Dual diagnosis:

When there is a
psychiatric disorder
on top of a
developmental or learning
IEP Day April 11, 2008

Joshua D. Feder, MD

Faculty, Interdisciplinary Council on Developmental and Learning

Disorders

Assistant Clinical Professor, Department of Psychiatry,

University of California at San Diego School of Medicine
 There are no ‘clean’
patients in
child and adolescent
• Dual Diagnosis in education =
Intellectual Disability + MH disorder
• Dual Diagnosis in Mental Health =
Psychiatric + Substance Problem
• Lumpers: ‘It is all TS’, or ‘It is all
Autism’
• Splitters: The person qualifies for
multiple diagnoses
 Practicalities:

• List and prioritize target symptoms

• Find the ‘lynchpins’ – e.g. alcohol,
inattention, depression – it’s different
for each individual  
 What are the diagnoses?

• And Depression
• And Substance Abuse
• And OCD
• And Psychosis
 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 too…so
many types and causes, with schizophrenias
the big family here
• Eating/elimination – anorexia, bulemia,
enuresis, encopresis, etc.
• Disruptive – including ADHD (inattentive,
Why does Diagnosis Matter?

• Maybe a specific treatment (‘true’

bipolar disorder, seizures, ADHD,
OCD, depression)
• Maybe acceptance (genetic, PANDAS)
 Screening overall Function
(HEADS)

• Home/ discipline
• Education/ occupation
• Activities/ friends
• Drugs/ medications
• Sex/ close relationships
 Assessment Ia:
History of the Present
Condition
• “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
• Prior treatment (medical, therapies,
 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 baby
games
• Milestones: e.g., walking, talking & toilet
training
• Common childhood illnesses – ear infections,
strep, asthma
• Schools and educational function
 Assessment Ic:
Individual Differences in
Regulation and Processing
• Sensory processing and integration
disorders
• Motor tone, function and planning
disorders
• Central auditory processing disorders;
receptive and expressive language
disorders
• Visual-spatial processing disorders
 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
• Higher levels – grey area thinking
 Assessment 1e:
More History…
• Family History – medical, psychiatric and
developmental
• 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, legal
problems, moves, etc.
• Safety check: seatbelts & driving habits;
sunscreen; securing meds, alcohol & toxins; hot
 Assessment II:
TIME WITH THE PERSON
• Twice, minimally? Recommendations by
professional organizations vs. realities
of medical practice
• The second time is almost always
different, and gives the opportunity to
check out ideas
• See with family? Alone?
• School visits?
• Home visits?
• Video?
 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 and
school assessments; outside
assessments, e.g. psychoeducational
 Variable presentation of
psychiatric conditions

• Colored by developmental level

• Colored by individual differences
(cognition, language, sensory
processing – tactile, auditory,
visual/spatial - also visual motor
integration and motor planning, etc.)
• Colored by quality of relationships
with those nearby
 Variable presentation of
psychiatric conditions
example: Depression in Early
Childhood with Intellectual
Disability
• Developmental – may be active or aggressive, appear
depressed
• Individual differences – might not have the words to
express sadness, might instead be bothered more by
sensory stimuli
• Relationships – might be helped a lot by a parent, but
inconsolable at preschool, and acting out
• Might present as a child who is biting and seems to
need sensory input, but after assessment you find a
strong family history of depression, ability of one
 Differential Diagnosis and
Target Symptoms

• Usually, going from chief complaint

to diagnosis is not easy, and the best
we can do is come up with a list of
target symptoms and a list of
possible diagnoses
 Treatment:

• Targets
• Priorities
GRIDDING OUT TARGET
SYMPTOMS VS.
 Priorities:

• SAFETY 1st
• Lynchpins
• ‘thorns’
• And maybe a few things that are just
as well left alone….
George Engel: Biopsychosocial
model

• Biological: exercise, diet, sleep,

nutrition, medication…
• Psychological: all kinds of therapies,
mind over illness
• Social: family, school, etc.
(WRAPAROUND concept)
 YOUR EXAMPLES HERE:

•
•
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 Resources:

• www.circlestretch.blogspot.com
• Professional groups: e.g. AACAP, Your
Child and Your Adolescent
• Diagnosis support groups: e.g. ASA,
TSA, CHADD, etc.
• Looking for ‘Kevin’