Dual Diagnosis and Self-Determination: Any Relationship? Karen L. Hobden & Barbara W. LeRoy Developmental Disabilities Institute Wayne State University 268-4809 Woodward, Detroit, MI 48202

Dual Diagnosis Dual Diagnosis: co-occurring intellectual disability and mental health problems (NADD, 2007). Historically, individuals with intellectual disabilities were assumed to be free from mental health concerns Recent research has suggested that people with intellectual disabilities may be at an increased risk. (Deb, Thomas, & Bright, 2001) This research was funded by a grant from the Ethel and James Flinn foundation. Historically, individuals with intellectual disabilities were assumed to be free from mental health concerns. More recently research has suggested that people with intellectual disabilities may be at an increased risk for psychological problems (Deb, Thomas, & Bright, 2001; Stromme & Diseth, 2000).

Assessment of a Dual Diagnosis Mini PAS-ADD (Prosser & Moss et al., 1998) A semi-structured interview No background in psychology needed, but must be trained to administer the interview. Asks questions of an informant who knows the individual well. Reasonable validity and reliability. The Mini PAS-ADD: A semi-structured interview that can be administered by individuals who do not have a background in psychological assessment. Interviewers must be trained in administering the instrument. The measure asks questions of informant who knows the individual well regarding the individual’s behavior. It has been found to have reasonable validity and reliability in assessing psychiatric disorders in individuals with intellectual disabilities (Moss, et al. 1998)

Mini PAS-ADD - 7 Subscales: Depression Anxiety Expansive Mood Disorder (Bipolar) Obsessive-Compulsive Disorder Psychosis Unspecified Disorder (including Dementia) Autism This measure yields 7 subscale scores related to the following psychiatric disorders: Depression Anxiety Expensive Mood Obsessive-Compulsive Disorder Psychosis Unspecified Disorder (including Dementia) Autism The authors of the test caution against using the Mini PAS-ADD alone to diagnose individuals. It is not meant to be a diagnostic tool in and of itself, but a screen for common psychiatric disorders. Individuals who exceed the threshold scorers on one or more of these subscales should have a subsequent psychiatric assessment. Also, the Mini PAS-ADD does not cover all psychiatric diagnoses in the DSM-IV, but only the more common ones.

Self-determination At the core of person-centered planning. Current best practice model for service delivery The law in Michigan -- Individuals with intellectual disabilities must be given the opportunity to make choices regarding their needs and goals Self-determination At the core of person-centered planning. The current best practice model for service delivery for individuals with intellectual disabilities The law in the state of Michigan --Individuals with intellectual disabilities and their families must be given the opportunity to express their wishes and make choices regarding their needs in terms of service delivery and their goals for the future.

Our Research Goals Evaluate the effectiveness of the Mini PAS-ADD in assessing mental illness in individuals with intellectual disabilities. Examine the relationship between dual diagnosis and self-determination Our Research This research was undertaken with two goals in mind: Evaluate the effectiveness of the Mini PAS-ADD in assessing mental health in individuals with intellectual disabilities. Examine the relationship between dual diagnosis and the level of self-determination evidenced by consumers.

MORC We conducted this research in collaboration with the Macomb Oakland Regional Center (MORC) MORC serves 1000 adults with mild or moderate intellectual disabilities. We are conducting this research in collaboration with the Macomb Oakland Regional Center (MORC), which serves over 4500 adults and children with developmental, physical, or psychiatric disabilities. MORC' serves approximately 1000 adults with mild or moderate intellectual disabilities. We estimate that about one third of these individuals have a dual diagnosis.

Procedure The Mini PAS-ADD was administered by a trained interviewer, typically in the informant's home or place of employment. The interviewers were employees of MORC and were either psychologists or social workers. The Mini PAS-ADD takes about 20 minutes to administer. The Mini PAS-ADD was administered by a trained interviewer, typically in the informant's home or place of employment. The interviewers were employees of MORC and were either psychologists or social workers.

