Psychiatric Assessment of the Person
With Mental Retardation
by VAN R.SILKA,MD;and MARK J. HAUSER, MD
As published in the Psychiatric Annals 27:3/March 1997
Dr Silka is Senior Psychiatrist, START Clinical Services,
Danvers, Massachusetts. Dr Hauser is Clinical Instructor in
Psychiatry Harvard Medical School; Assistant Clinical
Professor Department of Psychiatry University of Connecticut
School of Medicine; and Forensic Psychiatrist, Program in
Psychiatry and the Law, Massachusetts Mental Health Center
Address reprint requests to Mark J Hauser, MD, PD Box 222, Newtonville,
The psychiatrist who does not specialize in mental
retardation and developmental disabilities typically has had little or no exposure
in medical school or residency training to the special diagnostic and therapeutic
issues posed by this population,1 yet many psychiatrists will be called
on, at some time, to evaluate and treat individuals with mental
retardation, often in crisis situations requiring emergency admissions
or in inpatient facilities. It is essential, therefore, that
psychiatrists acquire the basic tools needed for assessment and
treatment planning at the interface of mental retardation and
WHAT IS MENTAL RETARDATION?
The DSM-1V2 defines mental retardation as follows:
- Significantly subaverage intellectual functioning-ie, an IQ of
approximately 70 or below.
- Deficits or impairments in adaptive functioning.
- Onset before age 18 years.
Levels of Severity
Mental retardation is subdivided into levels of severity based on IQ
and associated features (Table 1).
Individuals with mental retardation represent 1% to 3% of the general
population. Mental retardation is approximately 1.5 times more common in
boys than in girls.
Until recently, a significant proportion of individuals with mental
retardation were cared for in residential facilities such as state-run
training schools. Currently, however, the vast majority of the
developmentally disabled live in the community and use community
resources for treatment.
Mental retardation is highly heterogeneous as to cause. More than 250
biologic causes are known, most of which can be grouped under the
general categories of chromosomal abnormalities, other genetic factors,
prenatal and perinatal factors (eg, anoxia), acquired childhood
disorders, environmental factors (eg, lead),3and sociocultural factors.
Knowing the cause in a particular case can sometimes provide important
clues for understanding an individual's presentation; however, only
approximately 25% of cases of mental retardation have a known biologic
cause; in the remaining 75% of cases, the cause is unknown or is
traceable to nonbiologic (eg, psychosocial) factors.
MENTAL RETARDATION AND PSYCHIATRIC DISORDERS
It has been estimated that 40% to 70% of individuals with mental
retardation have diagnosable psychiatric disorders.4 This subgroup of
individuals, however, are not the only ones who come in contact with
psychiatrists. Like anyone else, a developmentally disabled person may
present with emotional, behavioral, interpersonal, or adjustment
problems that do not constitute major psychiatric disorders but that
may benefit nonetheless from psychiatric input. Psychiatrists should
remember that in clinical settings they do not have the opportunity to
see people with mental retardation living and working in the community
in a normal, non-problematic manner. As a result, they often do not have
a baseline with which to compare current functioning.
Psychiatrists called on to evaluate and treat developmentally disabled
individuals in either an emergency or inpatient setting need to be aware
of special considerations that set this population apart. These
considerations occur mainly in two areas: (1) working as part of a team
with the patient's regular caregivers; and (2) characteristics of mental
retardation that may confound the usual procedures for psychiatric
diagnostic assessment and treatment planning.
Levels of Severity of Mental Retardation
Precentage of Mentally Retarded Population
50-55 to 70
35-40 to 50-55
20-25 to 35-40
Relationships With Other Caregivers
Psychiatric care of individuals with mental retardation is most
effectively rendered when the psychiatrist uses an interdisciplinary
team model.5 The psychiatrist must take into account not only the acute
problem but also the patient's relationship to long-term caregivers.
These professionals tend to be deeply involved in the life of the
patient, who they care a great deal about and see as their "client."
They will likely contribute critically important diagnostic
information and play a crucial role in implementing the treatment plan.
