Transcript Mental Retardation: Definition, Classification and Systems

Mental Retardation: Definition,
Classification and Systems of
Supports (2002, A.A.M.R., 10th
ed.)
Bedoelingen van het
multidimensioneel systeem
een diagnose stellen
een classificatiesysteem uitwerken
een ondersteuningsplan opstellen
The 2002 system
« ...we need to look at how the
whole person functions within
their own family, culture,
community, school or
workplace... »
The 2002 system
« ...The 10th edition
conceptualizes mental
retardation as functional and
contextual instead of
statistical... »
A state of mental defect from birth, or from an early
age, due to incomplete cerebral development, in
consequence of which the person affected is unable
to perform his duties as member of society in the
position of life to which he is born (TREDGOLD,1908)
Mental Deficiency is a state of incomplete mental
development of such a kind and degree that the
individual is incapable of adapting himself to the
normal environment of his fellows in such a way to
maintain existence independently of supervision,
control or external support (TREDGOLD,1937)
A state of social incompetence obtained at maturity,
resulting from developmental arrest of constitutional
origin (heredity or acquired); the condition is
essentially incurable through treatment and
irremediable through training.
We observe that 6 criteria by statement or implication
have been generally considered essential to an
adequate definition and concept of mental retardation
(1) social incompetence (2) due to mental
subnormality (3) which has been developmentally
arrested (4) which obtains at maturity (5) is of
constitutional origin (6) is essentially incurable
(DOLL,1941)
In 1877 two terms were coined to describe different levels of
functioning based on decreasing language and speech abilities:
‘imbecility’ and ‘idiocy’.
Since 1910 people were classified (Stanford Binet since beginning of
20th century) based on numeral scores in three different categories :
‘morons’, ‘imbeciles’ and ‘idiots’.
Since the AAMR-definition from 1959 on and until 1983 people were
classified with levels of severity: mild, moderate, severe and
profound.
In 1992-definition AAMR wanted to get rid of the ‘power’ of IQ scores
and banned the classification in levels of severity. Levels of support
were introduced.
In 2002 version classification runs parallel with the purpose of
measurement.
Mental retardation refers to subaverage general intellectual functioning
which originates during the developmental period and is associated with
impairment in one or more of the following: (1) maturation, (2)learning (3)
social adjustment
IQ-Cutoff: less than one standard deviation below the population mean of
the age group involved in measures of general intellectual functioning
Both required : standardised IQ measures and measure of impairment in
one or more aspects of adaptive behavior (e.g. Vineland)
The developmental period: runs from birth through approximately 16
years
(HEBER, 1959)
Mental Retardation refers to subaverage general
intellectual functioning which originates during the
developmental period and is associated with
impairment in adaptive behavior (HEBER,1961) –
IQ-cutoff: greater than one SD below M (theoretically,
16% of the population)
diagnosis: standardised IQ and adaptive behavior
tests
developmental period: birth through age 16
In de loop van de geschiedenis werd de statistische
bovengrens verlegd. Daardoor werden minder mensen
gelabeld. De definitie van HEBER (1961) sloeg op 16%
van de bevolking, GROSSMAN (1973) veranderde de
cutoff score van 1 naar twee of meer
standaarddeviaties; bovendien moesten
intelligentietekort en problemen in adaptief gedrag
samen (‘concurrently’) voorkomen. De bedoelde
doelgroep werd alzo vernauwd tot 3% van de
bevolking.
Licht : 50-55 tot 70-75
matig: van 35- 40tot 50-55
ernstig: van 20 tot 35- 40
diep: minder dan 20
Mental Retardation refers to subaverage general
intellectual functioning existing concurrently with
deficits in adaptive behavior and manifested during
the developmental period (GROSSMAN, 1973)
IQ-cutoff: two or more (!!) SD’s below the M of the
population
Diagnosis: standardised IQ-test and adaptive behavior
tets
Developmental period: upper age limit of 18 (!!) years
Mental retardation refers to significantly subaverage
general intellectual functioning resulting in or
associated with concurrent impairments in adaptive
behavior and manifested in the developmental period
(GROSSMAN, 1983)
Mental Retardation refers to substantial limitations in
present functioning. It is characterized by
significantly subaverage intellectual functioning
existing concurrently with related limitations in 2 or
more of the following applicable adaptive skill areas:
communication, selfcare, home living, social skills,
community use, self-direction, health and safety,
functional academics, leisure and work.
