Mental Retardation Intellectual Disabilities: Main pitfalls in the current classification of mental

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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_at_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  are outdated and unacceptable for users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
• IASSID / AAMR
• US Presidents Commission
• DSM-IVTR 2005
• Is it adequate?

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
• 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
• 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 Substitute Intelligence by a
  grouping of cognitive impairments
• Criterion B Simplify, operationalise, and reach
  intnl. agreement on domains, types and
  assessment of adaptative skills
• Criterion C Should be deleted
• Criterion D Exclusion hierarchical criterion
  (i.e. MR when generalised developmental
  disorder is absent)
• 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)
• Polynomious polysemic approach
• Multiple 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 IIPers. 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
• 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

Royal College of Psychiatrists. DC-LD. OP 48.
Gaskell, 2001
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Behavioral Problems Assessment

• Independent
• Multiaxial approach
• Comprehensive
• Ecological-topographic approach
• 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