At the same time, referring caregivers sometimes distrust doctors and
medications.4'6 This aversion may lead them to delay getting a
consultation until they are "at the end of their rope" and feel as if
they can no longer cope with the patient, whose condition may have
worsened in the interim. They may simultaneously harbor unrealistic
expectations, such as that the psychiatrist will be a magical rescuer.
This ambivalence can have disruptive consequences. A successful
treatment outcome may depend in part on how well the psychiatrist can
bridge the gap between different conceptual models (medical versus
habilitative), clinical languages, and organizational styles.
Special Diagnostic Issues
Mental retardation may obscure the standard diagnostic indicators of
psychiatric disorders. For one thing, especially for the psychiatrist
unaccustomed to the normal manifestations of mental retardation, those
manifestations may overshadow symptoms attributable to psychiatric
illness.7 Moreover, impairments in cognitive and verbal skills make it
difficult for many developmentally disabled individuals to articulate abstract or
global concepts such as a depressed mood. Most DSM-IV diagnoses require
that the patient describe his or her internal state. Asking a person
with an IQ below 40 about hallucinations, delusions, or guilt is seldom
productive. On the other hand, the person's disorganized behavior may
have diagnostic significance.8
These are the challenges that people with mental retardation often pose
for psychiatric diagnosis. Sovner 9 identified four aspects of mental
retardation that may influence diagnosis:
- Intellectual distortion - emotional symptoms are difficult to elicit
because of deficits in abstract thinking and in receptive and expressive
- Psychosocial masking - limited social experiences can influence the
content of psychiatric symptoms (eg, mania presenting as a belief that
one can drive a car).
- Cognitive disintegration - decreased ability to tolerate stress,
leading to anxiety-induced decompensation (sometimes misinterpreted as
- Baseline exaggeration - increase in severity or frequency of chronic
maladaptive behavior after onset of psychiatric illness.
To allow for these possible distortions, Sovner9 proposed that the
standard diagnoses for mania and depression be modified, when applied to
the developmentally disabled, to focus on biologic signs and symptoms
and behavioral equivalents to subjective states.
PRINCIPLES OF EMERGENCY EVALUATION
In a crisis, the emergency room can serve as a safe holding environment,
a place for acute stabilization, emergency sedation, medical and
psychiatric evaluation, and disposition for further treatment. When
approaching a developmentally disabled person and his or her regular
caregivers in a crisis situation, following certain basic principles
helps set the stage for a less stressful, more nurturant, and more
accurate evaluation. Some of these guidelines are equally applicable to
the assessment of the developmentally disabled person in a more stable
inpatient or outpatient situation.
- Evaluate the patient in a safe, private, quiet place. Seeing, hearing,
and being seen and heard by other patients and staff can be frightening,
distracting, or over stimulating. Some individuals may deliberately attract
attention by behaving disruptively when they have an audience.
- Conduct the evaluation promptly. Having to wait may cause additional
- When possible, invite familiar staff, family, or both to keep the
patient company and provide history. Individuals with mental
retardation benefit from predictable, reassuring stimuli.
- Calm the patient and the caregivers. Attending to the needs and
concerns of the caregivers and encouraging them to contribute to the
solution can often help defuse the problem.
- Explain any procedures simply and clearly.
- Primum non nocere (first, do no harm). Unless absolutely necessary;
try to avoid measures such as seclusion and restraint that may increase
the individual's distress.
- Determine the reason for coming to the emergency room. This guideline
may seem obvious, but a hidden agenda may exist.
- Beware of the "vanishing" problem. A previously agitated patient who
calms down on arrival at the emergency room presents a diagnostic
dilemma because it is difficult to evaluate a behavior that is not in
evidence. Although the hospital staff may want to send the patient back,
the regular caregivers may fear a recurrence. It is therefore necessary
to evaluate the underlying problem, assess the likelihood of a
recurrence, and intervene appropriately.
- Do not attempt a definitive diagnosis in the emergency room, which is
especially problematic with the developmentally disabled population.
- Discourage use of the emergency room for behavioral control. The
emergency room should not be perceived by the patient, nor used by the
staff, as a form of punishment or threat. Nor should the psychiatrist be
cast as a bogeyman who, as a last resort, is there just to tranquilize
- It is not necessary to resolve the problem completely in the emergency
room. You may draw on the experience and resources of the caregivers or
refer to an appropriate community or state agency.
