Mild Mental Retardation With Undifferentiated SchizophreniaNCMH

Centro Escolar University

College of Nursing

Mendiola, Manila

In Partial Fulfilment of the Requirements

In

NCM 103

Mental Institution

National Center for Mental Health

MILD MENTAL RETARDATION WITH

UNDIFFERENTIATED

SCHIZOPHRENIA

Submitted by:

Gallos, Randell M.

BSN 3A /Group 3A

Submitted to:

Donie L. Brabante, RN, MAN

Clinical Instructor

1

T A B L E O F C O N T E N T S

CHAPTER I: INTRODUCTION A. Introduction to PsychopathologyB. Theoretical FrameworkC. Biographical DataD. Nursing History

1. Chief Complaint 2. History of present Illness 3. Previous Illness 4. Past Personal History 5. Family History 6. Social History

CHAPTER II: Presentation, Interpretation & Analysis of Data A. General AppearanceB. Motor BehaviorC. Sensorium & CognitionD. PerceptionE. AttitudeF. Defense MechanismsG. Affective StatesH. Thought Process

CHAPTER III DIAGNOSISA. Predisposing FactorsB. Psychodynamics / PsychopathologyC. Related Literature

1. Summary2. Reaction

D. Drug Study

CHAPTER IV: NURSING CARE PLAN

A. Process RecordingB. List of Prioritized Psychiatric Nursing Diagnosis

5 prioritized nursing diagnosis with rationale C. Psychiatric Nursing Care Plans

First 3 highly prioritized nursing diagnosis

CHAPTER V: PSYCHOTHERAPYA. Play Therapy B. Music & Art TherapyC. BibliotherapyD. Occupational TherapyE. Remotivation Therapy

APPENDICESA. MSA Tool used with the patientB. Art Therapy OutputC. List of Reference Materials used

a. Title of the Book / website

b. Author

c. Date published/searched from the net

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CHAPTER

1INTRODUCTION

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A.Introduction to Psychopathology

Psychopathology is a term which refers to either the study of mental illness or mental distress,

or the manifestation of behaviors and experiences which may be indicative of mental illness or

psychological impairment, such as abnormal, maladaptive behavior or mental activity.

Psychopathology is that branch of psychiatry which deals with the study of manifestation of

behaviours and experiences indicative of mental illness.

Psychopathology as the study of mental illness

Many different professions may be involved in studying mental illness or distress. Most notably,

psychiatrists and clinical psychologists are particularly interested in this area and may either be

involved in clinical treatment of mental illness, or research into the origin, development and

manifestations of such states, or often, both. More widely, many different specialties may be

involved in the study of psychopathology. For example, a neuroscientist may focus on brain

changes related to mental illness. Therefore, someone who is referred to as a psychopathologist,

may be one of any number of professions who have specialized in studying this area.

Psychiatrists in particular are interested in descriptive psychopathology, which has the aim of

describing the symptoms and syndromes of mental illness. This is both for the diagnosis of

individual patients (to see whether the patient's experience fits any pre-existing classification), or

for the creation of diagnostic systems (such as the Diagnostic and Statistical Manual of Mental

Disorders or International Statistical Classification of Diseases and Related Health Problems)

which define exactly which signs and symptoms should make up a diagnosis, and how

experiences and behaviours should be grouped in particular diagnoses (e.g. clinical depression,

paraphrenia, paranoia, schizophrenia).

Psychopathology should not be confused with psychopathy, which is a type of personality

disorder.

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Psychopathology as a descriptive term

The term psychopathology may also be used to denote behaviours or experiences which are

indicative of mental illness, even if they do not constitute a formal diagnosis. For example, the

presence of a hallucination may be considered as a psychopathological sign, even if there are not

enough symptoms present to fulfill the criteria for one of the disorders listed in the DSM or ICD.

In a more general sense, any behaviour or experience which causes impairment, distress or

disability, particularly if it is thought to arise from a functional breakdown in either the cognitive

and neurocognitive systems in the brain, may be classified as psychopathology.

Mental retardation is an idea, a condition, a syndrome, a symptom, and a source of pain and

bewilderment to many families. Its history dates back to the beginning of man's time on earth.

The idea of mental retardation can be found as far back in history as the therapeutic papyri of

Thebes (Luxor), Egypt, around 1500 B.C. Although somewhat vague due to difficulties in

translation, these documents clearly refer to disabilities of the mind and body due to brain

damage (Sheerenberger, 1983). Mental retardation is also a condition or syndrome defined by a

collection of symptoms, traits, and/or characteristics. It has been defined and renamed many

times throughout history. For example, feeblemindedness and mental deficiency were used as

labels during the later part of the last century and in the early part of this century. Consistent

across all definitions are difficulties in learning, social skills, everyday functioning, and age of

onset (during childhood). Mental retardation has also been used as a defining characteristic or

symptom of other disorders such as Down syndrome and Prader-Willi syndrome. Finally, mental

retardation is a challenge and potential source of stress to the family of an individual with this

disorder. From identification through treatment or education, families struggle with questions

about cause and prognosis, as well as guilt, a sense of loss, and disillusionment about the future.

The objective of this chapter is to provide the reader with an overview of mental retardation, a

developmental disability with a long and sometimes controversial history. Following a brief

historical overview, the current diagnostic criteria, epidemiological information and the status of

dual diagnosis will be presented. Comprehensive assessment and common interventions will also

be reviewed in some detail.

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Mental RetardationMental retardation is a generalized disorder, characterized by significantly impaired cognitive

functioning and deficits in two or more adaptive behaviors with onset before the age of 18. Once

focused almost entirely on cognition, the definition now includes both a component relating to

mental functioning and one relating to individuals' functional skills in their environment

Alternative terms

The term "mental retardation" is a diagnostic term denoting the group of disconnected categories

of mental functioning such as "idiot", "imbecile", and "moron" derived from early IQ tests,

which acquired pejorative connotations in popular discourse. The term "mental retardation"

acquired pejorative and shameful connotations over the last few decades due to the use of

"retarded" as an insult. This may have contributed to its replacement with euphemisms such as

"mentally challenged" or "intellectual disability". While "developmental disability" may be

considered to subsume other disorders (see below), "developmental disability" and

"developmental delay" (for people under the age of 18), are generally considered more

acceptable terms than "mental retardation".

* In North America mental retardation is subsumed into the broader term developmental

disability, which also includes epilepsy, autism, cerebral palsy and other disorders that develop

during the developmental period (birth to age 18.) Because service provision is tied to the

designation developmental disability, it is used by many parents, direct support professionals,

and physicians. However, in school-based settings, the more specific term mental retardation is

still typically used, and is one of 13 categories of disability under which children may be

identified for special education services under Public Law 108-446.

* The phrase intellectual disability is increasingly being used as a synonym for people with

significantly below-average cognitive ability.[1] These terms are sometimes used as a means of

separating general intellectual limitations from specific, limited deficits as well as indicating that

it is not an emotional or psychological disability. Intellectual disability may also used to describe

the outcome of traumatic brain injury or lead poisoning or dementing conditions such as

Alzheimer's disease. It is not specific to congenital disorders such as Down syndrome.

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The American Association on Mental Retardation continued to use the term mental retardation

until 2006.[2] In June 2006 its members voted to change the name of the organization to the

"American Association on Intellectual and Developmental Disabilities," rejecting the options to

become the AAID or AADD. Part of the rationale for the double name was that many members

worked with people with pervasive developmental disorders, most of whom do not have mental

retardation.[3]

In the UK, "mental handicap" had become the common medical term, replacing "mental

subnormality" in Scotland and "mental deficiency" in England and Wales, until Stephen Dorrell,

Secretary of State for Health for the United Kingdom from 1995-7, changed the NHS's

designation to "learning disability." The new term is not yet widely understood, and is often

taken to refer to problems affecting schoolwork (the American usage), which are known in the

UK as "learning difficulties." British social workers may use "learning difficulty" to refer to both

people with MR and those with conditions such as dyslexia.

In England and Wales between 1983 and 2008 the Mental Health Act 1983 defined "mental

impairment" and "severe mental impairment" as "a state of arrested or incomplete development

of mind which includes significant/severe impairment of intelligence and social functioning and

is associated with abnormally aggressive or seriously irresponsible conduct on the part of the

person concerned."[4] As behavior was involved, these were not necessarily permanent

conditions: they were defined for the purpose of authorizing detention in hospital or

guardianship. The term Mental Impairment was removed from the Act in November 2008, but

the grounds for detention remained. However, English statute law uses "mental impairment"

elsewhere in a less well-defined manner—e.g. to allow exemption from taxes—implying that

mental retardation without any behavioral problems is what is meant.

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Signs

Children with mental retardation may learn to sit up, to crawl, or to walk later than other

children, or they may learn to talk later. Both adults and children with mental retardation may

also exhibit the following characteristics:

* Delays in oral language development

* Deficits in memory skills

* Difficulty learning social rules

* Difficulty with problem solving skills

* Delays in the development of adaptive behaviors such as self-help or self-care skills

* Lack of social inhibitors

The limitations of cognitive functioning will cause a child with mental retardation to learn and

develop more slowly than a typical child. Children may take longer to learn language, develop

social skills, and take care of their personal needs such as dressing or eating. Learning will take

them longer, require more repetition, and skills may need to be adapted to their learning level.

Nevertheless, virtually every child is able to learn, develop and become participating members of

the community.

In early childhood mild mental retardation (IQ 50–69) may not be obvious, and may not be

identified until children begin school. Even when poor academic performance is recognized, it

may take expert assessment to distinguish mild mental retardation from learning disability or

emotional/behavioral disorders. As individuals with mild mental retardation reach adulthood,

many learn to live independently and maintain gainful employment.

Moderate mental retardation (IQ 35-49) is nearly always apparent within the first years of life.

Children with moderate mental retardation will require considerable supports in school, at home,

and in the community in order to participate fully. As adults they may live with their parents, in a

supportive group home, or even semi-independently with significant supportive services to help

them, for example, manage their finances.

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A person with a more severe mental retardation will need more intensive support and supervision

his or her entire life.

Diagnosis

According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV),[5] three criteria must be met for a diagnosis of mental retardation: an IQ below 70,

significant limitations in two or more areas of adaptive behavior (as measured by an adaptive

behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and

evidence that the limitations became apparent before the age of 18.

It is formally diagnosed by professional assessment of intelligence and adaptive behavior.

IQ below 70

The first English-language IQ test, the Terman-Binet, was adapted from an instrument used to

measure potential to achieve developed by Binet in France. Terman translated the test and

employed it as a means to measure intellectual capacity based on oral language, vocabulary,

numerical reasoning, memory, motor speed and analysis skills. The mean score on the currently

available IQ tests is 100, with a standard deviation of 15 (WAIS/WISC-IV) or 16 (Stanford-

Binet). Sub-average intelligence is generally considered to be present when an individual scores

two standard deviatons below the test mean. Factors other than cognitive ability (depression,

anxiety, etc.) can contribute to low IQ scores; it is important for the evaluator to rule them out

prior to concluding that measured IQ is "significantly below average".

The following ranges, based on Standard Scores of intelligence tests, reflect the categories of the

American Association of Mental Retardation, the Diagnostic and Statistical Manual of Mental

Disorders-IV-TR, and the International Classification of Diseases-10:

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Class IQ

Profound mental retardation Below 20

Severe mental retardation 20–34

Moderate mental retardation 35–49

Mild mental retardation 50–69

Borderline intellectual functioning 70–80

Since the diagnosis is not based only on IQ scores, but must also take into consideration a

person's adaptive functioning, the diagnosis is not made rigidly. It encompasses intellectual

scores, adaptive functioning scores from an adaptive behavior rating scale based on descriptions

of known abilities provided by someone familiar with the person, and also the observations of

the assessment examiner who is able to find out directly from the person what he or she can

understand, communicate, and the like.

Significant limitations in two or more areas of adaptive behavior

Adaptive behavior, or adaptive functioning, refers to the skills needed to live independently (or

at the minimally acceptable level for age). To assess adaptive behavior, professionals compare

the functional abilities of a child to those of other children of similar age. To measure adaptive

behavior, professionals use structured interviews, with which they systematically elicit

information about persons' functioning in the community from people who know them well.

There are many adaptive behavior scales, and accurate assessment of the quality of someone's

adaptive behavior requires clinical judgment as well. Certain skills are important to adaptive

behavior, such as:

* daily living skills, such as getting dressed, using the bathroom, and feeding oneself;

* communication skills, such as understanding what is said and being able to answer;

* social skills with peers, family members, spouses, adults, and others.

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Evidence that the limitations became apparent in childhood

This third condition is used to distinguish it from dementing conditions such as Alzheimer's

disease or due to traumatic injuries with attendant brain damage.

Causes

Down syndrome, fetal alcohol syndrome and Fragile X syndrome are the three most common

inborn causes. However, doctors have found many other causes. The most common are:

* Genetic conditions. Sometimes disability is caused by abnormal genes inherited from

parents, errors when genes combine, or other reasons. The most prevalent genetic conditions

include Down syndrome, Klinefelter's syndrome, Fragile X syndrome, Neurofibromatosis,

congenital hypothyroidism, Williams syndrome, Phenylketonuria (PKU), and Prader-Willi

syndrome. Other genetic conditions include Phelan-McDermid syndrome (22q13del), Mowat-

Wilson syndrome, genetic ciliopathy,[6] and Siderius type X-linked mental retardation (OMIM

300263) as caused by mutations in the PHF8 gene ((OMIM 300560).[7][8] In the rarest of cases,

abnormalities with the X or Y chromosome may also cause disability. 48, XXXX and 49,

XXXXX syndrome affect a small number of girls worldwide, while boys may be affected by 47,

XYY, 49, XXXXY, or 49, XYYYY.

* Problems during pregnancy. Mental disability can result when the fetus does not develop

properly. For example, there may be a problem with the way the fetus' cells divide as it grows. A

woman who drinks alcohol (see fetal alcohol syndrome) or gets an infection like rubella during

pregnancy may also have a baby with mental disability.

* Problems at birth. If a baby has problems during labor and birth, such as not getting enough

oxygen, he or she may have developmental disability due to brain damage.

* Exposure to certain types of disease or toxins. Diseases like whooping cough, measles, or

meningitis can cause mental disability if medical care is delayed or inadequate. Exposure to

poisons like lead or mercury may also affect mental ability.

* Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading

preventable cause of mental disability in areas of the developing world where iodine deficiency

is endemic. Iodine deficiency also causes goiter, an enlargement of the thyroid gland. More

common than full-fledged cretinism, as retardation caused by severe iodine deficiency is called,

is mild impairment of intelligence. Certain areas of the world due to natural deficiency and

governmental inaction are severely affected. India is the most outstanding, with 500 million

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suffering from deficiency, 54 million from goiter, and 2 million from cretinism. Among other

nations affected by iodine deficiency, China and Kazakhstan have instituted widespread

iodization programs, whereas, as of 2006, Russia had not.

* Malnutrition is a common cause of reduced intelligence in parts of the world affected by

famine, such as Ethiopia.

* Absence of in the brain of the arcuate fasciculus.

