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

2. 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).

3. 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)

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. Severity of Intellectual disability

13. Type of Residence

14. 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

15. Comparison of Diagnoses

16. Mini PAS-ADD vs Diagnosis on File

17. 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.

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

19. Results - Self-Determination by Diagnosis

20. 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

21. 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

22. 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

23. 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.

24. 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)

25. Contact Info
Karen Hobden
phone:
website