MANAGEMENT OF AGGRESSION OR SELF-INJURIOUS BEHAVIOR
The most common categories of acute presentations in individuals with
mental retardation are:
- New onset or escalation of aggression, self-injurious behavior, or
- Changes in mental status, such as:
- Hyperactivity or irritability
- Confusion or disorientation
- Lethargy or withdrawal
- Psychotic symptoms
- Other changes in mood, energy, or sleep patterns
- Medication side effects, especially extrapyramidal symptoms
- Physical complaints or behavioral manifestations that might signify
Of these, the most frequent cause of acute emergency presentations is
aggression or self-injurious behavior. Most individuals with mental
retardation do not display this kind of behavior. In those who do, it is
not necessarily an indicator of psychiatric illness. Rather, when verbal
expression is impaired, distress resulting from many possible causes
may be expressed through maladaptive behavior such as aggression and
self-injurious behavior. Such behavior may be seen as a final common
pathway for various medical, psychiatric, interpersonal, and
environmental circumstances. A diagnostic evaluation is therefore
Lowry and Sovner10 describe four functions of problem behavior that
should be considered in any evaluation:
- Socioenvironmental control. Aggression and self-injurious behavior
can be reinforced (ie, removing a person from an unpleasant situation
in response to such behavior will increase the probability that the
person will react similarly in the future).
- Communication. Problem behaviors can be a nonverbal means of
communicating a variety of messages (attention, discomfort, needs).11
- Modulation of physical discomfort. Medical conditions, including
medication side effects, can cause physical discomfort leading to
aggression or self-injurious behavior.
- Modulation of emotional discomfort. Problem behaviors can occur as a
state-dependent function of such disorders as major depression or
bipolar disorder, manic phase.12
Evaluation and Treatment Strategies
Lowry and Sovner10 have proposed a four-part strategy for evaluating and
treating problem behaviors:
- Conduct a comprehensive functional assessment of the problem
- Develop one or more working hypotheses.
- Select treatments that address the hypothesized function of the
- When a behavior serves multiple functions, target those derived from
biologic dysfunctions first.
When possible, treatment should be directed at the medical illness,
psychiatric disorder, or other underlying cause of the maladaptive
behavior. Table 2 shows a differential diagnosis for aggression, with
the appropriate treatment linked to the cause of the aggression.
Differential Diagnosis of Aggression and Possible Treatments
Aggression reflects medical illness.
Aggression reflects medication side effect.
Aggression reflects preseizure irritability.
Aggression reflects irritability secondary to
mania, depression, or organic mood disorder.
Aggression represents rage attacks.
Aggression is associated with task-related anxiety.
Aggression is associated with schizophrenia-related paranoid delusion.
Aggression is associated with inability to express needs.
Aggression is a means for obtaining positive reinforcers.
Aggression represents escape or avoidance behavior in the absence of an
Have medical team assess and treat medical condition.
Teach client to request medical care.
Have medical team discontinue and/or substitute medication.
Have medical team review anticonvulsant regimen to establish better
Treat with disorder-concordant drug, such as lithium for mania,
fluoxetine for depression, or carbamazepine for organic mental syndrome.
Teach patient anger management skills.
Treat with propranolol or another centrally acting beta blocker.
Teach cognitive-behavioral skills to decrease anxiety.
Prescribe an anti-anxiety agent such as buspirone.
Teach functional communication skills.
Enhance access to positive reinforcers. Teach socially acceptable,
Adapt environment to minimize aversive stimuli (eg, over-crowding).
Teach appropriate escape behavior.
Source: Pary RJ, Silka VR, Blaha SJ. Mental retardation. In: Thienhaus
OJ, ed. Manual of Clinical Hospital Psychiatry Washington, DC: American
Psychiatric Press; 1995:287-309.