Treatment and assistance

By most definitions mental retardation is more accurately considered a disability rather than a

disease. MR can be distinguished in many ways from mental illness, such as schizophrenia or

depression. Currently, there is no "cure" for an established disability, though with appropriate

support and teaching, most individuals can learn to do many things.

There are thousands of agencies in the United States that provide assistance for people with

developmental disabilities. They include state-run, for-profit, and non-profit, privately run

agencies. Within one agency there could be departments that include fully staffed residential

homes, day rehabilitation programs that approximate schools, workshops wherein people with

disabilities can obtain jobs, programs that assist people with developmental disabilities in

obtaining jobs in the community, programs that provide support for people with developmental

disabilities who have their own apartments, programs that assist them with raising their children,

and many more. The Burton Blatt Institute at Syracuse University works to advance the civic,

economic, and social participation of people with disabilities. There are also many agencies and

programs for parents of children with developmental disabilities.

Although there is no specific medication for mental retardation, many people with

developmental disabilities have further medical complications and may take several medications.

Beyond that there are specific programs that people with developmental disabilities can take part

in wherein they learn basic life skills. These "goals" may take a much longer amount of time for

them to accomplish, but the ultimate goal is independence. This may be anything from

independence in tooth brushing to an independent residence. People with developmental

disabilities learn throughout their lives and can obtain many new skills even late in life with the

help of their families, caregivers, clinicians and the people who coordinate the efforts of all of

these people.

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Archaic Terms

* Idiot indicated the greatest degree of intellectual disability, where the mental age is two

years or less, and the person cannot guard himself or herself against common physical dangers.

The term was gradually replaced by the term profound mental retardation.

* Imbecile indicated an intellectual disability less extreme than idiocy and not necessarily

inherited. It is now usually subdivided into two categories, known as severe mental retardation

and moderate mental retardation.

* Moron was defined by the American Association for the Study of the Feeble-minded in

1910, following work by Henry H. Goddard, as the term for an adult with a mental age between

eight and twelve; mild mental retardation is now the term for this condition. Alternative

definitions of these terms based on IQ were also used. This group was known in UK law from

1911 to 1959/60 as "feeble-minded".

* Mongolism was a medical term used to identify someone with Down syndrome. For obvious

reasons, the Mongolian People's Republic requested that the medical community cease use of the

term as a description of mental retardation. Their request was granted in the 1960s, when the

World Health Organization agreed that the term should cease being used within the medical

community.

* In the field of special education, educable (or "educable mentally retarded") refers to MR

students with IQs of approximately 50-75 who can progress academically to a late elementary

level. Trainable (or "trainable mentally retarded") refers to students whose IQs fall below 50 but

who are still capable of learning personal hygiene and other living skills in a sheltered setting,

such as a group home. In many areas, these terms have fallen out of favor in favor of "severe"

and "moderate" mental retardation. While the names change, the meaning stays roughly the same

in practice.

* Retarded comes from the Latin retardare, "to make slow, delay, keep back, or hinder." The

term was recorded in 1426 as a "fact or action of making slower in movement or time." The first

record of retarded in relation to being mentally slow was in 1895. The term retarded was used to

replace terms like idiot, moron, and imbecile because it was not a derogatory term. By the 1960s,

however, the term had taken on a partially derogatory meaning as well.

Perhaps the negative connotations associated with these numerous terms for mental retardation

reflect society's ambivalent attitude about the condition. There are competing desires among

elements of society, some of whom seek neutral medical terms, and others who want to use such

terms as weapons with which to abuse people.

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Today, the term "retarded" is slowly being replaced by new words like "special" or "challenged."

The term "developmental delay" is rapidly gaining popularity among caretakers and parents of

individuals with mental retardation. Using the word "delay" is preferred over "disability" by

many people, because that term (delay) encapsulates the core deficit that creates mental

retardation in the first place. Delay suggests that a person has been held back from their

potential, rather than someone who has been disabled.

Usage has changed over the years, and differed from country to country, which needs to be borne

in mind when looking at older books and papers. For example, "mental retardation" in some

contexts covers the whole field, but previously applied to what is now the mild MR group.

"Feeble-minded" used to mean mild MR in the UK, and once applied in the US to the whole

field. "Borderline MR" is not currently defined, but the term may be used to apply to people with

IQs in the 70s. People with IQs of 70 to 85 used to be eligible for special consideration in the US

public education system on grounds of mental retardation.

Along with the changes in terminology, and the downward drift in acceptability of the old terms,

institutions of all kinds have had to repeatedly change their names. This affects the names of

schools, hospitals, societies, government departments, and academic journals. For example, the

Midlands Institute of Mental Subnormality became the British Institute of Mental Handicap and

is now the British Institute of Learning Disability. This phenomenon is shared with mental health

and motor disabilities, and seen to a lesser degree in sensory disabilities.

Historical Perspective

The plight of individuals with developmental disabilities has been dependent on the customs and

beliefs of the era and the culture or locale. In ancient Greece and Rome, infanticide was a

common practice. In Sparta, for example, neonates were examined by a state council of

inspectors. If they suspected that the child was defective, the infant was thrown from a cliff to its

death. By the second century A.D. individuals with disabilities, including children, who lived in

the Roman Empire were frequently sold to be used for entertainment or amusement. The

dawning of Christianity led to a decline in these barbaric practices and a movement toward care

for the less fortunate; in fact, all of the early religious leaders, Jesus, Buddha, Mohammed, and

Confucius, advocated human treatment for the mentally retarded, developmentally disabled, or

infirmed (Sheerenberger, 1983).

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During the Middle ages (476 - 1799 A.D.) the status and care of individuals with mental

retardation varied greatly. Although more human practices evolved (i.e., decreases in infanticide

and the establishment of foundling homes), many children were sold into slavery, abandoned, or

left out in the cold. Toward the end of this era, in 1690, John Locke published his famous work

entitled An Essay Concerning Human Understanding. Locke believed that an individual was

born without innate ideas. The mind is a tabula rasa, a blank slate. This would profoundly

influence the care and training provided to individuals with mental retardation. He also was the

first to distinguish between mental retardation and mental illness; "Herein seems to lie the

difference between idiots and madmen, that madmen put wrong ideas together and reason from

them, but idiots make very few or no propositions and reason scarce at all (Doll, 1962 p. 23)."

A cornerstone event in the evolution of the care and treatment of the mentally retarded was the

work of physician Jean-Marc-Gaspard Itard (Sheerenberger, 1983) who was hired in 1800 by the

Director of the National Institutes for Deaf-Mutes in France to work with a boy named Victor.

Victor, a young boy, had apparently lived his whole life in the woods of south central France

and, after being captured and escaping several times, fled to the mountains of Aveyron. At about

age 12, he was captured once again and sent to an orphanage, found to be deaf and mute, and

moved to the Institute for Deaf-Mutes.

Based on the work of Locke and Condillac who emphasized the importance of learning through

the senses, Itard developed a broad educational program for Victor to develop his senses,

intellect, and emotions. After 5 years of training, Victor continued to have significant difficulties

in language and social interaction though he acquired more skills and knowledge than many of

Itard's contemporaries believed possible. Itard's educational approach became widely accepted

and used in the education of the deaf. Near the end of his life, Itard had the opportunity to

educate a group of children who were mentally retarded. He did not personally direct the

education of these children, but supervised the work of Edouard Seguin (Sheerenberger, 1983).

Seguin developed a comprehensive approach to the education of children with mental

retardation, known as the Physiological Method (Sheerenberger, 1983). Assuming a direct

relationship between the senses and cognition, his approach began with sensory training

including vision, hearing, taste, smell, and eye-hand coordination. The curriculum extended from

developing basic self-care skills to vocational education with an emphasis on perception,

coordination, imitation, positive reinforcement, memory, and generalization. In 1850, Seguin

moved to the United States and became a driving force in the education of individuals with

mental retardation. In 1876, he founded what would become the American Association on Metal

Retardation. Many of Seguin's techniques have been modified and are still in use today.

Over the next 50 years, two key developments occurred in the United States: residential training

schools were established in most states (19 state operated and 9 privately operated) by 1892, and

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the newly developed test of intelligence developed by Binet was translated in 1908 by Henry

Goddard, Director of Research at the training school in Vineland, New Jersey. Goddard

published an American version of the test in 1910. In 1935, Edgar Doll developed the Vineland

Social Maturity Scale to assess the daily living skills/adaptive behavior of individuals suspected

of having mental retardation. Psychologists and educators now believed that it was possible to

determine who had mental retardation and provide them with appropriate training in the

residential training schools.

During the early part of the 20th century, residential training schools proliferated and individuals

with mental retardation were enrolled. This was influenced by the availability of tests (primarily

IQ) to diagnose mental retardation and the belief that, with proper training, individuals with

mental retardation could be "cured". When training schools were unable to "cure" mental

retardation, they became overcrowded and many of the students were moved back into society

where the focus of education began to change to special education classes in the community. The

training schools, which were initially more educational in nature, became custodial living

centers.

As a result of the disillusionment with residential treatment, advocacy groups, such as the

National Association of Retarded Citizens and the President's Commission on Mental

Retardation, were established in the 1950's through the 1970's. The Wyatt-Stickney federal court

action, in the 1970's, was a landmark class action suit in Alabama establishing the right to

treatment of individuals living in residential facilities. Purely custodial care was no longer

acceptable. Concurrent with this case, the United States Congress passed the Education for the

Handicapped Act in 1975, now titled the Individuals with Disabilities Education Act. This Act

guaranteed the appropriate education of all children with mental retardation and developmental

disabilities, from school age through 21 years of age. This law was amended in 1986 to

guarantee educational services to children with disabilities age 3 through 21 and provided

incentives for states to develop infant and toddler service delivery systems. Today, most states

guarantee intervention services to children with disabilities between birth and 21 years of age.

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Definition/Diagnosis/Classification.

According to Sheerenberger (1983), the elements of the definition of mental retardation were

well accepted in the United States by 1900. These included: onset in childhood, significant

intellectual or cognitive limitations, and an inability to adapt to the demands of everyday life. An

early classification scheme proposed by the American Association on Mental Deficiency

(Retardation), in 1910 referred to individuals with mental retardation as feeble-minded, meaning

that their development was halted at an early age or was in some way inadequate making it

difficult to keep pace with peers and manage their daily lives independently (Committee on

Classification, 1910). Three levels of impairment were identified: idiot, individuals whose

development is arrested at the level of a 2 year old; imbecile, individuals whose development is

equivalent to that of a 2 to 7 year old at maturity; and moron, individuals whose mental

development is equivalent to that of a 7 to 12 year old at maturity.

Over the next 30 years, the definitions of mental retardation focused on one of three aspects of

development: the inability to learn to perform common acts, deficits or delays in social

development/competence, or low IQ (Yepsen, 1941). An example of a definition based on social

competence was proposed by Edgar Doll who proposed that mental retardation referred to

"social incompetence, due to mental subnormality, which has been developmentally arrested,

which obtains at maturity, is of constitutional origin, and which is essentially incurable" (Doll,

1936 p. 38). Fred Kuhlman, who was highly influential in the early development of intelligence

tests in the United States, believed mental retardation was "a mental condition resulting from a

subnormal rate of development of some or all mental functions" (Kuhlman, 1941 p. 213).

As a result of the conflicting views and definitions of mental retardation, a growing number of

labels used to refer to individuals with mental retardation, and a change in emphasis from a

genetic or constitutional focus to a desire for a function-based definition, the American

Association on Mental Deficiency (Retardation) proposed and adopted a three part definition in

1959. "Mental retardation refers to subaverage general intellectual functioning which originates

in the developmental period and is associated with impairment in adaptive behavior" (Heber,

1961). Although this definition included the three components of low IQ (<85), impaired

adaptive behavior, and origination before age 16, only IQ and age of onset were measurable with

the existing psychometric techniques. Deficits in adaptive behavior were generally based on

subjective interpretations by individual evaluators even though the Vineland Social Maturity

Scale was available (Sheerenberger, 1983).

In addition to the revised definition, a five level classification scheme was introduced replacing

the previous three level system which had acquired a very negative connotation. The generic

17

terms of borderline (IQ 67-83), mild (IQ 50-66), moderate (IQ 33-49), severe (16-32), and

profound (IQ <16) were adopted.

Due to concern about the over or misidentification of mental retardation, particularly in minority

populations, the definition was revised in 1973 (Grossman, 1973) eliminating the borderline

classification from the interpretation of significant, subaverage, general intellectual functioning.

The upper IQ boundary changed from <85 to < 70. This change significantly reduced the number

of individuals who were previously identified as mentally retarded impacting the eligibility

criteria for special school services and governmental supports. Many children who might have

benefitted from special assistance were now ineligible for such help. A 1977 revision (Grossman,

1977) modified the upper IQ limit to 70 - 75 to account for measurement error. IQ performance

resulting in scores of 71 through 75 were only consistent with mental retardation when

significant deficits in adaptive behavior were present.

The most recent change in the definition of mental retardation was adopted in 1992 by the

American Association on Mental Retardation. "Mental retardation refers to substantial

limitations in present functioning. It is characterized by significantly subaverage intellectual

functioning, existing concurrently with related limitations in two or more of the following

applicable adaptive skill areas: communication, self-care, home living, social skills, community

use, self-direction, health and safety, functional academics, leisure, and work. Mental retardation

manifests before age 18" (American Association on Mental Retardation, 1992). On the surface,

this latest definition does not appear much different than its recent predecessors. However, the

focus on the functional status of the individual with mental retardation is much more delineated

and critical in this definition. There is also a focus on the impact of environmental influences on

adaptive skills development that was absent in previous definitions. Finally, this revision

eliminated the severity level classification scheme in favor of one that addresses the type and

intensity of support needed: intermittent, limited, extensive, or pervasive. Practically, a child

under age 18 must have an IQ < 75 and deficits in at least 2 of the adaptive behavior domains

indicated in the definition to obtain a diagnosis of mental retardation.

18

Educational Classifications. While the medical and psychosocial communities were developing

an acceptable definition and classification system, the educational community adopted their own

system of classification. Their three level system separated school age children with mental

retardation into three groups based on predicted ability to learn (Kirk, Karnes, & Kirk, 1955).

Children who were educable could learn simple academic skills but not progress above fourth

grade level. Children who were believed to be trainable could learn to care for their daily needs

but very few academic skills. Children who appeared to be untrainable or totally dependent were

considered in need of long term care, possibly in a residential setting. Some form of this scheme

is still in use today in many school systems across the country.

DSM-IV. DSM-IV attempts to blend the 1977 and 1992 definitions put forth by the American

Association on Mental Retardation. It adopts the 1992 definition, but retains the severity level

classification scheme from the 1977 definition. The upper IQ limit is 70, and an individual must

have delays in at least two of the 10 areas outlined in the 1992 definition. In general, the

overview of mental retardation in DSM-IV is thorough and easy to follow. However, it should be

noted that comprehensive cognitive and adaptive skill assessment is necessary to make the

diagnosis; it should not be made on the basis of an office visit or developmental screening.

