Intellectual Disability Disorder in Early Childhood Case Study
Theo is a five-year-old boy born to 17-year-old Melanie. Unaware of her pregnancy until 20 weeks gestation, she used drugs and alcohol heavily. Theo’s biological father isn’t present; however, Melanie’s partner Peter has been present since Melanie’s pregnancy. Melanie has no contact with her whanau, however has been welcomed into Peter’s whanau who support the family. Family dynamics present as high stress due to the relationship strain of Melanie’s low mood and Theo’s challenging behaviours.
Theo, an only child is currently in his first year of mainstream primary school. Melanie reports Theo is able to feed himself with his hands, partially dress and toilet himself, however has concerns Theo isn’t developing like his peers, with motor delay, cognitive delay and speech difficulties. Theo is still learning to count past three as well as recognise letters, he can however when prompted write his own name. An educational psychologist has concerns regarding Theo’s development and separation issues, and the mental wellbeing of Melanie who struggles with Theo’s behaviour. Both parents are onboard seeking support.
Presenting Issues and Diagnosis
Melanie, unaware of her pregnancy until 20 weeks gestation heavily consumed alcohol and used drugs. Given teratogens can pass through the placenta, Theo’s birth outcomes and start to life were potentially compromised given teratogens can result in psychological and neurological deficits (Berk, 2013).
In infancy Theo slept throughout the night and had long day naps. When awake he was a placid, content baby who was easy to feed and a settled child, showing a secure attachment to his mother (Burton, Westen ; Kowalski, 2015).
At 12-months Theo was still reaching for toys, a developmental milestone usually observed in infants by four months (Dosman, Andrews ; Goulden, 2012). Similarly, Theo started walking at two, a milestone generally observed between 12 and 15 months (Dosman et al., 2012).
By three, Theo showed verbal delays and speech difficulties, speaking only using simple words, which Melanie and Peter had difficulty understanding despite children typically at three speaking in three to four-word sentences and be understood 75% of the time (Dosman et al., 2012). Melanie sought a hearing assessment which was normal. The audiologist referred Theo to a speech language therapist due to concerns of developmental delay.
At four, Theo and Melanie had a strong connection, attending and actively engaging in Kohanga Reo. As it became further evident Theo was developmentally behind his peers, Melanie had apprehensions about how Theo would cope at school. Melanie began reflecting on possible contributions her substance abuse had and the likelihood it led to Theo’s developmental delays, leading to low mood and withdrawal. Melanie become less engaging with Theo and Kohanga reo which started a pattern of irregular attendance, at which time Theo’s behaviour changed to making loud noises, banging toys on the table, throwing tantrums, showing separation anxiety as well as self-injuring through picking of his skin. Concerns regarding Melanie’s mental wellbeing were raised by the educational psychologist.
Upon entering school; Theo was only able to count to three, only recognised the letters in his name which he was able to write without prompting, however was still learning to hold a pencil. Theo was still mastering dressing himself and using utensils to eat. It was suggested Theo would require additional support in the form of a teacher aide to support his development of reading and writing skills.
It is hypothesised Theo’s diagnosis is moderate to severe Intellectual Disability Disorder (IDD) (American Psychiatric Association, 2013). The DSM-5 has three criteria that need to be met for an IDD diagnosis. The first being deficits in intellectual functions; this is seen in Theo’s case cognitively by currently only being able to count to three, which would be considered an age appropriate deficit (Weis, 2014). The second requires a deficit in adaptive functioning which limits the functioning in activities of daily life, this has been reported numerous times in Theo’s case for example his inability to dress himself fully, which again would be an age appropriate deficit (Weis, 2014). The third criteria Theo meets, that is the onset of the above deficits must occur during the development period (Weis, 2014). Theo presents with a high likelihood of meeting these three criteria, it should however be noted, a secondary potential diagnosis to be investigated would be that of fetal alcohol syndrome due to Melanie’s substance abuse during pregnancy, given this syndrome is proven to cause developmental delays (Berk, 2013). This comorbidity is hypothesised as influencing Theo’s symptoms and behaviours.