Treatment of aggression and self-injurious behavior secondary to mood
disorders or psychotic disorders has met with some success. Because it is not always
possible to diagnose the underlying psychiatric disorder or other cause,
a symptomatic approach is sometimes necessary. Symptomatic treatments
for aggression and self-injurious behavior include beta blockers,
particularly for individuals with rage attacks or chronic states of
overarousal13; buspirone when significant anxiety is present14; mood
stabilizers such as lithium and carbamazepine when irritability
exists15; neuroleptics16; opiate antagonists, such as naltrexone,
especially in autism17; and selective serotonin reuptake inhibitors,
such as fluoxetine, especially when the aggression is impulsive.18
INDICATIONS FOR HOSPITALIZATION
On the basis of the emergency evaluation, any
of the following dispositions may be agreed on:
Changes in the legal, institutional, and financial structure of
psychiatric care have set a higher threshold for inpatient
hospitalization. As in the general population, hospitalization is
clearly indicated when a person poses an imminent danger to self or
others because of a psychiatric illness. Hospitalization may also be
indicated when outpatient treatment has been unsuccessful in halting a
psychiatric decompensation or when a psychiatric illness has progressed
to the point that the person is no longer able to function in
the community. It is becoming increasingly difficult to obtain
hospitalization for extended medication trials or for initial
monitoring of a new course of pharmacologic treatment, despite that
hospitalization may be appropriate in some such situations. Finally,
Sovner and Hurley19 make clear that inpatient staff should not be
expected to assume responsibility for the treatment of long-standing
maladaptive behavior and to discharge a patient only after that behavior
- Return to current living situation
- Respite care or increased monitoring at home
- Medical treatment
- Inpatient psychiatric hospitalization
COMPONENTS OF A PSYCHIATRIC ASSESSMENT
The components of the assessment are described here for an inpatient
evaluation, but most can also be performed in an outpatient setting.
A thorough history, crucial for a psychiatric diagnosis, can be obtained
from three sources: the patient, other informants, and medical records.
The following guidelines are useful for interviewing the patient with
Informants such as the family, case manager, or staff from the day
program, worksite, or living site can provide information unobtainable
from the patient directly. It is helpful to empathize with the
informant's experience in caring for or working with developmentally
disabled people and to educate the staff or family about what data are
salient. Specifically, the following areas can be fruitful to explore:
- Talk to the patient, even if it appears that the patient might not
understand, because a person's receptive language skills are likely to
exceed his or her expressive skills.
- Pay attention to the patient's developmental level, which may
necessitate talking in a more concrete fashion, focusing on the here and
now, and using words appropriate to the patient's level of
- Avoid leading questions, to which many developmentally disabled
people are susceptible.20
- Use physical expressions and gestures to communicate with the
patient. Consider techniques such as metaphor and storytelling to
facilitate communication. Observe the patient's nonverbal
interactions, especially with familiar caregivers.
Patient records, if available, should be reviewed for the following
information, with emphasis on the annual assessment:
- Recent changes in the patient's physical or social environment, such
as a move from school to day programming or a workshop, a change of
residence, loss of a favorite staff member, or anniversary dates of
- Circumstantial patterns such as symptoms associated with a particular
setting or time of day. Maladaptive behavior that regularly occurs at
the workshop but not in the group home, or vice versa, can help
differentiate an underlying psychiatric disorder from a situational
- A longitudinal history to correlate with concurrent events such as
stressors, medical problems, and medication changes.21
- Psychologic evaluation - baseline data on IQ, level of adaptive
functioning, language and communication skills, and ability to interact
with others. These data can be contrasted with current status to identify
- Social and developmental history - pregnancy, birth process, and early
environment, any of which may cast light on the cause of mental
- Family history - mental retardation, mental illness, and other medical
- Medical history - incidence of cerebral palsy, sensory deficits,
epilepsy, and other neurologic disorders increases as IQ decreases.22 A
dysmorphologic syndrome often is associated with medical problems.23
- Physicians' and nurses' notes - sleep, weight, and activity levels;
previous consultations; laboratory findings; medication history. Drug
interactions can precipitate aggression or self-injurious behavior.