Mental retardation manifests before age 18.
(1992)
theoretisch model 1992:
triangle
The 1992-definition replaced the concept of global
adaptive behavior by 10 broad adaptive skill areas
and the requirement to document that 2 or more of
these areas could be documented as deficient
The 1992 definition introduced more than ever an
‘ecological approach’: with the term ‘present
functioning’ and the introduction of the factor
‘environment’
The practice of classifying individuals with mental
retardation into IQ-based subgroups was dropped.
Professionals were encouraged to accompany
diagnosis with descriptions of needed supports
Mental Retardation is a disability characterized by
significant limitations both in intellectual functioning
and in adaptive behavior as expressed in conceptual,
social and practical adaptive skills. The disability
originates before age 18.
(2002)
Five assumptions essential to the application of the
2002-definition
1. limitations in present functioning must be
considered within the context of community
environments typical of the individual’s age peers and
culture
2. valid assessment considers cultural and linguistic
diversity as well as differences in communication,
sensory, motor and behavioral factors
3. within an individual, limitations often coexist with
strengths
4. an important purpose of describing limitations is to
develop a profile of needed supports
5. with appropriate personalised supports over a
sustained period, the life functioning of the person
with mental retardation generally will improve
theoretisch model
2002, pag. 10
handboek
« mental retardation is a
disability »
« a disability is the expression of limitations in
individual functioning within a social
context,and represents a substantial
disadvantage to the individual. An individual’s
disability may be characterized by marked
and severe problems in the capacity to
function (impairments in bodily functions and
structures),the ability to function (activity
limitations) and the opportunity to function
(participation restrictions)
« characterised by significant
limitations in intellectual
functioning »
« ...intelligence is a general mental
capability.It includes: reasoning, planning,
solving problems, thinking abstractly,
comprehending complex idea’s, learning
quickly and learnig from experience... »
Limitations in intellectual functioning have to
be considered in light of four other
dimensions
assessment of
intellectual functioning
intellectual functioning is still best
represented by IQ-scores (although far from
perfect)
cut-off score: two standarddeviations below
the mean, considering the standard error of
instruments
m= 100, standard deviation= 15
IQ:65, 95% reliability score between 59 and
71
assessment of
intellectual functioning
GARDNER (1998): multiple intelligences
(naturalist – linguistic – logical mathematical
– spatial – musical – bodily kinesthetic interpersonal - intrapersonal )
GREENSPAN (since 1981): tripartite model
(conceptual intelligence – practical
intelligence – social intelligence)
GREENSPAN
conceptual intelligence =
equivalent to g
practical intelligence =
performance of everyday
skills
social intelligence = moral
judgement, empathy, social
skills, gullibility (being
tricked/manipulated),
credulity (believing
exaggerated clearly
inaccurate claims)
adaptive behavior
« ... is the collection of conceptual, social and practical skills that
have been learned by people in order to function in their
everyday lives... »
significant limitations = 2 standard deviations below the mean on
an overall score or on one of the three domains
limitations should be considered in light of the four other
dimensions
enkele voorbeelden van
adaptive behavior skills in
tabel 3.1; handboek pagina
42, werkboek pag.15
enkele bruikbare instrumenten
om adaptief gedrag te meten
Vineland Adaptive Behavior Scales
AAMR Adaptive Behavior Scales
Scales of Independent Behavior
Comprehensive Test of Adaptive
Behavior
Adaptive Behavior Assessment System
measurement problems
and adaptive behavior
there is a difference between performance and acquisition of
skills
problem behavior is not a characteristic of adaptive behavior
a lot of times we work with indirect observations and informants
(multimethod approach)
the individual’s physical condition and mental health plays an
enormous role
adaptive behavior has to be studied in the context of different
developmental periods (infancy, childhood, adolescence,
adulthood)
adaptive behavior must be examined in the context of an
individual’s culture that may influence opportunities, motivation
and performance
We need to look at how the whole person functions
within their own family, culture, community, school or
workplace :
* from a trait to a state of functioning
*holistic approach
*ecological model
there are three major functions of assessment:
diagnosis, classification, and planning of supports for
the person
each function has a number of possible purposes:
establishing service eligibility, research, organising
information, development of a plan for the provision of
supports for an individual
selection of the most appropriate measures or tools
will depend on the function and specific purpose to be
fulfilled
FUNCTION 1: diagnosis of mental retardation based
on 3 criteria
significant limitations in intellectual
functioning
significant limitations in adaptive
behavior as expressed in practical,
social and conceptual adaptive skills
age of onset before age 18
Age of onset : before age 18.