ICD-10. ICD-10 is the tenth revision of the International Classification of Diseases (World

Health Organization, 1993). It is currently in use in some countries around the world but will not

be adopted for use in the United States until after the year 2000. ICD-10 differs from ICD-9 in at

least two key ways. First, it includes more diagnoses and is, consequently, much larger. The

second major change is the coding scheme. The diagnostic codes have been changed from

numeric codes to codes that begin with an alphabet letter and are followed by two or more

numbers (e.g., mild mental retardation has changed from 317 to F70).

ICD-10 characterizes mental retardation as a condition resulting from a failure of the mind to

develop completely. Unlike DSM-IV and the Classification Manual of the AAMR, ICD-10

suggests that cognitive, language, motor, social, and other adaptive behavior skills should all be

used to determine the level of intellectual impairment. ICD-10 also supports the idea of dual

diagnosis, suggesting that mental retardation may be accompanied by physical or other mental

disorders.

Four levels of mental retardation are specified in ICD-10: F70 mild (IQ 50 - 69), F71 moderate

(IQ 35 - 49), F72 severe (IQ 20 - 34), and F73 profound (IQ below 20). IQ should not be used as

the only determining factor. Clinical findings and adaptive behavior should also be used to

19

determine level of intellectual functioning. Two additional classifications are possible: F78 other

mental retardation and F79 unspecified mental retardation. Other mental retardation (F78) should

be used when associated physical or sensory impairments make it difficult to establish the degree

of impairment. Unspecified mental retardation (F79) should be used when there is evidence of

mental retardation but not enough information to establish a level of functioning (e.g., a toddler

with significant delays in development who is too young to be assessed with an IQ measure).

Epidemiology

Over the past 50 years the prevalence and incidence of mental retardation have been affected by

changes in the definition of mental retardation, improvements in medical care and technology,

societal attitudes regarding the acceptance and treatment of an individual with mental

retardation, and the expansion of educational services to children with disabilities from birth

through age 21. The theoretical approach to determining the prevalence of mental retardation

uses the normal bell curve to estimate the number of individuals whose IQ falls below the

established criterion score. For example, 2.3% of the population of the United States has an IQ

score below 70, and 5.5% has an IQ score below 75. However, this estimate does not account for

adaptive behavior skills. Based on empirical sampling, Baroff (1991) suggested that only 0.9%

of the population can be assumed to have mental retardation. Following a review of the most

recent epidemiological studies, McLaren and Bryson (1987) reported that the prevalence of

mental retardation was approximately 1.25% based on total population screening. When school

age children are the source of prevalence statistics, individual states report rates from 0.3% to

2.5% depending on the criteria used to determine eligibility for special educational services, the

labels assigned during the eligibility process (e.g., developmental delay, learning disability,

autism, and/or mental retardation), and the environmental and economic conditions within the

state (U.S. Department of Education, 1994). It is estimated that approximately 89% of these

children have mild mental retardation, 7% have moderate mental retardation, and 4% have

severe to profound mental retardation. In addition, McLaren and Bryson (1987) report that the

prevalence of mental retardation appears to increase with age up to about the age of 20, with

significantly more males than females identified.

20

Etiology. There are several hundred disorders associated with mental retardation. Many of these

disorders play a causal role in mental retardation. However, most of the causal relationships must

be inferred (McLaren & Bryson, 1987). The American Association on Mental Retardation

subdivides the disorders that may be associated with mental retardation into three general areas:

prenatal causes, perinatal causes, and postnatal causes. It should be noted that some causes can

be determined much more reliably than others. For example, chromosomal abnormalities such as

Down syndrome can be assumed to be causal with more certainty than some postnatal infections.

It should also be noted that mental retardation is both a symptom of other disorders as well as a

unique syndrome or disorder.

Causes associated with level of mental retardation. The most common factor associated with

severe mental retardation (including the moderate, severe, and profound levels of mental

retardation) has been chromosomal abnormality, particularly Down syndrome (McLaren &

Bryson, 1987). In approximately 20 to 30% of the individuals identified with severe mental

retardation the cause has been attributed to prenatal factors, such as chromosomal abnormality.

Perinatal factors such as perinatal hypoxia account for about 11%, and postnatal factors such as

brain trauma account for 3 to 12% of severe mental retardation. In 30 to 40% of cases, the cause

is reported to be unknown.

The etiology of mild mental retardation is much less delineated. Between 45 and 63% of the

cases are attributed to unknown etiology. Fewer cases of prenatal and perinatal causes are

reported, with the largest number attributed to multiple factors (prenatal) and hypoxia (perinatal).

Very few postnatal causes have been linked to mild mental retardation (McLaren & Bryson,

1987).

Associated disorders. A variety of disorders are associated with mental retardation. These

include: epilepsy, cerebral palsy, vision and hearing impairments, speech/language problems,

and behavior problems (McLaren & Bryson, 1987). The number of associated disorders appears

to increase with the level of severity of mental retardation (Baird & Sadovnick, 1985).

21

Psychopathology

Studies estimating the prevalence of mental health disorders among individuals with mental

retardation suggest that between 10 and 40% meet the criteria for a dual diagnosis of mental

retardation and a mental health disorder (Reiss, 1990). The range in prevalence rates appears to

be due to varying types of population sampling. When case file surveys are conducted, the

prevalence rates are consistently around 10%. The use of psychopathology rating scales in

institutional or clinic samples produces the much higher 40% prevalence rate (Reiss, 1990). The

actual prevalence may lie somewhere in between these two estimates. This may be the case due

to the tendency of mental health professionals to consider behavior disorders in individuals with

mental retardation as a symptom of their delayed development. Nevertheless, individuals with

mental retardation appear to display the full range of psychopathology evidenced in the general

population (Jacobson, 1990; Reiss, 1990). Individuals with mild cognitive limitations are more

likely to be given a dual diagnosis than children with more significant disabilities (Borthwick-

Duffy & Eyman, 1990).

Assessment

Assessment of a child suspected of having a developmental disability, such as mental retardation,

may establish whether a diagnosis of mental retardation or some other developmental disability

is warranted, assessing eligibility for special educational services, and/or aid in determining the

educational or psychological services needed by the child and family. At a minimum, the

assessment process should include an evaluation of the child's cognitive and adaptive or

everyday functioning including behavioral concerns, where appropriate, and an evaluation of the

family, home, and/or classroom to establish goals, resources, and priorities.

Globally defined, child assessment is the systematic use of direct as well as indirect procedures

to document the characteristics and resources of an individual child (Simeonsson & Bailey,

1992). The process may be comprised of various procedures and instruments resulting in the

confirmation of a diagnosis, documentation of developmental status, and the prescription of

intervention/treatment (Simeonsson & Bailey, 1992). A variety of assessment instruments have

been criticized for insensitivity to cultural differences resulting in misdiagnosis or mislabeling.

However, assessments have many valid uses. They allow for the measurement of change and the

evaluation of program effectiveness and provide a standard for evaluating how well all children

have learned the basic cognitive and academic skills necessary for survival in our culture. Given

that the use of existing standardized instruments to obtain developmental information as part of

the assessment process may bring about certain challenges, there does not appear to be a

reasonable alternative (Sattler, 1992). Thus, it becomes necessary to understand assessment and

22

its purpose so that the tools which are available can be used correctly, and the results can be

interpreted in a valid way.

The four components of assessment (Sattler, 1992), norm-referenced tests, interviews,

observations, and informal assessment, complement each other and form a firm foundation for

making decisions about children. The use of more than one assessment procedure provides a

wealth of information about the child permitting the evaluation of the biological, cognitive,

social and interpersonal variables that affect the child's current behavior. In the diagnostic

assessment of children, it is also important to obtain information from parents and other

significant individuals in the child's environment. For school-age children, teachers are an

important additional source of information. Certainly, major discrepancies among the findings

obtained from the various assessment procedures must be resolved before any diagnostic

decisions or recommendations are made. For example, if the intelligence test results indicate that

the child is currently functioning in the mentally retarded range, while the interview findings and

adaptive behavior results suggest functioning in a average range, it would become necessary to

reconcile these disparate findings before making a diagnosis.

Developmental Delay or Mental Retardation

In diagnosing infants or preschoolers, it is important to distinguish between mental retardation

and developmental delay. A diagnosis of mental retardation is only appropriate when cognitive

ability and adaptive behavior are significantly below average functioning. In the absence of

clear-cut evidence of mental retardation, it is more appropriate to use a diagnosis of

developmental delay. This acknowledges a cognitive or behavioral deficit, but leaves room for it

to be transitory or of ambiguous origin (Sattler, 1992). In practice, children under the age of 2

should not be given a diagnosis of mental retardation unless the deficits are relatively severe

and/or the child has a condition that is highly correlated with mental retardation (e.g., Down

syndrome).

23

Cognitive/Developmental Assessment Tools

Bayley Scales of Infant Development - Second Edition (Bayley, 1993): The Bayley Scales is an

individually administered instrument for assessing the development of infants and very young

children. It is appropriate for children from 2 months to 3½ years. It is comprised of three scales,

the Mental Scale, the Motor Scale, and the Behavior Rating Scale. The Mental Scale assesses the

following areas: recognition memory, object permanence, shape discrimination, sustained

attention, purposeful manipulation of objects, imitation (vocal/verbal and gestural), verbal

comprehension, vocalization, early language skills, short-term memory, problem-solving,

numbers, counting, and expressive vocabulary. The Motor Scale addresses the areas of gross and

fine motor abilities in a relatively traditional manner. The Behavior Rating Scale is used to rate

the child's behavioral and emotional status during the assessment. Performance on the Mental

and Motor Scales is interpreted through the use of standard scores (mean = 100; standard

deviation = 15). The Behavior Rating Scale is interpreted by the use of percentile ranks. The

Bayley Scales were standardized using a stratified sample of 1,700 infants and toddlers across 17

age groupings closely approximating the U.S. Census Data from 1988. The manual includes

validity studies and case examples. The Bayley Scales is one of the most popular infant

assessment tools. It can also be used to obtain the developmental status of children older than 3

½ who have very significant delays in development and cannot be evaluated using more age-

appropriate cognitive measures (e.g., a 6 year old with a developmental level of 2 years).

The Differential Ability Scales (DAS) (Elliott, 1990): The DAS consists of a battery of

individually administered cognitive and achievement tests subdivided into three age brackets:

lower preschool (2 ½ years to 3 years, 5 months), upper preschool (3 ½ years to 5 years, 11

months), and school age (6 years to 17 years, 11 months). The cognitive battery focuses on

reasoning and conceptual abilities and provides a composite standard score, the General

Conceptual Ability (GCA) score. Verbal and Nonverbal cluster standard scores and individual

subtest standard scores are also available. The DAS has several advantages over other similar

measures. It has a built-in mechanism for assessing significantly delayed children who are over

the age of 3 ½ years. It can also provide information comparable to other similar instruments in

about half the time. Finally, it is very well standardized and correlates highly with other

cognitive measures (i.e., the Wechsler Scales).

Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) (Wechsler, 1989):

The WPPSI-R can be utilized for children ranging in age from 3 years to 7 years, 3 months.

Though separate and distinct from the WISC-III (discussed below), it is similar in form and

content. The WPPSI-R is considered a downward extension of the WISC-III. These two tests

overlap between the ages of 6 and 7 years, 3 months. The WPPSI-R has a mean of 100 and

standard deviation of 15, with scaled scores for each subtest having a mean of 10 and a standard

24

deviation of 3. It contains 12 subtests organized into one of two major areas: the Verbal Scale

includes Information, Similarities, Arithmetic, Vocabulary, Comprehension, and Sentences

(optional) subtests; the Performance Scale includes Picture Completion, Geometric Design,

Block Design, Mazes, Object Assembly, and Animal Pegs (optional) subtests. The WPPSI

contains 9 subtests similar to those included in the WISC-III (Information, Vocabulary,

Arithmetic, Similarities, Comprehension, Picture Completion, Mazes, Block Design, and Object

Assembly) and 3 unique subtests (Sentences, Animal Pegs, and Geometric Design). Three

separate IQ scores can be obtained: Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ.

The WPPSI-R was standardized on 1,700 children equally divided by gender and stratified to

match the 1986 U.S. census data. This instrument cannot be used with severely disabled children

(IQ's below 40) and, with younger children, may need to be administered over two sessions due

to the length of time required to complete the assessment.

Wechsler Intelligence Scale for Children-III (WISC-III) (Wechsler, 1991): The WISC-III can be

utilized for children ranging in age from 6 years through 16 years of age. It is the middle

childhood to middle adolescence version of the Wechsler Scale series. It contains 13 subtests

organized into two major areas: the Verbal Scale includes Information, Similarities, Arithmetic,

Vocabulary, Comprehension, and Digit Span (optional) subtests; the Performance Scale includes

Picture Completion, Picture Arrangement, Block Design, Object Assembly, Coding, and the

optional subtests of Mazes, and Symbol Search. Three separate IQ scores can be obtained:

Verbal Scale IQ, Performance Scale IQ, and Full Scale IQ. Each of these separate IQ's are

standard scores with a mean of 100 and a standard deviation of 15, with scaled scores for each

subtest having a mean of 10 and a standard deviation of 3. The WISC-III was standardized on a

sample of 2,200 American children selected as representative of the population on the basis of

1988 U.S. census data.

Wechsler Adult Intelligence Scale - Revised (WAIS-R) (Wechsler, 1981): The WAIS-R covers an

age range of 16 years, 0 months to 74 years, 11 months. The revised version contains about 80%

of the original WAIS and was modified mainly due to cultural considerations. There are 11

subtests: Verbal Scale - Information, Similarities, Arithmetic, Vocabulary, Comprehension, and

Digit Span; Performance Scale - Picture Completion, Picture Arrangement, Block Design, Object

Assembly, and Digit Symbol. The WAIS-R was standardized in the 1970's on a sample of 1,880

white and non-white Americans equally divided among gender. The WAIS-R has a mean of 100

and a standard deviation of 15 with the scaled scores for each subtest having a mean of 10 and a

standard deviation of 3.

Stanford-Binet:Fourth Edition (SB: FE) (Thorndike, Hagen, & Sattler, 1986): The SB: FE is

appropriate for use on individuals ranging in age from 2 to 23. It is comprised of 15 subtests,

though only 6 (Vocabulary, Comprehension, Pattern Analysis, Quantitative, Bead Memory, and

25

Memory for Sentences) are used in all age groups. The other 9 subtests (Picture Absurdities,

Paper Folding and Cutting, Copying, Repeating Digits, Similarities, Form-Board Items, Memory

for Objects, Number Series, and Equation Building) are administered on the basis of age. Unlike

previous editions, the SB: FE uses a point scale similar to that of the Wechsler Scales, is more

culturally sensitive, and includes some new items in the areas of memory for objects, number

series, and equation building.

Once administered, the SB: FE yields three types of scores: age scores (or scaled scores), area

scores (general intelligence, crystallized intelligence and short-term memory, specific factors,

and specific factors plus short-term memory), and a Composite Score (similar to the Full-Scale

IQ of the Wechsler). The SB: FE Composite Score has a mean of 100 and a standard deviation of

16 (unlike the Wechsler's standard deviation of 15).