Longitudinal behavioral data, when correlated with concurrent events
such as environmental stresses, medical problems, and changes in
medications, can contribute significantly to diagnosis and treatment. If
possible, identify target behaviors that are symptoms of the (known or suspected)
underlying psychiatric disorder and may be drug responsive, such as
sleep disturbance in major depression. Establish baseline rates of the
target behavior(s) to monitor response to treatment. A behavioral
psychologist can help design, monitor, and educate the staff about data
Mental Status Examination
The mental status examination is an essential step in differentiating
psychiatric from medical or situational problems. As modified for
individuals at lower levels of functioning, it may include the person's
general appearance; relationship to the examiner and others in the
room; level and fluctuation of consciousness; psychomotor retardation
or agitation; mood; range and appropriateness of affect; ability to
communicate; ability to follow simple commands; visuospatial memory;
orientation; and any observed abnormal involuntary movements, tremors,
stereotypies, automatisms, or self-injurious behavior.
When longer hospital stays were the rule, various rating scales and
assessment tools were developed for persons with mental
retardation.24'25 Although their use has been greatly curtailed by
limitations on inpatient stays, situations may still arise in which
such instruments can be employed feasibly.
Physical Examination and Diagnostic Studies
A thorough medical evaluation is needed to rule out an organic cause of
a change in mental status or maladaptive behavior. This aspect of the
assessment is especially important because people with mental
retardation have an elevated rate of associated physical disabilities.
The physical examination must be performed systematically and
patiently. Occasionally, when the individual is uncooperative and
organic pathology is strongly suspected, sedation may be necessary.
The evaluation resembles that performed to identify the causes of
delirium and dementia in a geriatric population. Routine laboratory work
consists of an EKG, measurement of electrolyte levels, a complete blood
count, screening blood chemistry, urinalysis, measurement of folate and
B-12 levels, syphilis serology, and thyroid function tests. Depending on
the differential diagnosis, other laboratory tests may include an EEG, a
brain imaging scan such as CT or MRI, and blood level measurements,
especially of anticonvulsants.
Drug interactions and medication side effects must also be considered.
- Benzodiazepines with long half-lives may accumulate, leading to
drowsiness and mental clouding. Short-acting benzodiazepines may cause
interdose rebound symptoms, with marked worsening of anxiety just prior
to scheduled doses. In autistic individuals, benzodiazepines may cause
- Anticonvulsants may produce excessive sedation. Occasionally,
phenobarbital may have paradoxic disinhibiting effects.
- Antipsychotic drugs can have serious side effects, such as
Parkinsonism and akathisia, that may be confused with worsening
agitation. Such misdiagnosis can lead to a counterproductive increase
in the neuroleptic dose. Excessive doses of antipsychotic drugs can
interfere with alertness and overall performance. On the other hand, a
precipitous reduction in dosage can lead to problems such as agitation,
behavioral deterioration, and worsening abnormal involuntary movements,
which may represent transient withdrawal dyskinesias.
- Other medications whose effects should be monitored include
antihypertensive drugs, eyedrops for glaucoma (often beta-adrenergic
blockers), and allergy medications (almost all anticholinergic or
As part of the interdisciplinary team approach, the scope of the
evaluation may be broadened to include, as needed, consultations with
the disciplines of internal medicine, gynecology, neurology and
behavioral neurology, neuropsychology, pharmacology, hearing and speech
therapy,19 physical therapy, occupational therapy, and leisure skills
The treatment plan should:
- include community caregivers and hospital staff.
- formulate specific treatment goals, remembering what can reasonably
be accomplished within a relatively short inpatient stay.
- avoid (as much as possible) treatments that cannot be continued in the
community, such as medications taken as required or seclusion and
- take into account the crucial importance of variables such as
consistency versus change in the patient's environment, greater or
lesser supervision of the patient's activities, identification of
possible stressors, and implementation of behavioral management
- use therapy, activity groups, or both to bring out the person's
capacity for learning and participation (for more cognitively impaired
or acutely psychotic individuals, focus groups may be used to improve
The use of medications should be reserved for appropriate target
disorders and syndromes. Medications should not be administered to the
patient simply as a response to staff anxiety. To avoid this common
pitfall, the psychiatrist may need to confront staff expectations
skillfully, explaining that although "we all would want to have a
medication that would treat the symptoms without side effects," such a
medication does not exist. Emphasizing the possible environmental causes of
problem behaviors can also help reduce the demand for indiscriminate
prescription of medications.