To confirm the diagnosis of IDD, two further forms of information are required; intelligence testing and an adaptive functioning assessment. Intelligence tests score an individual’s cognitive abilities in a number of areas including the ability to reason, show abstract thinking, problem solve, speed processing and general knowledge (Weis, 2014), results have a mean of 100, with results below 70 indicating deficits in the intellectual functioning. Given the criteria for diagnosis includes a deficit in intellectual functioning, Theo needs to be tested and score below 70 (Weis, 2014). An adaptive functioning assessment would evaluate Theo’s ability to function both developmentally and socio-culturally, giving an indication of the likelihood of future independence and his ability to participate socially as well as communicate (Weis, 2014). Deficits in adaptive functioning in one or more areas of daily life would meet criteria two of IDD (Weis, 2014).
An assessment allows clinicians to evaluate the emotional wellbeing and build an understanding of an individual through a series of questions, tests and physical examinations which when integrated from multiple sources provides a comprehensive assessment and diagnosis of a conditional along with determining symptom severity, treatment options and general function impairment (Schwartz-Mette et al., 2016). There are four components of a psychological assessment, these components when collected collectively provide an understanding of the individual and help to form a hypothesis about their behavior, level of functioning and future treatment options (Weis, 2014).
Clinical interviews through a series of questions ensures clinicians gain information around life history, demographic information, medical history including psychiatric and psychological history, information on both past and current behaviours, emotions, attitudes as well as relevant information for the presenting problem. (Barlow, Durand ; Hoffman, 2015). Ensuring a culturally appropriate assessment is vital, including acknowledgement of tikanga and the inclusion of whanau in the assessment process (Dyall et al., n.d.). In Theo’s case the clinician could invite Theo, Melanie and Peter to meet with her, as well extending the invite out to extend whanau and his teachers. By widening the group, it will ensure those who have regular contact and are aware of Theo’s function are included (Weis, 2014). It would be the clinician’s goal to gain an overall understanding of Theo’s psychological history as well as his developmental history, what his current functioning is and the restrictions that may be present as well as how he relates to those around him socially, such as parents, whanau, teachers and school peers which is done through building report and empathetically listening to the concerns whilst reflecting their thoughts and providing a plan for a way to address the concerns (Weis, 2014). As part of the interview, the clinician will look at Theo’s current functioning in three ways, through his overt behaviours such as observing him picking his skin and other observable behaviours. By observing his emotions such as the appropriateness of his interactions with his whanau as well as cognitive functioning by assessing his intelligence, his attention, his thought processes and his judgement (Weis, 2014). The goal of clinical interviews is for the clinician to review the criterial after the interview and report on Theo’s psychiatric diagnosis (Weis, 2014).
When assessing children, reports from parents, whanau and teachers on behaviours are useful, however when the clinician is able to observe these behaviours herself, this provides additional valuable insight and as such is a vital step in the assessment process (Weis, 2014). Behavioural assessments are useful in naturalistic settings, these natural settings for Theo are in the home and in his classroom and provide the clinician the ability to watch Theo interact and respond as he would on a typical day in his day to day settings (Weis, 2014). A functional analysis would be useful whilst observing Theo’s behavior, which comes from the theory that his behavior is intentional in which the purpose of him receiving his desired outcome (Weis, 2014). In Theo’s case his desired outcome when making loud noises is for Melanie not to leave when he is at school, in this example the antecedent of the behavior is Melanie dropping Theo off to his class room, and the consequence of his behavior is that Melanie stays to comfort him. By observing Theo’s behaviour the clinician will be able to use these findings of antecedents and consequences to put together a treatment plan to reduce the unwanted behaviours.