Overlap between the WISC-III and the Stanford-Binet:Fourth Edition: The WISC-III is

appropriate between the ages of 6-16, while the Stanford-Binet: Fourth Edition is appropriate

between the ages of 2 and 23. While the child is between 6 and 16, either test is appropriate.

Correlations range from .66 to .83 between the WISC-R Full Scale IQ and the Fourth Edition

composite. Results from Thorndike, Hagen, and Sattler (1986) show that while the two tests

yield approximately equal scores, they are not interchangeable. This is partly due to the fact that

they operate on different standard deviations (Sattler, 1992).

Overlap between the WAIS-R and the Stanford-Binet:Fourth Edition: Results for individuals

with and without mental retardation are similar in that the WAIS-R yields higher scores than the

Stanford-Binet Fourth Edition.

Special Note: Assessment Tools for Individuals with Mental Retardation. The Stanford-Binet:

Fourth Edition and the Wechsler Scales are useful instruments in assessing mild mental

retardation; however, neither is designed to test individuals with severe/profound mental

retardation. In addition, due to the high floor on the Wechsler Scales the publisher recommends

that a child obtain raw score credit in at least 3 subtests of the Verbal Scale and the Performance

Scale before assuming they provide useful information. Raw score for 6 subtests, 3 Verbal and 3

Performance are recommended for a valid Full Scale IQ.

McCarthy Scales of Children's Abilities (McCarthy, 1972): The McCarthy Scales can be used

with children between the ages of 2 ½ years and 8 ½ years. It contains six scales: Verbal Scale,

Perceptual-Performance Scale, Quantitative Scale, Memory Scale, Motor Scale, and General

Cognitive Scale. In addition to yielding a General Cognitive Index (GCI), the McCarthy Scales

provide several ability profiles (verbal, non-verbal reasoning, number aptitude, short-term

memory, and coordination). The overall GCI has a mean of 100 and a standard deviation of 16

and is an estimate of the child's ability to apply accumulated knowledge to the tasks in the scales.

26

The ability profiles, in particular, make the McCarthy Scales useful for assessing young children

with learning problems. The GCI is not interchangeable with the IQ score rendered by the

Wechsler Scales; therefore, caution is advised in making placement decisions based on the GCI,

especially in the case of children with mental retardation (Sattler, 1992).

Assessing Adaptive Behavior

Adaptive behavior is an important and necessary part of the definition and diagnosis of mental

retardation. It is the ability to perform daily activities required for personal and social sufficiency

(Sattler, 1992). Assessment of adaptive behavior focuses on how well individuals can function

and maintain themselves independently and how well they meet the personal and social demands

imposed on them by their cultures. There are more than 200 adaptive behavior measures and

scales. The most common scale is the Vineland Adaptive Behavior Scales (Sparrow, Balla, &

Cicchetti, 1984).

Vineland Adaptive Behavior Scales (VABS) (Sparrow, Balla, & Cicchetti, 1984): The VABS is a

revision of the Vineland Social Maturity Scale (Doll, 1953) and assesses the social competence

of individuals with and without disabilities from birth to age 19. It is an indirect assessment in

that the respondent is not the individual in question but someone familiar with the individual's

behavior. The VABS measures four domains: Communication, Daily Living Skills,

Socialization, and Motor Skills. An Adaptive Behavior Composite is a combination of the scores

from the four domains. A Maladaptive Behavior domain is also available with two of the three

forms of administration. Each of the domains and the Composite has a mean of 100 and a

standard deviation of 15. Three types of administration are available: the Survey Form (297

items), the Expanded Form (577 items, 297 of which are from the Survey Form), and the

Classroom Edition (244 items for children age 3-13). The Survey and Expanded Forms were

standardized on a representative sample of the 1980 U.S. census data including 3,000 individuals

ranging in age from newborn to 18 years, 11 months. There are norms for individuals with

mental retardation, children with behavior disorders, and individuals with physical handicaps.

The Classroom Edition was standardized on a representative sample of the 1980 U.S. census data

including 3,0000 students, ages 3 to 12 years, 11 months. Caution is advised when using this

scale with children under the age of two because children with more significant delays frequently

attain standard scores that appear to be in the low average range of ability. In this case more

weight should be placed on the age equivalents that can be derived.

The American Association on Mental Retardation (AMMR) Adaptive Behavior Scale (ABS): The

ABS has two forms which address survival skills and maladaptive behaviors in individuals living

in residential and community settings (ABS-RC:2; Nihira, Leland, & Lambert, 1993) or school

27

age children (ABS-S:2; Lamber, Nahira, & Leland, 1993). It is limited in scope and should be

used with caution. A new scoring method has recently been devised that can generate scores

consistent with the 10 adaptive behavior areas suggested in the 1992 definition of mental

retardation (Bryant, Taylor, & Pedrotty-Rivera, 1996). The results of this assessment can be

readily translated into objectives for intervention.

Achievement Tests

Intelligence tests are broader than achievement tests and sample from a wider range of

experiences, but both measure aptitude, learning, and achievement, to some degree (Sattler,

1992). Achievement tests (such as reading and mathematics) are heavily dependent on formal

learning, are more culturally bound, and tend to sample more specific skills than do intelligence

tests. Intelligence tests measure one's ability to apply information in new and different ways,

whereas achievement tests measure mastery of factual information (Sattler, 1992). Intelligence

tests are better predictors of scholastic achievement contributing to the decision-making

processes in schools and clinics, and they are a better predictor of educability and trainability

than other achievement tests because they sample the reasoning capacities developed outside

school which should also be applied in school.

To determine if learning potential is being fully realized, results from an IQ test and standardized

tests of academic achievement can be compared. If there is a significant difference between IQ

and achievement, the child may benefit from special assistance in the academic area identified.

Achievement Assessment Tools That Can Be Used With Children With Mild Learning

Disorders.

Woodcock-Johnson Psycho-Educational Battery - Revised (Woodcock & Johnson, 1990): The

Woodcock-Johnson is comprised of 35 tests assessing cognitive ability (vocabulary, memory,

concept formation, spacial relations, and quantitative concepts) and achievement (reading,

spelling, math, capitalization, punctuation, and knowledge of science, humanities, and social

studies). Though the test batteries can be used with individuals from age 2 through adulthood,

not all tests are administered at every age. The Cognitive Ability Battery and the Achievement

Battery each have a recommended standard and supplemental batteries. The Achievement

Battery can be used with preschool children (4 or 5 year olds) through adults. They each provide

scores which can be converted into standard scores with a mean of 100 and a standard deviation

of 15. By comparing the Tests of Cognitive Ability and the Tests of Achievement, the

Woodcock-Johnson allows for the assessment of an Aptitude/achievment discrepancy. The

discrepancy reflects disparity between cognitive and achievement capabilities. The Woodcock-

28

Johnson was standardized on a representative sample of 6,359 individuals ranging in age from 2

to 95 from communities throughout the United States.

The Wide Range Achievement Test - Revised (WRAT-R) (Jastak & Wilkinson, 1984): The

WRAT-R is a brief achievement test and contains three subtests: Reading, Spelling, Arithmetic.

The WRAT-R is divided into two levels: Level One (ages 5 years, 0 months to 11 years, 11

months), and Level Two (ages 12 years, 0 months to 74 years, 11 months). The WRAT-R has a

mean of 100 and a standard deviation of 15. It also provides T scores, scaled scores, grade-

equivalent scores, and percentile ranks. It was standardized on a sample of 5,600 individuals in

28 age groups (5-74 years).

A variety of other achievement tests are available for assessing academic performance. These

include, but are not limited to, the Kaufman Test of Educational Achievement (Kaufman &

Kaufman, 1985) and the Wechsler Individual Achievement Test (1992).

Other Assessment Tools

Peabody Picture Vocabulary Test - Revised (PPVT-R) (Dunn & Dunn, 1981): The PPVT-R is

appropriate for individuals between the ages of 2½ and adulthood and measures receptive

knowledge of vocabulary. It is a multiple choice test requiring only a pointing response and no

reading ability, thus making it useful for hearing individuals with a wide range of abilities,

particularly children with language based disabilities. The revised edition is more sensitive to

gender-based stereotypes and cultural issues; in fact only 37% of the original items were

retained. The PPVT-R has two forms, L and M, with 175 plates in each form in ascending order

of difficulty. Each plate consists of four clearly drawn pictures, one of which is the correct

response to the word given by the experimenter. Standard scores have a mean of 100 with a

standard deviation of 15. The PPVT-R was standardized on a national sample of 4,200 children

(2½ - 18) and 828 adults (19 - 40) equally divided among gender and based on 1970 U.S. census

data. The PPVT-R was designed to assess breadth of receptive vocabulary and not as a screening

tool for measuring intellectual level of functioning. PPVT-R scores are not interchangeable with

IQ scores obtained via the Stanford-Binet: Fourth Edition or the Wechsler Tests.

Columbia Mental Maturity Scale: The Columbia Mental Maturity Scale (Burgemeister, Blum, &

Lorge, 1972) is a test of general reasoning ability that can be used with children who have

significant physical limitations. It is appropriate for children between the ages of 3 ½ years and 9

years, 11 months. The Columbia has a mean of 100, a standard deviation of 16, and can be

interpreted using age equivalents. When used in conjunction with the Peabody Picture

29

Vocabulary Test - Revised, it can provide reasonably accurate cognitive status information

comparable to the more common intelligence tests.

Leiter International Performance Scale: The Leiter International Performance Scale (Leiter,

1948) is a nonverbal assessment of intelligence. Although the norms are dated, it provides useful

information about the cognitive status of children with hearing impairments or severe language

disabilities. It can be used with children aged 2 through adults. It is currently under revision and

will likely be a useful tool in the future (Roid & Miller, 1997).

For a description of a wide range of other specialty tests, the reader is referred to the Assessment

of Children by Jerome Sattler (1992).

Dual Diagnosis

Appropriate assessment of psychopathology in people with dual diagnosis is important because:

a) it can suggest the form of treatment; b) it may ensure access to and funding for special

services; and c) it can be used to evaluate subsequent interventions (Sturmey, 1995). Brain

damage, epilepsy and language disorders are risk factors for psychiatric disorders and are often

associated with mental retardation (Rutter, Tizard, Graham, & Whitmore, 1976; Sturmey, 1995).

Social isolation, stigmatization, and poor social skills put individuals with mental retardation at

further risk for affective disorders (Reiss & Benson, 1985). The relationship between emotional

disorders and mental retardation has been noted by many researchers (Bregman,

1991;Menolascino, 1977; Reiss, 1982). Rates of emotional disorders are more prevalent in

children with mental retardation than children without mental retardation (Bregman, 1988; Lewis

& MacLean, 1982; Matson, 1982, Russell, 1985). As noted previously, epidemiological studies

of psychiatric disorders in individuals with mental retardation show that this population

experiences higher rates of psychopathology (Corbett, 1985; Gostason, 1985). Though children

with mental retardation are diagnosed with psychiatric disorders more often than children

without mental retardation, they are usually diagnosed with the same types of disorders.

However, uncommon psychiatric disorders may be found in children with severe and profound

levels of mental retardation (Batshaw & Perret, 1992).

An additional problem is the application of DSM-IV criteria to individuals with mental

retardation. Though the DSM has proven useful in diagnosing individuals with mild or moderate

mental retardation (especially when the criterion are modified in some way, leading to problems

in clearly operationalized definitions), many psychologists and psychiatrists rely more on

biological markers, observable signs, and patterns of family psychopathology to diagnose

individuals with severe and profound mental retardation thus implying that the DSM may not be

30

as useful with this population (Sturmey, 1995). The mismatch between behaviors scripted in the

DSM-IV and psychopathology presented in individuals with mental retardation can lead to under

diagnosing of these individuals (Sturmey, 1995). Because the DSM is so widely used by

psychiatrists, psychologists, health insurance companies, and because of the way it is

coordinated with the International Classification of Diseases (ICD), it will continue to be the

main diagnostic source. Practitioners should take care not to modify the DSM criteria for their

own use and instead should use the criteria as they are prescribed and document cases where the

criteria are inadequate to make a comprehensive diagnosis (Sturmey, 1995).

Most psychologists in the mental health field have little exposure to individuals with mental

retardation and are sometimes uncomfortable treating these individuals; in fact, many

professionals seem unaware that this group can experience mental health problems (Reiss &

Szyszko, 1983). Mental health and mental retardation systems have been separated in this

country for many years making it difficult to administratively serve people with both mental

retardation and mental health disorders (Matson & Sevin, 1994). Recently, there has been a

heightened awareness of need to pursue behavioral-psychiatric assessment, diagnosis, and

treatment of people with mental retardation and mental health problems (Bregman, 1991; Eaton

& Menolascino, 1982; Reiss, 1990).

A variety of behavioral assessment tools are available and provide key information for

practioners in this area. A few of the commonly used measures or checklists include: the Child

Behavior Checklist (Achenbach & Edelbrock, 1986), the Conners Parent (or Teacher) Rating

Scale (Conners, 1990), the Revised Behavior Problem Checklist (Quay & Peterson, 1987), and

the Social Skills Rating System (Gresham & Elliott, 1990). These measures are only as reliable

as the parent, guardian, or teacher completing them. However, they can provide useful

information about the nature of the behavioral problems or competencies of the child. All of the

scales noted above focus primarily on behavioral difficulties with the exception of the Social

Skills Rating System which includes items that address prosocial behaviors.

Interdisciplinary Approach

Because children with mental retardation often have other problems, it is necessary to involve a

team of practitioners from different areas (e.g., child psychiatrist, social worker, child

psychologist, special education teacher, speech and language specialist, and community

agencies), in the comprehensive diagnosis. This type of interdisciplinary team approach is

relatively new but is considered to be imperative for comprehensive assessment, treatment, and

management of children with mental retardation (Lubetsky, Mueller, Madden, Walker, & Len,

1995). A natural extension of the interdisciplinary approach is the involvement of the family in

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the decision-making process. In fact, recent government and educational initiatives such as

Public Law 99-457 and Public Law 102-119 require the involvement of parents and

professionals in early intervention services (Lubetsky et al, 1995). A family-centered

interdisciplinary approach begins with an assessment of the child (including school history,

obtained from parents and school records), family (family marital and parenting history), and

community resources. Medical, developmental and psychiatric histories are obtained. Behavioral

analysis, psychoeducational, speech and language testing are completed. Medical and

neurological assessments are performed.

Intervention

Psychoeducational Intervention

As a result of federal legislation developed with the aid and encouragement of a number of

advocacy groups (i.e., the Individuals with Disabilities Education Act; Public Law 94-142,

Public Law 99-457, and Public Law 102-119), children and adolescents with mental retardation

or related developmental disorders are entitled to free and appropriate intervention. Appropriate

intervention should be based on the needs of the child as determined by a team of professionals,

address the priorities and concerns of the family, and be provided in the least restrictive most

inclusive setting (i.e., where they have every opportunity to benefit from interacting with

nondisabled peers and the community resources available to all other children).