We know that a lot of persons don’t get their diagnosis before the
age of 18.
Date of diagnosis is not a synonym for ‘age of onset’ !!
Function 2: Classification and Description
We can describe the individual’s strengths and limitations in each
of the five dimensions. This information can be used to develop
individual support plans, research, classification, communication
about selected characteristics
a multidimensional theoretical
model: strenghts and limitations
intellectual abilities
adaptive behavior
participation,interactions,social roles
health
context
(1992)
1.Intellectual functioning and adaptive skills
2. Psychological and Emotional Considerations
3. Health and Physical Considerations
4. Environmental Considerations
vergelijkende tabel
1992-2002
tabel werkboek
pag.8
Dimension 3: Participation, Interactions and
Social Roles
positive environments foster growth,development and well-being
participation and interaction are best determined by directly observing
one’s engagement in everyday activities
participation refers to an individual’s involvement in and execution of
tasks in real life situations.It denotes the degree of involvement,
including society’s response to the individual’s level of functioning
social roles refer to a set of valued activities normal for a specific age
group
lack of participation and interactions can result from hampered
availability or accessibility of resources, accomodations or services
lack of participation and interactions frequently limit the fullfillment of
valued social roles
Dimension 4 : Health and etiological factors
Physical and Mental Health, social well-being
they can have an enormous impact on
functioning
etiology has to be seen in a multifactorial
approach: biomedical factors, social factors,
behavioral factors and educational factors
primary, secondary and tertiary prevention
Dimension 5: context (environment and culture)
context in ecological perspective:micro, meso and
macro-system
the assessment of the context is not typically
accomplished with standardized measures
Does the context provide OPPORTUNITIES?:
community presence – choice – competence –
respect – community participation
Does the context foster WELL-BEING?: health and
personal safety – material comforts and financial
security – community and civic activities – leisure and
recreation – development and stimulation – work ...
some informal but interesting questions
What are you doing?
where are doing it?
when are you doing it?
with whom are you doing it?
Function 3: Systems of Support
supports are resources and strategies that
aim to promote the development, education,
interests and personal well-being of a person
and that enhance individual functioning
services are one type of support
individual functioning results from the
interaction of supports with the 5 dimensions
well organised and matched supports can
improve the functional capabilities of
individuals
supports model
handboek figuur 9.1, pag.148
supports model: key aspects
ecological approach: discrepancy between a person’s
capabilities and the competencies required to
function in an environment
risk and protective factors have to be taken into
account
the model evaluates nine different ‘support areas’
for each area the ‘intensity of support’ is evaluated
there are different ‘support functions’
supports can be evaluated through the desired
personal outcomes
three-step process
identifying relevant support areas
identifying relevant support activities
determining the intensity of support
support areas
human development
teaching and education
home living
community living
employment
health and safety
behavioral
social
protection and advocacy
support functions
teaching
befriending
financial planning
employee assistance
behavioral support
in home living assistance
community access and use
health assistance
level of support
frequency (1)less than monthly (2) monthly (3)weekly (4)daily
(5)hourly or more frequently
daily support times (1)none (2) under 30 minutes (3)
30 minutes to less than 2 hours (4)2 hours to less than 4 hours
(5)4 hours or more
type of supports: (1) none (2) monitoring
(3) verbal/gestural prompting (4) partial physical assistance (5)
full physical assistance
systems of supports
person
family and friends
informal supports
generic services
specialised services
op komst: de SUPPORTS INTENSITY
SCALE
evaluation of supports
scheme : book pag.165
outcome categories
key indicators
measures
outcome categories
independence
relationships
contributions
school and community participation
personal well-being
indicators : tabel 9.4 pag 167 handboek
supports:characteristics
supports occur in regular, integrated
environments
support systems are following a certain logic
support activities are person centered
supports need to be coordinated
supports are fluctuating during different life
stages
supports: human rights basis
supports are to be based on person-centered
planning
supports are to be based on the power of
self-advocacy and empowerment
supports are to be based on personalreferenced outcomes (reflecting individuals
rights, values, preferences and that involve
inclusion and participation)
werkbladen A.A.M.R.