive and expressive languagedisorders
Visual-spatial processing disorders
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Assessment Id:
Social-Emotional Growth Regulation and calm attention
Capacity for warm engagement
Beginning circles of interaction Beginning themes and symbols
Complex symbols, communication, and
play Logical thinking, cause and effect in
social problem solving
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Assessment 1e:M r Hi t r
Family History medical, psychiatric anddevelopmental
Growth - height, weight, head circumference,level of physical/ sexual development
Medical review of systems hearing, vision,allergies, cardiac, neurologic, surgery &anesthesia, serious medical illness,hospitalizations
Psychiatric review of systems covering the
SOAPED areas, but also violence, aggression,suicidality, mistreatment, discipline, legalproblems, moves, etc.
Safety check: seatbelts & driving habits;
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Assessment II:TIME WITH THE PER N
Twice, minimally? Recommendations byprofessional organizations vs. realitiesof medical practice
The second time is almost alwaysdifferent, and gives the opportunity tocheck out ideas
See with family? Alone?
School visits? Home visits?
Video?
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Assessment III:
Collateral Information
People teachers, therapists,doctors, other caregivers, relatives,
job coaches, etc.
Records medical (labs, consults,growth charts, etc.); I.E.P.s andschool assessments; outside
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Variable presentation of
psychiatric conditions
Colored by developmental level
Colored by individual differences(cognition, language, sensoryprocessing tactile, auditory,visual/spatial - also visual motorintegration and motor planning, etc.)
Colored by quality of relationships
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Variable presentation ofpsychiatric conditions
example: Depression in EarlyChildhood with Intellectual
Developmental may be active or aggressive, appeardepressed
Individual differences might not have the words toexpress sadness, might instead be bothered more bysensory stimuli
Relationships might be helped a lot by a parent, butinconsolable at preschool, and acting out
Might present as a child who is biting and seems toneed sensory input, but after assessment you find a
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Differential Diagnosis and T r t m t m
Usually, going from chief complaint
to diagnosis is not easy, and the bestwe can do is come up with a list oftarget symptoms and a list ofpossible diagnoses
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Treatment:
Targets
Priorities
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GRIDDING OUT TARGET
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Priorities:
SAFETY 1st
Lynchpins
thorns
And maybe a few things that are justas well left alone.
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George Engel: Biopsychosocialmodel
Biological: exercise, diet, sleep,nutrition, medication
Psychological: all kinds of therapies,mind over illness
Social: family, school, etc.(WRAPAROUND concept)
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YOUR EXAMPLES HERE:
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Resources:
www.circlestretch.blogspot.com Professional groups: e.g. AACAP, Your
Childand Your Adolescent
Diagnosis support groups: e.g. ASA,TSA, CHADD, etc.
Looking for Kevin
http://www.circlestretch.blogspot.com/http://www.circlestretch.blogspot.com/