Infant/Toddler Services

Services to infants and toddlers can be home-based, center-based, or some combination of the

two. The nature of the services should be determined based on the results of the child assessment

and family priorities for the child. These should be used to develop an Individual Family Service

Plan for the child which includes all parties participating in the intervention and is coordinated

by a Services Coordinator (case manager) who is available and acceptable to the family. The

services may include assistive technology, intervention for sensory impairments, family

counseling, parent training, health services, language services, nursing intervention, nutrition

counseling, occupational therapy, physical therapy, case management, and transportation to

services.

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Preschool and School Services

Services to preschool children, ages 3 through 5, and school-aged children, 6 through 21, can be

home-based, but are more frequently center-based. As in the case of infants and toddlers, a team

evaluation and parent input is used to develop an intervention plan. This plan, the Individualized

Education Plan (IEP), details the objectives for improving the child's skills and may include

family or parent focused activities. Services may include special education provided by a

certified teacher and focused on the needs of the child, child counseling, occupational therapy,

physical therapy, language therapy, recreational activities, school health services, transportation

services, and parent training or counseling. These services should be provided in the most

inclusive least restrictive setting (e.g., a regular preschool program, Headstart Center, child's

home).

Social/Interpersonal Intervention

Social and interpersonal interventions can be both preventative and therapeutic. As noted above,

children with mental retardation are at an increased risk for behavioral disorders. Therefore, a

variety of group social and recreational activities should be included in the child's educational

program. These activities should include nondisabled peers and may include participation at

birthday parties, attending recreational activities such as ball games and movies, participating in

youth sports activities, and visiting community sites such as the zoo. The goal of these activities

should be to teach appropriate social skills relevant to group participation and building self-

esteem.

Parents also may benefit from prevention activities. Respite care provided by trained individuals

can afford parents the opportunity to address their own needs (e.g., personal time, medical

appointments, socializing with peers, etc.). They can be much more effective in parenting when

their own needs have been met. Social or parent support groups can also be an outlet for parents

to discuss their feelings with individuals who have similar experiences. These groups may be

syndrome specific (e.g., Parent Advocates for Down Syndrome) or more generic in nature.

Therapeutic interventions with the children and families may include family therapy, individual

child behavior therapy, parent training, and group therapy with mildly mentally disabled children

and adolescents focusing on developing appropriate social skills. Child behavioral interventions

can be used to teach self-care, vocational, leisure, interpersonal, and survival skills (e.g., finding

a public restroom). Disruptive behaviors such as tantrumming, self-injury, noncompliance, and

aggression toward others can also be addressed through behavioral techniques. The most

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frequent form of behavioral intervention for problematic behavior involves differential

reinforcement of incompatible and/or other behaviors (Batshaw & Perret, 1992).

Psychopharmacological Intervention

Treatment specifying the use of medication should only be considered when a particular

psychiatric condition know to benefit from a particular drug coexists with the mental retardation

or developmental disability. This may take the form of a severe depression, obsessive-

compulsive disorder, attention deficit-hyperactivity disorder, or a variety of other psychiatric

disorders. There are few well controlled studies of drug treatments with children who have

mental retardation. It should also be noted that the use of medication as a form of chemical

restraint should be avoided. In addition, when drug treatment is used, it should only be one

component of an overall treatment approach (Batshaw & Perret, 1992).

Final Comments

An invaluable resource in evaluating and treating children with mental retardation is the child's

family. Consequently, including the families of children with or at-risk for disabilities in every

phase of intervention, from identification to planning to implementation through monitoring

should be considered. However, including families in decisions about the treatment or

management of their children's problems presents new challenges. Nevertheless, trying to

understand and include families in the decision-making process can ultimately be rewarding and

beneficial for all involved.

Level of Family Involvement

How and when should families be included in decision making? There is no standard formula for

answering this question. Families, like individuals, vary tremendously. Nevertheless, there are

some issues that must be considered when involving families in team decisions about their child

with a disability. First, the team must be receptive to including families in the decision-making

process. This involves some effort on the part of the non-family team members to encourage

family participation. In addition, the team must decide what child and family concerns are related

to enhancing the development of the child. These should be the focus of generating family-

oriented service delivery alternatives.

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Second, the team must consider the level of knowledge and understanding of the family related

to the disability of the child and/or the service/treatment options. If families are to participate in

the decision-making process they must have the knowledge necessary to select appropriate

alternatives. It is unfair to assume that families will not understand or cannot make appropriate

decisions about the care of their child. They are the consumers and need to be given the chance

to make an informed choice.

Finally, once the family has an adequate understanding of the condition and service/treatment

alternatives, they may need to be nurtured through the team decision-making process. Most

families have never been faced with participating as a member of a team of professionals and

may initially be reticent or nonparticipatory in discussions unless they are specifically invited to

do so. Certainly, as a primary care provider the parent or family member has more at stake than

the other team members. Over time, however, the cautious or reticent family member may

become an active and vital team member.

Encouraging Parent Participation

Health and education professionals who participate as team members must actively pursue

parent-professional partnerships in the decision-making process. The logical first step is to

acknowledge the value of the parent-professional relationship. Parents should be viewed as equal

partners who can make important and necessary contributions in the planning, decision-making,

process. If professionals are reluctant to or refuse to acknowledge parents as partners in the

process, they run the risk of alienating them resulting in a lack of interest or participation in

necessary services. Once the non-family team members accept the parents or other relevant

family members as equal partners in the planning process, strategies to encourage continued

active participation should be developed and implemented.

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Mild Intellectual Disability (MID) also

referred to as Mild Mental Retardation

Many of the characteristics of MID correspond to those of Learning Disabilities. The intellectual

development will be slow, however, MID students have the potential to learn within the regular

classroom given appropriate modifications and/or accommodations.Some MID students will

require greater support and/or withdrawal than others will. MID students, like all students

demonstrate their own strengths and weaknesses. Depending on the educational jurisdiction,

criteria for MID will often state that the child is functioning approximately 2-4 years behind or 2-

3 standard deviations below the norm or have an IQ under 70-75. The intellectual disability may

vary from mild to profound.

How are MID Students Identified?

Depending on the education jurisdiction, testing for MID will vary. Generally, a combination of

assessment methods are used to identify mild intellectual disabilities. Methods may or may not

include IQ scores or percentiles, adaptive skills cognitive tests in various areas, skills-based

assessments, and levels of academic achievement. Some jurisdictions will not use the term MID

but will use mild mental retardation.

Academic Implications

Students with MID may demonstrate some, all or a combination of the following characteristics:

2-4 years behind in cognitive development which could include math, language, short

attention spans, memory difficulties and delays in speech development.

Social Relationships are often impacted. The MID child may exhibit behavior problems, be

immature, display some obsessive/compulsive behaviors and lack the understanding of

verbal/non verbal clues and will often have difficulty following rules and routines.

Adaptive Skill Implications. (Everyday skills for functioning) These children may be clumsy,

use simple language with short sentences, have minimal organization skills and will need

reminders about hygiene - washing hands, brushing teeth (life skills). etc.

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Weak Confidence is often demonstrated by MID students. These students are easily

frustrated and require opportunities to improve self esteem. Lots of support will be needed to

ensure they try new things and take risks in learning.

Concrete to Abstract thought is often missing or significantly delayed. This includes the

lacking ability to understand the difference between figurative and literal language.

Best Practices

Use simple, short, uncomplicated sentences to ensure maximum understanding.

Repeat instructions or directions frequently and ask the student if further clarification is

necessary.

Keep distractions and transitions to a minimum.

Teach specific skills whenever necessary.

Provide an encouraging, supportive learning environment that will capitalize on student

success and self esteem.

Use appropriate program interventions in all areas where necessary to maximize success.

Use alternative instructional strategies and alternative assessment methods.

Help the MID student develop appropriate social skills to support friend and peer

relationships.

Teach organizational skills.

Use behavior contracts   and reinforce positive behavior if necessary.

Ensure that your routines and rules   are consistent. Keep conversations as normal as possible

to maximize inclusion with peers. Teach the difference between literal/figurative language.

Be patient! Assist with coping strategies.

Disabilities

Learning Disabilities

Physical Disabilities

Mental Retardation

Teaching Strategies

Inclusional Strategies

Helping with Reading

Teach Rules and Routines

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Behavior

5-Step Behavior Plan

Best Practices

Behavior Plans

38

SchizophreniaSchizophrenia occurs in about 1 percent of the general U.S. population. That means that more

than 3 million Americans suffer from the illness.

The disorder manifests itself in a broad range of unusual behaviors, which cause profound

disruption in the lives of the patients suffering from the condition and in the lives of the people

around them. Schizophrenia strikes without regard to gender, race, social class or culture.

One of the most important kinds of impairment caused by schizophrenia involves the person’s

thought processes. The individual can lose much of the ability to rationally evaluate his

surroundings and interactions with others.

There can be hallucinations and delusions, which reflect distortions in the perception and

interpretation of reality. The resulting behaviors may seem bizarre to the casual observer, even

though they may be consistent with the schizophrenic’s abnormal perceptions and beliefs.

Nearly one-third of those diagnosed with schizophrenia will attempt suicide. About 10 percent of

those with the diagnosis will commit suicide within 20 years of the beginning of the disorder.

Patients with schizophrenia are not likely to share their suicidal intentions with others, making

life-saving interventions more difficult. The risk of depression needs special mention due to the

high rate of suicide in these patients.

The most significant risk of suicide in schizophrenia is among males under 30 who have some

symptoms of depression and a relatively recent hospital discharge. Other risks include imagined

voices directing the patient toward self-harm (auditory command hallucinations) and intense

false beliefs (delusions).

The relationship of schizophrenia to substance abuse is significant. Due to impairments in insight

and judgment, people with schizophrenia may be less able to judge and control the temptations

and resulting difficulties associated with drug or alcohol abuse.

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In addition, it is not uncommon for people suffering from this disorder to try to “self-medicate”

their otherwise debilitating symptoms with mind-altering drugs. The abuse of such substances,

most commonly nicotine, alcohol, cocaine and marijuana, impedes treatment and recovery.

The chronic abuse of cigarettes among schizophrenic patients is well-documented and probably

related to the mind-altering effects of nicotine. Some researchers believe that nicotine affects

brain chemical systems that are disrupted in schizophrenia; others speculate that nicotine

counters some of the unwanted reactions tomedications used to treat the disease.

It is not uncommon for people diagnosed with schizophrenia to die prematurely from other

medical conditions, such as coronary artery disease and lung disease. It is unclear whether

schizophrenic patients are genetically predisposed to these physical illnesses or whether such

illnesses result from unhealthy lifestyles associated with schizophrenia.

Schizophrenia usually first appears in a person during their late teens or throughout their

twenties. It affects more men than women, and is considered a life-long condition which rarely is

"cured," but rather treated. The primary treatment for schizophrenia and similar thought

disorders is medication. Unfortunately, compliance with a medication regimen is often one of the

largest problems associated with the ongoing treatment of schizophrenia. Because people who

live with this disorder often go off of their medication during periods throughout their lives, the

repercussions of this loss of treatment are acutely felt not only by the individual, but by their

family and friends as well.

Successful treatment of schizophrenia, therefore, depends upon a life-long regimen of both drug

and psychosocial, support therapies. While the medication helps control the psychosis associated

with schizophrenia (e.g., the delusions and hallucinations), it cannot help the person find a job,

learn to be effective in social relationships, increase the individual's coping skills, and help them

learn to communicate and work well with others. Poverty, homelessness, and unemployment are

often associated with this disorder, but they don't have to be. If the individual finds appropriate

treatment and sticks with it, a person with schizophrenia can lead a happy and successful life.

But the initial recovery from the first symptoms of schizophrenia can be an extremely lonely

experience. Individuals coping with the onset of schizophrenia for the first time in their lives

require all the support that their families, friends, and communities can provide.

With such support, determination, and understanding, someone who has schizophrenia can learn

to cope and live with it for their entire life. But stability with this disorder means complying with

the treatment plan set up between the person and their therapist or doctor, and maintaining the

balance provided for by the medication and therapy. A sudden stopping of treatment will most

often lead to a relapse of the symptoms associated with schizophrenia and then a gradual

recovery as treatment is reinstated

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SYMPTOMS

Schizophrenia is characterized by at least 2 of the following symptoms, for at least one month:

Delusions

Hallucinations

Disorganized speech (e.g., frequent derailment or incoherence)

Grossly disorganized or catatonic behavior

Negative symptoms (e.g., a "flattening" of one's emotions, alogia, avolition; see

below)

(Only one symptom is required if delusions are bizarre orhallucinations consist of a voice

keeping up a running commentary on the person's behavior or thoughts, or two or more voices

conversing with each other.)

For a significant portion of the time since the onset of the disturbance, one or more major areas

of functioning such as work, interpersonal relations, or self-care are markedly below the level

achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve

expected level of interpersonal, academic, or occupational achievement).

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been considered as

alternative explanations for the symptoms and have been ruled out. The disturbance must also

not be due to the direct physiological effects of use or abuse of a substance (e.g., alcohol, drugs,

medications) or a general medical condition.

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the

additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are

also present for at least a month (or less if successfully treated).

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DIAGNOSIS OF SCHIZOPHRENIA

DSM-IV diagnostic criteria for schizophrenia

In DSM-IV, the diagnosis of schizophrenia depends upon the presence of characteristic

symptoms, a minimum duration of those symptoms, a minimum duration of the disorder, the

presence of social/occupational dysfunction, and adifferentiation from mood, schizoaffective,

other psychotic disorders, general medical conditions, substance-induced disorders and pervasive

developmental disorder

According to DSM-IV, there are no strictly pathognomonic symptomsof schizophrenia.

Characteristic symptoms are conceptualized as falling into two broad categories: positive and

negative. There are four groups of positive symptoms—delusions, hallucinations, disorganized

speech, and grossly disorganized or catatonic behaviour—and one group of negative symptoms,

which includes affective flattening, alogia avolition.

A. Characteristic Symptoms

Two (or more) of the following, each present for a significant portion of time during a 1-month

period (or less if successfully treated);

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, that is, affective flattening, alogia, or avolition.

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist

of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or

more voices conversing with each other.

B. Social/occupational dysfunction

For a significant portion of the time since the onset of the disturbance, one or more major areas

of functioning such as work, interpersonal relations, or self-care are markedly below the level

achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve

expected level of interpersonal academic, or occupational achievement).

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C. Duration

Continuous signs of the disturbance persist for at least 6 months. This 6-month period must

include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.

active phase symptoms) and may include periods of prodromal or residual symptoms. During

these prodromal or residual periods, the signs of the disturbance may be manifested by only

negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form

(e.g. odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out

because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently

with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase

symptoms, their total duration has been brief relative to the duration of the active and residual

periods.

E. Substance/general medical condition exclusion

The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse,

a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the

additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are

also present for at least a month (or less if successfully treated).

The DSM-IV diagnostic criteria for schizophrenia require the presence of symptoms from at

least two of the groups listed above. Symptoms from only one group are required if delusions are

bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s

behaviour or thoughts, or two or more voices conversing with each other. Each of the symptoms

must be present for a significant portion of time during a one-month period (or less if

successfully treated).

