Dual diagnosis:

When there is a psychiatric

disorder
on top of a developmental or
learning disorder

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 psychiatry

• Dual Diagnosis in education =

Intellectual Disability + MH disorder
• Dual Diagnosis in Mental Health =
Psychiatric + Substance Problem
• Lumpers: ‘It isall TS’, or ‘It
isallAutism’
• 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,
hyperactive, combined), oppositional defiant
disorder, conduct disorders
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, etc.)
 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
• Friends and social 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
• Praxis –executive functioning: ideas to plans to
sequences to execution, adaptation
 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 water; helmets;
hydration; guns & weapons; gates, pools, stairs, sockets,
and trampolines
 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 testing; OT, Speech,
other reports
 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 parent to soothe the
child appropriately, etc., and depression become one of
many possibilities to consider
 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.
TREATMENTS
 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:
 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’