When antipsychotic drugs are used for non-specific sedation, the danger
is that their use will be continued indefinitely, resulting in
preventable side effects. Short-term administration of a benzodiazepine
is a better choice for nonspecific sedation. Of course, medications may
be needed for longer-term treatment of depression, bipolar disorder,
psychotic disorders, obsessive-compulsive disorder, or attention deficit
disorder. In addition, short-term pharmacologic treatment may be useful
when certain symptoms have not responded to environmental
interventions.26 Among these symptoms are the following:
In these circumstances, medications should be prescribed with
essentially the same indications, contraindications, precautions,
doses, and monitoring as in the general psychiatric population but with
special attention to possible behavioral effects in those with mental
- sleep disturbances (eg, with a benzodiazepine or trazodone)
- agitation (eg, with a benzodiazepine)
- impulsivity, aggression, and self-injurious behavior (eg, with empiric
trials of buspirone, beta-adrenergic blockers, selective serotonin
reuptake inhibitors, or carbamazepine)
Appropriate acute or short-term inpatient treatment, coupled with
long-term treatment recommendations, has the purpose of returning the
individual to his or her prior environment or other suitable community
setting. Effective discharge planning often strengthens the supports
provided by an existing placement even as it facilitates continued
psychiatric care. Most patients have an existing caretaking system to
which they can return. To prevent the psychiatric unit from becoming a
long-term residential facility for difficult clients, the referring
agency should guarantee in writing a placement after discharge.19
Ideally, discharge planning, including plans for outpatient follow up
and the provision of any additional services, should begin at the
initial treatment planning meeting or even before admission.
Communication is the key to effective planning. Early and continual
contact with all community supports, from family to outpatient
therapists, is imperative. Questions to be addressed include the
This focus will help hospital staff propose realistic aftercare
treatment plans based on available resources and provider capabilities.
The initial meeting may also identify a liaison who can smooth the
transition between hospital and community.
- Who is responsible for which service (case manager, family, agency,
client, and others)?
- What is expected from this hospitalization?
- What are the minimal discharge criteria?
The patient, when stable, should be given a therapeutic pass to his or
her home or day program. This transitional step not only tests the
resilience of clinical improvement but also lets the patient see that he
or she still has a room and a job available.
Before discharge, a conference should be held to articulate a shared
understanding about future treatment planning. The psychiatrist and
hospital staff should see that the following points are covered:
The special case of discharge planning for the adult with mental
retardation who can no longer be cared for at home by relatives (such as
elderly parents) is dealt with elsewhere.27
- Review the course of hospitalization and discuss how a subsequent
inpatient stay can be avoided or shortened.
- Create a data collection mechanism to assist the regular caregivers in
observation, recording, and communication of pertinent information.
- Recommend any additional appropriate tests.
- Coordinate follow-up appointments and identify triggers for
unscheduled telephone or in-person follow up.
The psychiatrist should be aware of several important legal
The diagnosis of mental retardation does not by itself imply that the
individual is incompetent to consent to treatment. Competence must be
assessed on a case-by-case basis. An individual who appears to
understand the benefits, risks, and alternatives to psychiatric
hospitalization should be given the opportunity to sign in voluntarily,
unless a guardian has been appointed by the court. In an emergency setting,
life-threatening problems warrant emergency treatment, even in the absence of
informed consent. If someone is clearly not competent, a long-term caregiver
or family member should be asked to consent to the evaluation and treatment.
In cases where competence is impaired, guardianship may already have been
established or may need to be considered. When a legal guardian has been appointed,
authorization for evaluation and treatment must be obtained from the guardian,
except in life-threatening emergencies.
Mandated Reporting of Abuse of Disabled Persons
Many states have statutes that require medical personnel to report any
suspicion of abuse.
Many states have entered into binding legal agreements as a result of lawsuits
initiated by plaintiffs to improve the quality of care delivered to people with
mental retardation. These consent decrees may mandate procedural safeguards and
specific measures of quality of treatment.
The authors are indebeted to Archie Brodsky for his help with the manuscript.
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