Supporting individuals who are both developmentally delayed as well as diagnosed with a mental illness is, at best, a challenging proposition. However, as more & more individuals with developmental disabilities are successfully supported in their home communities it is this portion of the population, which is struggling. Frequently, it is the combination of challenges that keeps them from being adequately served by either support system as they are shuttled back & forth in search of a "more appropriate" placement. To stop this scenario it is essential for ethical human service professionals to stop passing the buck & develop a support system sensitive to both the individuals cognitive limitations as well as their changes in mental health status. So what are the keys to developing a successful plan? Those who have been effective list the following 10 things as crucial: 1. Double-check your psychiatric diagnosis Because the "science" of mental health diagnosis relies so heavily on self-report (usually not available or reliable in this population) it is extremely easy to misdiagnosis a psychiatric condition. Frequently when an individual is misdiagnosed the medication prescribed to improve the situation may actually be contributing to the problems.

2. Be aware that many psychiatric conditions can "look" different in someone with a developmental disability. For instance, if you are observing a 30-year old man & he appears to be talking to himself that might be considered a psychiatric manifestation. On the other hand, if you observing a 30 year old man with developmental delays (& therefore a cognitive age of 4) who is talking to himself he may simply be engaging in verbal rehearsal, a developmentally normal milestone at that developmental age (4). Bottom line -- be sure you know what you're dealing with.

3. Do your medication homework Because of the complex nature of their diagnosis, these individuals tend to end up on multiple medications. As a support person, you need to be highly educated about the possible side effects & interactions of these medications & constantly on the alert. All too often, medication side effects are reported as "new" symptoms & "treated" with additional medication rather than simply reducing or eliminating the medication causing the side effect.

4. Find the right doctor & psychiatrist to complement your team To successfully support individuals with a dual diagnosis you need a knowledgeable team. That includes both your doctor & your psychiatrist. To be effective they will need to be:

** familiar with developmental disabilities as well as mental health issues

** up to date on medications, medication side effects/interactions & new treatment options

** willing to research unusual symptom presentations &

** willing to listen to input from those who know the person best -- namely you & your direct support staff.

5. Create flexible, well-trained support staff To be successful, especially in a community setting, an individual with a dual diagnosis will need to be surrounded by a support network that understands both the nature of their mental health condition, how it interacts with their developmental disability, & how to adjust their support procedures during mental health episodes.

6. Collect & use behavioral data Individuals with mental health issues, especially mood disorders, tend to live in a highly emotional environment & draw all those around them into that atmosphere. In order to make sure that your team makes clear-headed logical decisions, it is essential to use objective behavioral measures to help gage the level & intensity of changes. Over time, this data will also allow you to see patterns of behavior & then to anticipate coming mood changes so that mental health episodes are approached in a more prepared & conscious manner.

7. Integrate your behavioral & psychiatric information Once you've collected objective data on the individuals' mental health patterns, it is essential to share this information with your team's psychiatrist. Sending the data (& someone who can explain it in a knowledgeable & straightforward manner) along to the individual's psychiatric consultation will improve the accuracy of their treatment & allow the individual to reach stabilization as quickly as possible, with a minimum of medication(s) and side effects.

8. Develop a network of support around the individual Along with the well-trained staff mentioned above, it is advisable to help the individual develop trusted relationships with a number of other people in their lives. This gives them a variety of options when they are feeling insecure or emotionally charged. It allows them to seek out whoever they feel would best understand their current concern & confide in them, possible avoiding or minimizing a mental health crisis.

9. Always have a back up plan! That being said, in the best-laid support plans, there will be moments of crisis. That, unfortunately, is simply the nature of mental illness. So it is critical to think through as much as possible how crises will be managed before they happen. For instance:

** When this set of circumstances occur -- we will seek inpatient psychiatric care at hospital X.

** If there are legal allegations -- we will follow the individual justice plan developed in cooperation with local law enforcement officials.

** If these symptoms reach this level -- we will increase the individual's access to mental health counseling to this number of visits per week.

** If these symptoms occur -- we will implement the individual's suicide prevention plan.

** If the individual cycles in & out of competency to make life decisions -- we will work with the local court & family members to establish a plan for conservatorship or guardianship with criteria for when and how long it would be necessary.

10. Know when you need help As with any challenging field, there will be moments when you and your team will simply be out of ideas & unsure what to do next. When that moment occurs, don't be afraid to ask for help. Go to other professionals who are experienced with this population & seek out feedback. Frequently a fresh perspective will get your team back on track or at least offer a direction to head while you re-group.

One final note: This is a highly complex population & this article is by no means exhaustive. Please use the information provided here as a place to start & learn all that you can about successful treatment methods from our resources & those of others if you are supporting individuals within this population. We would also like to express our thanks to Robert Simmons, one of our consulting psychologists, who provided the tips contained in today's column.

© 2001 Lisa Simmons