Norm-referenced tests are a set of standardised tests or tasks which measure Theo’s behaviours which can then be compared to those of his peers. This could be done through intelligence tests, looking at his verbal comprehension, perceptual reasoning, his working memory and his processing speed (Weis, 2014). Looking at Theo’s adaptive functioning would provide invaluable information in Theo’s case as this would look at Theo’s ability levels to do day to day tasks such as getting dressed and toileting, his ability to maintain attention in class, his social abilities and interactions with peers and how he copes and functions and his deficits in intellectual functioning. Being norm-referenced, allows Theo’s abilities to be compared relative to his peers (Weis, 2014).
Informal assessments have no scientific measurement and thus need to be used with caution, however information from evaluations done in different conditions or testing undertaken in the classroom can provide a rich depth of information to supplement the above assessment techniques (Framingham, 2016).
Given Theo is of Maori descent, it is essential clinicians ensure they are aware of the cultural needs of Theo and his whanau whilst going throughout an assessment. Clinicians have a responsibility under the Treaty of Waitangi as well as the Intellectual Disability Act to ensure that tikanga and kaupapa Maori perspectives are at the forefront of the assessment process (Ministry of Health, 2004).
Case formulation examines the unique predisposing, precipitating, perpetuating and protective factors (Carr, 2006). Case formulation involves information gathering from multiple sources, such as family history, medical history and social interactions with parents, whanau teachers and peers. This provides a wider range of information to establish a more complete understanding of the individual’s difficulties (Manassis, 2014). This wealth of information allows for all the unique and intricate pieces of an individual’s life, along with their personal life experiences and circumstances, those with their family as well as those experienced the school environment. When combined this provides a meaningful synopsis which is multifaceted and provides a wider background information than just a summary or when information is presented in isolation without considering other factors (Henderson ; Martin, 2014.) Case formulation when used alongside a diagnosis is proven to provide a more effective treatment to individuals who present with psychological disorders (Manassis, 2014).
Predisposing factors such as family history, genetics, medical and psychiatric history are what makes a child vulnerable to the presenting symptoms (Henderson ; Martin, 2014). For Theo, his predisposing factors include Melanie’s substance abuse during pregnancy. Studies have proven teratogens such as alcohol and drugs can lead to increased risk of developmental delays and behavioral difficulties (Ornoy & Ergaz, 2010). Melanie’s low mood and poor socioeconomic housing situation put her at an increased risk of substance abuse, which is only further increased with a drinking culture amongst Maori youth linking alcohol use with their identity (Bpac, 2010).
From a Maori perspective, the Meihana model has been developed as a culturally safe way of incorporating the individual’s life experiences and providing a narrative or hypothesis of the individuals symptoms, the circumstances around how the issues developed, the functional relationship between symptoms and life experiences and the current factors which contribute to maintaining them. The Meihana model is unique in that it encompasses uniquely Maori cultural dimensions (Pitama et al., 2017). Given the importance of being culturally aware it would be recommended that the clinician follow this model when putting together the synopsis or case formulation for Theo.
Precipitating factors look at the current symptoms that are presented and if there are connections with current life events as well as if there are any concurrent illnesses (Henderson & Martin, 2014). Melanie showed symptoms of depressive disorder with the lack of connection to her whanau having moved out of home at any early age, this through the Maori model Te Whare Tapa Wha, illustrates an unbalanced taha whanau which increased her risk of further illness and likely contributed to her substance abuse (Ministry of Health, 2017).
Perpetuating factors are the factors that allow the condition to continue (Henderson & Martin, 2014). With Melanie’s low mood and withdrawal from active engagement with Theo, his behaviour has changed and he is presenting with undesired behaviours. As Melanie yells and becomes angry in response to Theo’s behaviours they further adverse behaviours.
Finally, protective factors are Theo’s strengths, his resilience and his supports (Henderson ; Martin, 2014). Theo was an easy baby with a calm disposition and has a secure attachment with Melanie. Despite the circumstances at the time of Melanie’s pregnancy, Theo was born into a home that loved, supported, provided for and cared for. Theo’s parents are both onboard and willing to engage in support to better the outcomes despite Theo’s disability. He has external whanau support as well as the support of his school who are onboard with providing the support he requires in the classroom which provides an invaluable foundation from which he will grow. It is expected that with support and treatment the current behavioural outbursts will be managed and Theo will once again display his calm temperament.