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According to DSM-IV, schizophrenia is accompanied by marked social or occupational

dysfunction for a significant portion of the time since the onset of the disturbance. The

dysfunction must be present in at least one major area such as work, interpersonal relations or

self-care.

DSM-IV requires that continuous signs of the disturbance persist for at least 6 months. This 6-

month period may include periods when only negative or less severe symptoms are present. Such

periods are referred to as prodromal or residual, depending on whether they precede or follow the

one-month period of characteristic symptoms described above. Classification of course can be

applied only after at least one year has elapsed since the initial onset of active-phase symptoms.

According to DSMIV, the course of schizophrenia is variable. The manual lists the following

course specifiers: episodic with inter-episode residual symptoms; episodic with no inter-episode

residual symptoms; continuous; single episode in partial remission; single episode in full

remission; other or unspecified pattern.

Concerning differential diagnosis, DSM-IV emphasizes the distinction between schizophrenia

and mood disorders. If psychotic symptoms occur exclusively during periods of mood

disturbance, the diagnosis is mood disorder with psychotic features. If mood episodes have

occurred during active-phase symptoms, and if their total duration has been brief relative to the

duration of active and residual periods, the diagnosis is schizophrenia. If a mood episode is

concurrent with the active-phase symptoms of schizophrenia, and if mood symptoms have been

present for a substantial portion of the total duration of the disturbance, and if delusions or

hallucinations have been present for at least 2 weeks in the absence of prominent mood

symptoms, the diagnosis is schizoaffective disorder.

The differentiation between schizophrenia, brief psychotic disorder and schizophreniform

disorder rests upon a criterion of duration: less than one month for brief psychotic disorder; more

than one month but less than 6 months for schizophreniform disorder; at least 6 months for

schizophrenia. The differential diagnosis between schizophrenia and delusional disorder rests on

the nature of the delusions (in delusional disorder they are nonbizarre) and the absence of other

characteristic symptoms of schizophrenia such as hallucinations, disorganized speech and

behaviour, or prominent negative symptoms.

Schizophrenia and pervasive developmental disorder are distinguished by a number of criteria,

including in particular the presence of prominent delusions and hallucinations in the former but

not in the latter.

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Finally, the diagnosis is not made if the disturbance is due to the direct physiological effects of a

substance or a general medical condition.

DSM-IV describes five subtypes of schizophrenia: paranoid, disorganized, catatonic,

undifferentiated and residual. Post-psychotic depressive disorder of schizophrenia and simple

deteriorative disorder or simple schizophrenia is described in Appendix B, among conditions

requiring further study. In both the ICD-10 and the DSM-IV there is a distinction between

positive and negative characteristic symptoms of schizophrenia. According to the definition

provided in DSM-IV, ‘‘the positive symptoms appear to reflect an excess or distortion of normal

functions, whereas the negative symptoms appear to reflect a diminution or loss in normal

functions’’.

In both ICD-10 and DSM-IV, positive symptoms include hallucinations and delusions,

disorganized thought and speech, as well as disorganized and catatonic behaviour. In both

systems, negative symptoms include affective flattening or blunting of emotional responses,

alogia or paucity of speech, and apathy or avolition.

The reliability and validity of psychiatric diagnoses that are based on explicit diagnostic criteria

have been investigated in a number of studies during recent decades. According to Kendell

[106], psychiatric diagnoses are now as reliable as the clinical judgements made in other

branches of medicine. High reliability does not, however, by itself predict high validity.

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Different Types of Schizophrenia:

Paranoid schizophrenia a person feels extremely suspicious, persecuted, grandiose, or

experiences a combination of these emotions.

Disorganized schizophrenia a person is often incoherent but may not have delusions.

Catatonic schizophrenia a person is withdrawn, mute, negative and often assumes very unusual

postures.

Residual schizophrenia a person is no longer delusion or hallucinating, but has no motivation or 

interest in life. These symptoms can be most devastating.

Positive Symptoms Negative Symptoms

Delusions

Hallucinations

Disorganized

thinking

Agitation

Lack of drive or

initiative

Social withdrawal

Apathy

Emotional

unresponsiveness

The kinds of symptoms that are utilized to make a diagnosis of schizophrenia differ between

affected people and may change from one year to the next within the same person as the disease

progresses. Different subtypes of schizophrenia are defined according to the most significant and

predominant characteristics present in each person at each point in time. The result is that one

person may be diagnosed with different subtypes over the course of his illness.

Paranoid Subtype

The defining feature of the paranoid subtype is the presence of auditory hallucinations or

prominent delusional thoughts about persecution or conspiracy. However, people with this

subtype may be more functional in their ability to work and engage in relationships than people

with other subtypes of schizophrenia. The reasons are not entirely clear, but may partly reflect

that people suffering from this subtype often do not exhibit symptoms until later in life and have

46

achieved a higher level of functioning before the onset of their illness. People with the paranoid

subtype may appear to lead fairly normal lives by successful management of their disorder.

People diagnosed with the paranoid subtype may not appear odd or unusual and may not readily

discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve around

some characteristic theme, and this theme often remains fairly consistent over time. A person’s

temperaments and general behaviors often are related to the content of the disturbance of

thought. For example, people who believe that they are being persecuted unjustly may be easily

angered and become hostile. Often, paranoid schizophrenics will come to the attention of mental

health professionals only when there has been some major stress in their life that has caused an

increase in their symptoms. At that point, sufferers may recognize the need for outside help or

act in a fashion to bring attention to themselves.

Since there may be no observable features, the evaluation requires sufferers to be somewhat open

to discussing their thoughts. If there is a significant degree of suspiciousness or paranoia present,

people may be very reluctant to discuss these issues with a stranger.

There is a broad spectrum to the nature and severity of symptoms that may be present at any one

time. When symptoms are in a phase of exacerbation or worsening, there may be some

disorganization of the thought processes. At this time, people may have more trouble than usual

remembering recent events, speaking coherently or generally behaving in an organized, rational

manner. While these features are more characteristic of other subtypes, they can be present to

differing degrees in people with the paranoid subtype, depending upon the current state of their

illness. Supportive friends or family members often may be needed at such times to help the

symptomatic person get professional help.

Disorganized Subtype

As the name implies, this subtype’s predominant feature is disorganization of the thought

processes. As a rule, hallucinations and delusions are less pronounced, although there may be

some evidence of these symptoms. These people may have significant impairments in their

ability to maintain the activities of daily living. Even the more routine tasks, such as dressing,

bathing or brushing teeth, can be significantly impaired or lost.

Often, there is impairment in the emotional processes of the individual. For example, these

people may appear emotionally unstable, or their emotions may not seem appropriate to the

context of the situation. They may fail to show ordinary emotional responses in situations that

evoke such responses in healthy people. Mental health professionals refer to this particular

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symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular

or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral

service or other solemn occasion.

People diagnosed with this subtype also may have significant impairment in their ability to

communicate effectively. At times, their speech can become virtually incomprehensible, due to

disorganized thinking. In such cases, speech is characterized by problems with the utilization and

ordering of words in conversational sentences, rather than with difficulties of enunciation or

articulation. In the past, the term hebephrenic has been used to describe this subtype.

Catatonic Subtype

The predominant clinical features seen in the catatonic subtype involve disturbances in

movement. Affected people may exhibit a dramatic reduction in activity, to the point that

voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically

increase, a state known as catatonic excitement.

Other disturbances of movement can be present with this subtype. Actions that appear relatively

purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often

to the exclusion of involvement in any productive activity.

Patients may exhibit an immobility or resistance to any attempt to change how they appear. They

may maintain a pose in which someone places them, sometimes for extended periods of time.

This symptom sometimes is referred to as waxy flexibility. Some patients show considerable

physical strength in resistance to repositioning attempts, even though they appear to be

uncomfortable to most people.

Affected people may voluntarily assume unusual body positions, or manifest unusual facial

contortions or limb movements. This set of symptoms sometimes is confused with another

disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other

symptoms associated with the catatonic subtype include an almost parrot-like repeating of what

another person is saying (echolalia) or mimicking the movements of another person

(echopraxia). Echolalia and echopraxia also are seen in Tourette’s Syndrome.

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Undifferentiated Subtype

The undifferentiated subtype is diagnosed when people havesymptoms of schizophrenia that are

not sufficiently formed or specific enough to permit classification of the illness into one of the

other subtypes.

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty

as to the correct subtype classification. Other people will exhibit symptoms that are remarkably

stable over time but still may not fit one of the typical subtype pictures. In either instance,

diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

Residual Subtype

This subtype is diagnosed when the patient no longer displays prominent symptoms. In such

cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions

or idiosyncratic behaviors may still be present, but their manifestations are significantly

diminished in comparison to the acute phase of the illness.

Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of

impairment affect each patient’s life to varying degrees. Some people require custodial care in

state institutions, while others are gainfully employed and can maintain an active family life.

However, the majority of patients are at neither of these extremes. Most will have a waxing and

waning course marked with some hospitalizations and some assistance from outside support

sources.

People having a higher level of functioning before the start of their illness typically have a better

outcome. In general, better outcomes are associated with brief episodes of symptoms worsening

followed by a return to normal functioning. Women have a better prognosis for higher

functioning than men, as do patients with no apparent structural abnormalities of the brain.

In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in

childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure

to return to prior levels of functioning after acute episodes.

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are

not sufficiently formed or specific enough to permit classification of the illness into one of the

other subtypes.

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The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty

as to the correct subtype classification. Other people will exhibit symptoms that are remarkably

stable over time but still may not fit one of the typical subtype pictures. In either instance,

diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

How Is It Diagnosed?

Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it

depends on establishing the slowly progressive development of the characteristic

“negative” symptoms of schizophrenia without any history of hallucinations, delusions, or other

manifestations of an earlier psychotic episode, and with significant changes in personal

behaviour, manifest as a marked loss of interest, idleness, and social withdrawal.

Psychotherapy

Psychotherapy is not the treatment of choice for someone with schizophrenia. Used as an adjunct

to a good medication plan, however, psychotherapy can help maintain the individual on their

medication, learn needed social skills, and support the person's weekly goals and activities in

their community. This may include advice, reassurance, education, modeling, limit setting, and

reality testing with the therapist. Encouragement in setting small goals and reaching them can

often be helpful.

People with schizophrenia often have a difficult time performing ordinary life skills such as

cooking and personal grooming as well as communicating with others in the family and at work.

Therapy or rehabilitation therapy can help a person regain the confidence to take care of

themselves and live a fuller life.

Group therapy, combined with drugs, produces somewhat better results than drug treatment

alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained

when group therapy focuses on real-life plans, problems, and relationships; on social and work

roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on

some practical recreational or work activity. This supportive group therapy can be especially

helpful in decreasing social isolation and increasing reality testing (Long, 1996).

Family therapy can significantly decrease relapse rates for the schizophrenic family member. In

high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time

in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below

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10 percent. This therapy encourages the family to convene a family meeting whenever an issue

arises, in order to discuss and specify the exact nature of the problem, to list and consider

alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

Medications

Schizophrenia appears to be a combination of a thought disorder, mood disorder, and anxiety

disorder. The medical management of schizophrenia often requires a combination of

antipsychotic, antidepressant, and antianxiety medication. One of the biggest challenges of

treatment is that many people don't keep taking the medications prescribed for the disorder. After

the first year of treatment, most people will discontinue their use of medications, especially ones

where the side effects are difficult to tolerate.

As a recent National Institute of Mental Health Study indicated, regardless of the drug, three-

quarters of all patients stop taking their medications. They stopped the schizophrenia

medications either because they did not make them better or they had intolerable side effects.

The discontinuation rates remained high when they were switched to a new drug, but patients

stayed on clozapine about 11 months, compared with only three months for Seroquel, Risperdal

or Zyprexa, which are far more heavily marketed -- and dominate sales. Because of findings such

as this, it's generally recommended that someone with schizophrenia begin their treatment with a

drug such asclozapine (clozapine is often significantly cheaper than other antipsychotic

medications). Clozapine (also known as clozaril) has been shown to be more effective than many

newer antipsychotics as well.

Antipsychotic medications help to normalize the biochemical imbalances that cause

schizophrenia. They are also important in reducing the likelihood of relapse. There are two major

types of antipsychotics, traditional and new antipsychotics.

Traditional antipsychotics effectively control the hallucinations, delusions, and confusion of

schizophrenia. This type of antipsychotic drug, such as haloperidol, chlorpromazine, and

fluphenazine, has been available since the mid-1950s. These drugs primarily block dopamine

receptors and are effective in treating the "positive" symptoms of schizophrenia.

Side effects for antipsychotics may cause a patient to stop taking them. However, it is important

to talk with your doctor before making any changes in medication since many side effects can be

controlled. Be sure to weigh the risks against the potential benefits that antipsychotic drugs can

provide.

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Mild side effects: dry mouth, blurred vision, constipation, drowsiness and dizziness. These side

affects usually disappear a few weeks after the person starts treatment.

More serious side effects: trouble with muscle control, muscle spasms or cramps in the head and

neck, fidgeting or pacing, tremors and shuffling of the feet (much like those affecting people

with Parkinson's disease).

Side effects due to prolonged use of traditional antipsychotic medications: facial ticks, thrusting

and rolling of the tongue, lip licking, panting and grimacing.

There are many newer antipsychotic medications available since the 1990's, including Seroquel,

Risperdal, Zyprexa and Clozaril. Some of these medications may work on both the serotonin and

dopamine receptors, thereby treating both the "positive" and "negative" symptoms of

schizophrenia. Other newer antipsychotics are referred to as atypical antipsychotics, because of

how they affect the dopamine receptors in the brain. These newer medications may be more

effective in treating a broader range of symptoms of schizophrenia, and some have fewer side

effects than traditional antipsychotics. Learn more about the atypical antipsychotics used to help

treat schizophrenia.

Coping Guidelines For The Family

1. Establish a daily routine for the patient to follow.

2. Help the patient stay on the medication.

3. Keep the lines of communication open about problems or fears the patient may have.

4. Understand that caring for the patient can be emotionally and physically exhausting. Take

time for yourself.

5. Keep your communications simple and brief when speaking with the patient.

6. Be patient and calm.

7. Ask for help if you need it; join a support group.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical

profession because very few professionals are involved in them. Adjunctive community support

groups in concurrence with psychotherapy is usually beneficial to most people who suffer from

schizophrenia. Caution should be utilized, however, if the person's symptoms aren't under control

of a medication. People with this disorder often have a difficult time in social situations,

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therefore a support group should not be considered as an initial treatment option. As the person

progresses in treatment, a support group may be a useful option to help the person make the

transition back into daily social life.

Another use of self-help is for the family members of someone who lives with schizophrenia.

The stress and hardships causes of having a loved one with this disorder are often overwhelming

and difficult to cope with for a family. Family members should use a support group within their

community to share common experiences and learn about ways to best deal with their

frustrations, feelings of helplessness, and anger.