Assessment of Self-determination 22 Item Scale Assessing choice making – living arrangements, community involvement, employment/finances Completed by supports coordinator in collaboration with individual Self-determination

Self Determination Scale Living arrangements – amount of choice exercised in terms of where they live, who they live with, what they eat, when they bathe, etc. Community involvement – do they vote, attend a place of worship regularly, belong to cultural groups, clubs, or social organizations? Employment/finances– do they have an ATM card, control over their budget, are they employed, do they make minimum-wage or higher? The self-determination scale consists of three indices of choice in areas of Living arrangements Community involvement Employment/finances

Our Sample 231 participants (100 assessed on the Mini PAS-ADD, 151 on the SD Checklist). 49% female; 51% male The mean age was 49 (range of 18 to 87) 89% White; 7% African-American 86% had a guardian. 62% had a pre-existing dual diagnosis

Severity of Intellectual disability

Type of Residence

Results – Mini PAS-ADD 29% had a dual diagnosis according to the Mini PAS-ADD 4% Depression 10% Anxiety 3% Expansive Mood (Bipolar Disorder) 11% Obsessive-Compulsive 10% Psychosis 5% Unspecified Disorder 4% Autism

Comparison of Diagnoses

Mini PAS-ADD vs Diagnosis on File

Pre-existing Diagnosis, but No Mini PAS-ADD: Why? 57% taking psychotropic medication that could have reduced or eliminated symptoms. Individuals’ symptoms may have stabilized over time Some individuals may have been misdiagnosed. Reasons why individuals previously diagnosed as having a psychiatric disorder did not reach the threshold on any of the subscales of the Mini PAS-ADD. Effects of medication For those individuals who had a pre-existing diagnosis but no diagnosis on the Mini PAS-ADD, 50% were taking some form of psychotropic medication (e.g., antidepressants, antipsychotics, tranquilizers, benzodiazepines, etc.). These medications could reduce or neutralize symptoms. Also, the individuals’ symptoms may have stabilized over time.

Diagnostic Match by Psychotropic Medication The chi-square test is significant.

Results - Self-Determination by Diagnosis

Self-Determination Rankings for Persons with Dual Diagnosis - Top Third Indicator % Present 1 Has unstructured Time 98.2 2 Shops in Community 95.9 3 Chooses TV Program 94.2 4 Has access to private space 91.8 5 Has a Bank Account 87.6 6 Chooses when to bathe 71.9 7 Lives in typical residence in the community 71.5 8 Chooses what to eat 63.9

Self-Determination Rankings for Persons with Dual Diagnosis - Middle Third Indicator % Present 9 Plans/takes vacations 60.8 10 Chooses where to live 60.2 11 Attends Worship Service 43.3 12 Chooses personal doctor 37.6 13 Goes on spontaneous outings 37.5 14 Sees family members when chooses 33.5 15 Joins community organizations 29.4

Self-Determination Rankings for Persons with Dual Diagnosis - Bottom Third Indicator % Present 16 Chooses roommate 29.4 17 Has personal budget 28.4 18 Has access to telephone for personal use 21.1 19 Has employment 15.2 20 Makes minimum wage or more 14.7 21 Votes in community elections 14.3 22 Uses ATM for discretionary funds 5.9

Conclusions - Mini PAS-ADD Mini PAS-ADD is a quick, easy-to-use screen for psychiatric disorders in individuals with intellectual disabilities. May be most effective in individuals not currently on psychotropic medication.

Conclusions – Self Determination No one is very self-determined No overall differences by type of diagnosis Some indication that people with a dual diagnosis have less choice in whether they: Vote (χ²=6.42, p < 05) Join social organizations or clubs (χ²=4.52, p < 05) See family members regularly (χ²=10.47, p < 01) Have their own phone (χ²=5.81, p < 05)

Contact Info Karen Hobden email: khobden@wayne.edu phone: 313-577-7980 website http://ddi.wayne.edu/