The main goal of treatment for IDD, regardless of its severity is to address the undesired and challenging behaviours that Theo presents with (Weis, 2014). In Theo’s case, these include loud verbal outbursts, tantrums, banging toys or objects as well has his self-injury through the picking at his skin. Given these symptoms began showing as Melanie withdrew from her once active participation and attention (Weis, 2014), it is therefore these behaviours are serving the purpose of Theo gaining Melanie’s attention in the form of a negative reinforcement (Burton et al., 2014)
Treatment or interventions are designed to produce meaningful improvements in the life of both Theo as well as his parents and extended support systems (Weis, 2014). Given each individual with IDD has a unique set of deficits, and is at varying stages of cognitive, motor and social development, intervention needs to be individualised to ensure Theo is able to minimise the adverse effects of his disability as well as those experienced by his family and increase the likelihood of desirable outcomes (American Speech-Language-Hearing Association, ASLHA n.d.).
It would be recommended that Theo stays in his mainstream school, which with the additional support of a teacher aide will allow him to be included in the same curriculum as his peers of the same age (Weis, 2014). By following an inclusive practice model, teachers and aides will be able to work with Theo’s strengths as opposed to focusing on his disability which will provide better opportunities to succeed educationally (Shaddock, Giorcelli ; Smith, 2007). It is also important to set a plan and regularly review it with the inclusion of whanau, given the importance of Maori individuals being part of a wider social system (Durie, 2003).
It would be recommended that behavioural interventions and therapy are introduced to Theo and his parents, with the goal of reducing undesired behaviours (ASLHA, n.d.). Applied behaviour analysis would be beneficial for Theo, this approach aims to identify the undesired behaviours, the cause of these behaviours and work at changing them (Weis, 2014). A clinician would observe Theo’s behaviours, looking for antecedents that trigger the behaviour and the maintain behaviour and put in place a plan so these are no longer being reinforced (Weis, 2014). Engaging in positive reinforcement or differential reinforcement, this technique whereby positive reinforcement is given for desirable behaviours and undesirable behaviours are ignored. This could be implemented in Theo’s case when Melanie leaves him at school; if he refrains from making loud noises, his teacher could praise him and put a sticker on a ‘reward chart’, that could later be exchanged after meeting a set requirement for a positive reward such as choosing the story to be read for the class. Using negative punishment techniques may also assist with reducing the undesired behaviour, this would mean when Melanie drops Theo to his class, she could kiss and cuddle him and say goodbye before immediately leaving and not engaging in outbursts (Weis, 2014).
Prescribing of Risperidone is available to children over the age of 5, for the treatment of disruptive behaviours, impulsiveness and self-injury. This antipsychotic medication aims to improve the symptoms (Medsafe, 2017). Research has shown this medication is effective in reducing the challenging behaviours of children with intellectual disabilities in the short term, however the significant side effects are not without risk (Mcquire et al., 2016). Given Theo has previously been described as having a calm temperament, it would be recommended that other therapy options are tried first to reduce his disruptive behaviours prior to starting medication (NICE, 2015).
Raising a child with IDD brings unique challenges to parents and their relationship. It is recommended Melanie seeks assessment for depressive symptoms, and counselling to help her work through thoughts around her substance abuse and historical stressors. It would be recommended Melanie and Peter seek support through support groups within their community, to build relationships and support systems. Melanie with the support of iwi elders may wish to reconnected with her whanau as well as with cultural activities she once enjoyed to support her mental wellbeing given she is at a higher risk of mental health issues as a Maori woman (Ministry of Health, 2018) and parent of an IDD child (Weis, 2014).
Intellectual Disability Disorder in Early Childhood Case Study