Cause of Schizophrenia

There is no known single cause of schizophrenia. Many diseases, such as heart disease, result

from an interplay of genetic, behavioral and other factors, and this may be the case for

schizophrenia as well. Scientists do not yet understand all of the factors necessary to produce

schizophrenia, but all the tools of modern biomedical research are being used to search for genes,

critical moments in brain development, and other factors that may lead to the illness.

Can It Be Inherited?

It has long been known that schizophrenia runs in families. People who have a close relative with

schizophrenia are more likely to develop the disorder than are people who have no relatives with

the illness. For example, a monozygotic (identical) twin of a person with schizophrenia has the

highest risk -- 40 to 50 percent -- of developing the illness. A child whose parent has

schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia in the

general population is about 1 percent.

Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are

involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal

difficulties like intrauterine starvation or viral infections, perinatal complications, and various

nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet

understood how the genetic predisposition is transmitted, and it cannot yet be accurately

predicted whether a given person will or will not develop the disorder.

Several regions of the human genome are being investigated to identify genes that may confer

susceptibility for schizophrenia. The strongest evidence to date leads to chromosomes 13 and 6

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but remains unconfirmed. Identification of specific genes involved in the development of

schizophrenia will provide important clues into what goes wrong in the brain to produce and

sustain the illness and will guide the development of new and better treatments. To learn more

about the genetic basis for schizophrenia, the NIMH has established a Schizophrenia Genetics

Initiative that is gathering data from a large number of families of people with the illness.

Is It Caused by a Chemical Defect in the Brain?

Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly.

Neurotransmitters, substances that allow communication between nerve cells, have long been

thought to be involved in the development of schizophrenia. It is likely, although not yet certain,

that the disorder is associated with some imbalance of the complex, interrelated chemical

systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. This area

of research is promising.

Is It Caused by a Physical Abnormality in the Brain?

There have been dramatic advances in neuroimaging technology that permit scientists to study

brain structure and function in living individuals. Many studies of people with schizophrenia

have found abnormalities in brain structure (for example, enlargement of the fluid-filled cavities,

called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or

function (for example, decreased metabolic activity in certain brain regions).

It should be emphasized that these abnormalities are quite subtle and are not characteristic of all

people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic

studies of brain tissue after death have also shown small changes in distribution or number of

brain cells in people with schizophrenia. It appears that many (but probably not all) of these

changes are present before an individual becomes ill, and schizophrenia may be, in part, a

disorder in development of the brain.

Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have

found that schizophrenia may be a developmental disorder resulting when neurons form

inappropriate connections during fetal development. These errors may lie dormant until puberty,

when changes in the brain that occur normally during this critical stage of maturation interact

adversely with the faulty connections. This research has spurred efforts to identify prenatal

factors that may have some bearing on the apparent developmental abnormality.

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In other studies, investigators using brain-imaging techniques have found evidence of early

biochemical changes that may precede the onset of disease symptoms, prompting examination of

the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile,

scientists working at the molecular level are exploring the genetic basis for abnormalities in brain

development and in the neurotransmitter systems regulating brain function.

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B.

Theoretical

Framework

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1.Freud’s Theories

a. Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the

development of personality. Freud’s Stages of Psychosexual Development are, like other stage

theories, completed in a predetermined sequence and can result in either successful completion

or a healthy personality or can result in failure, leading to an unhealthy personality. This theory

is probably the most well known as well as the most controversial, as Freud believed that we

develop through stages based upon a particular erogenous zone. During each stage, an

unsuccessful completion means that a child becomes fixated on that particular erogenous zone

and either over– or under-indulges once he or she becomes an adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures

(sucking). Too much or too little gratification can result in an Oral Fixation or Oral Personality

which is evidenced by a preoccupation with oral activities. This type of personality may have a

stronger tendency to smoke, drink alcohol, over eat, or bite his or her nails. Personality wise,

these individuals may become overly dependent upon others, gullible, and perpetual followers.

On the other hand, they may also fight these urges and develop pessimism and aggression toward

others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on

eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has to

learn to control anal stimulation. In terms of personality, after effects of an anal fixation during

this stage can result in an obsession with cleanliness, perfection, and control (anal retentive). On

the opposite end of the spectrum, they may become messy and disorganized (anal expulsive).

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Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed that

during this stage boy develop unconscious sexual desires for their mother. Because of this, he

becomes rivals with his father and sees him as competition for the mother’s affection. During

this time, boys also develop a fear that their father will punish them for these feelings, such as by

castrating them. This group of feelings is known as Oedipus Complex ( after the Greek

Mythology figure who accidentally killed his father and married his mother).

Later it was added that girls go through a similar situation, developing unconscious sexual

attraction to their father. Although Freud Strongly disagreed with this, it has been termed the

Electra Complex by more recent psychoanalysts.

According to Freud, out of fear of castration and due to the strong competition of his father, boys

eventually decide to identify with him rather than fight him. By identifying with his father, the

boy develops masculine characteristics and identifies himself as a male, and represses his sexual

feelings toward his mother. A fixation at this stage could result in sexual deviancies (both

overindulging and avoidance) and weak or confused sexual identity according to psychoanalysts.

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed and

children interact and play mostly with same sex peers.

Genital Stage (puberty on). The final stage of psychosexual development begins at the start of

puberty when sexual urges are once again awakened. Through the lessons learned during the

previous stages, adolescents direct their sexual urges onto opposite sex peers, with the primary

focus of pleasure is the genitals.

b. Freud's Structural and Topographical Models of Personality

Sigmund Freud's Theory is quite complex and although his writings on psychosexual

development set the groundwork for how our personalities developed, it was only one of five

parts to his overall theory of personality.  He also believed that different driving forces develop

during these stages which play an important role in how we interact with the world.

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Structural Model (id, ego, superego)

According to Freud, we are born with our Id.  The id is an important part of our personality

because as newborns, it allows us to get our basic needs met.  Freud believed that the id is based

on our pleasure principle.  In other words, the id wants whatever feels good at the time, with no

consideration for the reality of the situation.  When a child is hungry, the id wants food, and

therefore the child cries.  When the child needs to be changed, the id cries.  When the child is

uncomfortable, in pain, too hot, too cold, or just wants attention, the id speaks up until his or her

needs are met.

The id doesn't care about reality, about the needs of anyone else, only its own satisfaction.  If you

think about it, babies are not real considerate of their parents' wishes.  They have no care for

time, whether their parents are sleeping, relaxing, eating dinner, or bathing.  When the id wants

something, nothing else is important.

Within the next three years, as the child interacts more and more with the world, the second part

of the personality begins to develop.  Freud called this part the Ego.  The ego is based on the

reality principle.  The ego understands that other people have needs and desires and that

sometimes being impulsive or selfish can hurt us in the long run.  Its the ego's job to meet the

needs of the id, while taking into consideration the reality of the situation.  

By the age of five, or the end of the phallic stage of development, the Superego develops.  The

Superego is the moral part of us and develops due to the moral and ethical restraints placed on us

by our caregivers.  Many equate the superego with the conscience as it dictates our belief of right

and wrong.

In a healthy person, according to Freud, the ego is the strongest so that it can satisfy the needs of

the id, not upset the superego, and still take into consideration the reality of every situation.   Not

an easy job by any means, but if the id gets too strong, impulses and self gratification take over

the person's life.  If the superego becomes to strong, the person would be driven by rigid morals,

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would be judgmental and unbending in his or her interactions with the world.  You'll learn how

the ego maintains control as you continue to read.

c. Topographical Model

Freud believed that the majority of what we experience in our lives, the underlying emotions,

beliefs, feelings, and impulses are not available to us at a conscious level.  He believed that most

of what drives us is buried in our unconscious.  If you remember the Oedipus and Electra

Complex, they were both pushed down into the unconscious, out of our awareness due to the

extreme anxiety they caused.  While buried there, however, they continue to impact us

dramatically according to Freud.

The role of the unconscious is only one part of the model.  Freud also believed that everything

we are aware of is stored in our conscious.  Our conscious makes up a very small part of who we

are.  In other words, at any given time, we are only aware of a very small part of what makes up

our personality; most of what we are is buried and inaccessible.

The final part is the preconscious or subconscious.  This is the part of us that we can access if

prompted, but is not in our active conscious.  Its right below the surface, but still buried

somewhat unless we search for it.  Information such as our telephone number, some childhood

memories, or the name of your best childhood friend is stored in the preconscious.

Because the unconscious is so large, and because we are only aware of the very small conscious

at any given time, this theory has been likened to an iceberg, where the vast majority is buried

beneath the water's surface.  The water, by the way, would represent everything that we are not

aware of, have not experienced, and that has not been integrated into our personalities, referred

to as the nonconscious.

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d. Ego Defense Mechanisms

We stated earlier that the ego's job was to satisfy the id's impulses, not offend the moralistic

character of the superego, while still taking into consideration the reality of the situation.  We

also stated that this was not an easy job.  Think of the id as the 'devil on your shoulder' and the

superego as the 'angel of your shoulder.'  We don't want either one to get too strong so we talk to

both of them, hear their perspective and then make a decision.  This decision is the ego talking,

the one looking for that healthy balance.

Before we can talk more about this, we need to understand what drives the id, ego, and

superego.  According to Freud, we only have two drives; sex and aggression.  In other words,

everything we do is motivated by one of these two drives.

Sex, also called Eros or the Life force, represents our drive to live, prosper, and produce

offspring.  Aggression, also called Thanatos or our Death force, represents our need to stay alive

and stave off threats to our existence, our power, and our prosperity.

Now the ego has a difficult time satisfying both the id and the superego, but it doesn't have to do

so without help.  The ego has some tools it can use in its job as the mediator, tools that help

defend the ego.  These are called Ego Defense Mechanisms or Defenses.  When the ego has a

difficult time making both the id and the superego happy, it will employ one or more of these

defenses:

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DEFENSE DESCRIPTION EXAMPLE

denial arguing against an

anxiety provoking

stimuli by stating it

doesn't exist

denying that your physician's

diagnosis of cancer is correct and

seeking a second opinion

displacement taking out impulses on

a less threatening

target

slamming a door instead of hitting as

person, yelling at your spouse after

an argument with your boss

intellectualization avoiding unacceptable

emotions by focusing

on the intellectual

aspects

focusing on the details of a funeral as

opposed to the sadness and grief

projection placing unacceptable

impulses in yourself

onto someone else

when losing an argument, you state

"You're just Stupid;" homophobia

rationalization supplying a logical or

rational reason as

opposed to the real

reason

stating that you were fired because

you didn't kiss up the the boss, when

the real reason was your poor

performance

reaction

formation

taking the opposite

belief because the true

belief causes anxiety

having a bias against a particular race

or culture and then embracing that

race or culture to the extreme

regression returning to a previous

stage of development

sitting in a corner and crying after

hearing bad news; throwing a temper

tantrum when you don't get your way

repression pulling into the forgetting sexual abuse from your

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unconscious childhood due to the trauma and

anxiety

sublimation acting out

unacceptable impulses

in a socially

acceptable way

sublimating your aggressive impulses

toward a career as a boxer; becoming

a surgeon because of your desire to

cut; lifting weights to release 'pent

up' energy

suppression pushing into the

unconscious

trying to forget something that causes

you anxiety

Ego defenses are not necessarily unhealthy as you can see by the examples above.  In face, the

lack of these defenses, or the inability to use them effectively can often lead to problems in life. 

However, we sometimes employ the defenses at the wrong time or overuse them, which can be

equally destructive.

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2.Kohlberg’s Stages of Moral Development

Although it has been questioned as to whether it applied equally to different genders and

different cultures, Kohlberg’s (1973) stages of moral development is the most widely cited. It

breaks our development of morality into three levels, each of which is divided further into two

stages:

Preconventional Level (up to age nine):

     ~Self Focused Morality~

1. Morality is defined as obeying rules and avoiding negative consequences. Children in this

stage see rules set, typically by parents, as defining moral law.

2. That which satisfies the child’s needs is seen as good and moral.

Conventional Level (age nine to adolescence):

     ~Other Focused Morality~

3. Children begin to understand what is expected of them by their parents, teacher, etc. Morality

is seen as achieving these expectations.

4. Fulfilling obligations as well as following expectations are seen as moral law for children in

this stage.

Postconventional Level (adulthood):

     ~Higher Focused Morality~ 

5. As adults, we begin to understand that people have different opinions about morality and that

rules and laws vary from group to group and culture to culture. Morality is seen as upholding the

values of your group or culture.

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6. Understanding your own personal beliefs allow adults to judge themselves and others based

upon higher levels of morality. In this stage what is right and wrong is based upon the

circumstances surrounding an action. Basics of morality are the foundation with independent

thought playing an important role.

3.Piaget’s Theory of Cognitive Development

Piaget's four stages

Sensorimotor period

The Sensorimotor Stage is the first of the four stages of cognitive development. "In this stage,

infants construct an understanding of the world by coordinating sensory experiences (such as

seeing and hearing) with physical, motoric actions." "Infants gain knowledge of the world from

the physical actions they perform on it." "An infant progresses from reflexive, instinctual action

at birth to the beginning of symbolic thought toward the end of the stage." "Piaget divided the

sensorimotor stage into six sub-stages"

Sub-Stage Age Description

1 Simple ReflexesBirth-6

weeks

"Coordination of sensation and action through reflexive

behaviors"[. Three primary reflexes are described by Piaget:

sucking of objects in the mouth, following moving or interesting

objects with the eyes, and closing of the hand when an object

makes contact with the palm (palmar grasp). Over the first six

weeks of life, these reflexes begin to become voluntary actions;

for example, the palmar reflex becomes intentional grasping.

2 First habits and

primary circular

reactions phase

6 weeks-

4 months

"Coordination of sensation and two types of schemes: habits

(reflex) and primary circular reactions (reproduction of an event

that initially occurred by chance). Main focus is still on the

infant's body." As an example of this type of reaction, an infant

might repeat the motion of passing their hand before their face.

Also at this phase, passive reactions, caused by classical or

operant conditioning, can begin

3 Secondary circular 4-8 Development of habits. "Infants become more object-oriented,

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reactions phase months

moving beyond self-preoccupation; repeat actions that bring

interesting or pleasurable results." This stage is associated

primarily with the development of coordination between vision

and prehension. Three new abilities occur at this stage: intentional

grasping for a desired object, secondary circular reactions, and

differentiations between ends and means. At this stage, infants

will intentionally grasp the air in the direction of a desired object,

often to the amusement of friends and family. Secondary circular

reactions, or the repetition of an action involving an external

object begin; for example, moving a switch to turn on a light

repeatedly. The differentiation between means and ends also

occurs. This is perhaps one of the most important stages of a

child's growth as it signifies the dawn of logic

4 Coordination of

secondary circular

reactions stage

8-12

months

"Coordination of vision and touch--hand-eye coordination;

coordination of schemes and intentionality." This stage is

associated primarily with the development of logic and the

coordination between means and ends. This is an extremely

important stage of development, holding what Piaget calls the

"first proper intelligence." Also, this stage marks the beginning of

goal orientation, the deliberate planning of steps to meet an

objective

5 Tertiary circular

reactions, novelty,

and curiosity

12-18

months

"Infants become intrigued by the many properties of objects and

by the many things they can make happen to objects; they

experiment with new behavior." This stage is associated primarily

with the discovery of new means to meet goals. Piaget describes

the child at this juncture as the "young scientist," conducting

pseudo-experiments to discover new methods of meeting

challenges

6 Internalization of

Schemes

18-24

months

"Infants develop the ability to use primitive symbols and form

enduring mental representations." This stage is associated

primarily with the beginnings of insight, or true creativity. This

marks the passage into the preoperational stage.

"By the end of the sensorimotor period, objects are both separate from the self and permanent."

"Object permanence is the understanding that objects continue to exist even when they cannot be

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seen, heard, or touched." "Acquiring the sense of object permanence is one of the infant's most

important accomplishments, according to Piaget."

Preoperational Period

The Preoperational stage is the second of four stages of cognitive development. By observing

sequences of play, Piaget was able to demonstrate that towards the end of the second year, a

qualitatively new kind of psychological functioning occurs.

(Pre)Operatory Thought is any procedure for mentally acting on objects. The hallmark of the

preoperational stage is sparse and logically inadequate mental operations. During this stage, the

child learns to use and to represent objects by images, words, and drawings. The child is able to

form stable concepts as well as mental reasoning and magical beliefs. The child however is still

not able to perform operations; tasks that the child can do mentally rather than physically.

Thinking is still egocentric: The child has difficulty taking the viewpoint of others. Two

substages can be formed from preoperational thought.

The Symbolic Function Substage

Occurs between about the ages of 2 and 4. The child is able to formulate designs of

objects that are not present. Other examples of mental abilities are language and pretend

play. Although there is an advancement in progress, there are still limitations such as

egocentrism and animism. Egocentrism occurs when a child is unable to distinguish

between their own perspective and that of another person's. Children tend to pick their

own view of what they see rather than the actual view shown to others. An example is an

experiment performed by Piaget and Barbel Inhelder. Three views of a mountain are

shown and the child is asked what a traveling doll would see at the various angles; the

child picks their own view compared to the actual view of the doll. Animism is the belief

that inanimate objects are capable of actions and have lifelike qualities. An example is a

child believing that the sidewalk was mad and made them fall down.

The Intuitive Thought Substage

Occurs between about the ages of 4 and 7. Children tend to become very curious and ask

many questions; begin the use of primitive reasoning. There is an emergence in the

interest of reasoning and wanting to know why things are the way they are. Piaget called

it the intuitive substage because children realize they have a vast amount of knowledge

but they are unaware of how they know it. Centration and conservation are both

involved in preoperational thought. Centration is the act of focusing all attention on one

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characteristic compared to the others. Centration is noticed in conservation; the awareness

that altering a substance's appearance does not change its basic properties. Children at

this stage are unaware of conservation. They are unable to grasp the concept that a certain

liquid can stay the same regardless of the container shape. In Piaget's most famous task,

a child is represented with two identical beakers containing the same amount of liquid. ]

The child usually notes that the beakers have the same amount of liquid. When one of the

beakers is poured into a taller and thinner container, children who are typically younger

than 7 or 8 years old say that the two beakers now contain a different amount of liquid.

The child simply focuses on the height and width of the container compared to the

general concept. Piaget believes that if a child fails the conservation-of-liquid task, it is a

sign that they are at the preoperational stage of cognitive development. The child also

fails to show conservation of number, matter, length, volume, and area as well. Another

example is when a child is shown 7 dogs and 3 cats and asked if there are more dogs than

cats. The child would respond positively. However when asked if there are more dogs

than animals, the child would once again respond positively. Such fundamental errors in

logic show the transition between intuitiveness in solving problems and true logical

reasoning acquired in later years when the child grows up.

Piaget considered that children primarily learn through imitation and play throughout these first

two stages, as they build up symbolic images through internalized activity.

Studies have been conducted among other countries to find out if Piaget's theory is universal.

Psychologist Patricia Greenfield conducted a task similar to Piaget's beaker experiment in the

West African nation of Senegal. Her results stated that only 50 percent of the 10-13 year olds

understood the concept of conservation. Other cultures such as central Australia and New Guinea

had similar results. If adults had not gained this concept, they would be unable to understand the

point of view of another person. There may have been discrepencies in the communication

between the experimenter and the children which may have altered the results. It has also been

found that if conservation is not widely practiced in a particular country, the concept can be

taught to the child and training can improve the child's understanding. Therefore, it is noted that

there are different age differences in reaching the understanding of conservation based on the

degree to which the culture teaches these tasks.

Concrete operational stage

The Concrete operational stage is the third of four stages of cognitive development in Piaget's

theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 12

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years and is characterized by the appropriate use of logic. Important processes during this stage

are:

Seriation—the ability to sort objects in an order according to size, shape, or any other

characteristic. For example, if given different-shaded objects they may make a color gradient.

Transitivity- The ability to recognize logical relationships among elements in a serial order, and

perform 'transitive inferences' (for example, If A is taller than B, and B is taller than C, then A

must be taller than C).

Classification—the ability to name and identify sets of objects according to appearance, size or

other characteristic, including the idea that one set of objects can include another.

Decentering—where the child takes into account multiple aspects of a problem to solve it. For

example, the child will no longer perceive an exceptionally wide but short cup to contain less

than a normally-wide, taller cup.

Reversibility—the child understands that numbers or objects can be changed, then returned to

their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals t,

t−4 will equal 4, the original quantity.

Conservation—understanding that quantity, length or number of items is unrelated to the

arrangement or appearance of the object or items.

Elimination of Egocentrism—the ability to view things from another's perspective (even if they

think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box,

leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in

the concrete operations stage will say that Jane will still think it's under the box even though the

child knows it is in the drawer.

Children in this stage can, however, only solve problems that apply to actual (concrete) objects

or events, and not abstract concepts or hypothetical tasks.

Formal operational stage

The formal operational period is the fourth and final of the periods of cognitive development in

Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around

11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond

concrete experiences and begin to think abstractly, reason logically and draw conclusions from

the information available, as well as apply all these processes to hypothetical situations. The

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abstract quality of the adolescent's thought at the formal operational level is evident in the

adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is

when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin

to think more as a scientist thinks, devising plans to solve problems and systematically testing

solutions. They use hypothetical-deductive reasoning, which means that they develop

hypotheses or best gueses, and systematically deduce, or conclude, which is the best path to

follow in solving the problem.[ During this stage the young adult is able to understand such

things as love, "shades of gray", logical proofs and values. During this stage the young adult

begins to entertain possibilities for the future and is fascinated with what they can be.

Adolescents are changing cognitively also by the way that they think about social matters.

Adolescent Egocentrism governs the way that adolescents think about social matters and is the

heightened self-consciousness in them as they are which is reflected in their sense of personal

uniqueness and invincibility. Adolescent egocentrism can be dissected into two types of social

thinking, imaginary audience that involves attention getting behavior, and personal fable which

involves an adolescent's sense of personal uniqueness and invincibility.

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4. Jung's Theory of Psychological Types and the MBTI®

Instrument

"The purpose of the Myers-Briggs Type Indicator® is to make the theory of psychological types

described by C. G. Jung (1921/1971) understandable and useful in people's lives. The essence of

the theory is that much seemingly random variation in behavior is actually quite orderly and

consistent, being due to basic differences in the way individuals prefer to use their perception

and judgment."

Perception involves all the ways of becoming aware of things, people, happenings, or ideas.

Judgment involves all the ways of coming to conclusions about what has been perceived. If

people differ systematically in what they perceive and in how they reach conclusions, then it is

only reasonable for them to differ correspondingly in their interests, reactions, values,

motivations, and skills.

The MBTI instrument is based on Jung's ideas about perception and judgment, and the attitudes

in which these are used in different types of people. The aim of the MBTI instrument is to

identify, from self self-report of easily recognized reactions, the basic preferences of people in

regard to perception and judgment, so that the effects of each preference, singly and in

combination, can be established by research and put into practical use.

The MBTI instrument differs from many other personality instruments in these ways:

It is designed to implement a theory; therefore the theory must be understood to

understand the MBTI instrument.

The theory postulates dichotomies; therefore some of the psychometric properties are

unusual.

Based on the theory, there are specific dynamic relationships between the scales, which

lead to the descriptions and characteristics of sixteen "types."

The MBTI instrument contains four separate indices. Each index reflects one of four basic

preferences which, under Jung's theory, direct the use of perception and judgment. The

preferences affect not only what people attend to in any given situation, but also how they draw

conclusions about what they perceive.

Extraversion–Introversion (E–I)

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The E–I index is designed to reflect whether a person is an extravert or an introvert in the sense

intended by Jung. Jung regarded extraversion and introversion as "mutually complementary"

attitudes whose differences "generate the tension that both the individual and society need for the

maintenance of life." Extraverts are oriented primarily toward the outer world; thus they tend to

focus their perception and judgment on people and objects. Introverts are oriented primarily

toward the inner world; thus they tend to focus their perception and judgment upon concepts and

ideas.

Sensing–Intuition (S–N)

The S–N index is designed to reflect a person's preference between two opposite ways of

perceiving; one may rely primarily upon the process of sensing (S), which reports observable

facts or happenings through one or more of the five senses; or one may rely upon the less

obvious process of intuition (N), which reports meanings, relationships and/or possibilities that

have been worked out beyond the reach of the conscious mind.

Thinking–Feeling (T–F)

The T–F index is designed to reflect a person's preference between two contrasting ways of

judgment. A person may rely primarily through thinking (T) to decide impersonally on the basis

of logical consequences, or a person may rely primarily on feelings (F) to decide primarily on the

basis of personal or social values.

Judgment–Perception (J–P)

The J–P index is designed to describe the process a person uses primarily in dealing with the

outer world, that is, with the extraverted part of life. A person who prefers judgment (J) has

reported a preference for using a judgment process (either thinking or feeling) for dealing with

the outer world. A person who prefers perception (P) has reported a preference for using a

perceptive process (either S or N) for dealing with the outer world.

The Four Preferences of the MBTI instrument

Index Preferences

Between E–I

E Extraversion or

I Introversion

Affects Choices as to

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Whether to direct perception judgment mainly on the outer world (E) or mainly on the inner

world of ideas.

Between S–N

S Sensing perception or

N Intuitive perception

Affects Choices as to

Which kind of perception is preferred when one needs or wishes to perceive

Between T–F

T Thinking judgment or

F Feeling judgment

Affects Choices as to

Which kind of judgment to trust when one needs or wishes to make a decision

Between J–P

J Judgment or

P Perception

Affects Choices as to

Whether to deal with the outer world in judging (J) attitude (using T or F) or in the perceptive (P)

attitude (using S or N)

The Sixteen Types

According to theory, by definition, one pole of each of the four preferences is preferred over the

other pole for each of the sixteen MBTI types. The preferences on each index are independent of

preferences for the other three indices, so that the four indices yield sixteen possible

combinations called "types," denoted by the four letters of the preferences (e.g., ESTJ, INFP).

The theory postulates specific dynamic relationships between the preferences. For each type, one

process is the leading or dominant process and a second process serves as an auxiliary. Each type

has its own pattern of dominant and auxiliary processes and the attitudes (E or I) in which these

are habitually used. The characteristics of each type follow from the dynamic interplay of these

processes and attitudes.

Processes and attitudes

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Attitudes refer to extraversion (E) or introversion (I).

Processes of perception are sensing (S) and intuition (N).

Processes of judgment are thinking (T) and feeling (F).

The style of dealing with the outside world is shown by judgment (J) or perception (P).

In terms of the theory, people may reasonably be expected to develop greater skill with the

processes they prefer to use and with the attitudes in which they prefer to use these processes.

For example, if they prefer the extraverted attitude (E), they are likely to be more mature and

effective in dealing with the world around them than with the inner world of concepts and ideas.

If they prefer the perceptive process of sensing (S), they are likely to be more effective in

perceiving facts and realities than theories and possibilities, which are in the sphere of intuition.

If they prefer the judgment process of thinking (T), they are likely to have better developed

thinking judgments than feeling judgments. And if they prefer to use judgment (J) rather than

perception (P) in their attitude to the world around them, they are likely to be better organizing

the events of their lives than they are to experiencing and adapting to them. On the other hand, if

a person prefers introversion, intuition, feeling, and the perceptive attitude (INFP), then the

converse of the description above is likely to be true.

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5. Peplau’s Theory of Theory of Interpersonal Relations

Identified four sequential phases in the interpersonal relationship:

1.      Orientation

2.      Identification

3.      Exploitation

4.      Resolution

Orientation phase

Problem defining phase

Starts when client meets nurse as stranger

Defining problem and deciding type of service needed

Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and

expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems and to use available

resources and services

Factors influencing orientation phase

Identification phase

Selection of appropriate professional assistance

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Patient begins to have a feeling of belonging and a capability of dealing with the problem

which decreases the feeling of helplessness and hopelessness

Exploitation phase

Use of professional assistance for problem solving alternatives

Advantages of services are used is based on the needs and interests of the patients

Individual feels as an integral part of the helping environment

They may make minor requests or attention getting techniques

The principles of interview techniques must be used in order to explore ,understand and

adequately deal with the underlying problem

Patient may fluctuates on independence

Nurse must be aware about the various phases of communication

Nurse aids the patient in exploiting all avenues of help and progress is made towards the

final step

Resolution phase

Termination of professional relationship

The patients needs have already been met by the collaborative effect of patient and nurse

Now they need to terminate their therapeutic relationship and dissolve the links between

them.

Sometimes may be difficult for both as psychological dependence persists

Patient drifts away and breaks bond with nurse and healthier emotional balance is

demonstrated and both becomes mature individuals

Interpersonal theory and nursing process

Both are sequential and focus on therapeutic relationship

Both use problem solving techniques for the nurse and patient to collaborate on, with the

end purpose of meeting the patients needs

Both use  observation communication and recording as basic tools utilized by nursing

Assessment

Data collection and analysis

[continuous]

Orientation

Non continuous data

collection

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May not be a felt need Felt need

Define needs

Nursing diagnosis

Planning

Mutually set goals 

Identification

Interdependent goal setting

Implementation

Plans initiated towards

achievement of mutually set

goals

May be accomplished by

patient , nurse or family

Exploitation

Patient actively seeking and

drawing help

Patient initiated

Evaluation

Based on mutually expected

behaviors

May led to termination and

initiation of new plans  

Resolution

Occurs after other phases

are completed successfully

Leads to termination

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6.Carl Roger’s Humanistic Theory

The Person-Centered Approach

While Maslow was more of a theorist, Carl Rogers was more of a therapist.   His professional

goal was more on helping people change and improve their lives.  He was a true follower of

humanistic ideation and is often considered the person who gave psychotherapy it's basic

humanistic undertones.

Rogers believed in several key concepts that he believed must be present in order for healthy

change to take place.  His approach to treatment is called Client or Person-Centered-Therapy

because it sees the individual, rather than the therapist or the treatment process as the center of

effective change.  These basic concepts include:

1. Unconditional Positive Regard: The therapist must believe that people are basically good

and must demonstrate this belief to the client. Without unconditional positive regard, the

client will not disclose certain information, could feel unworthy, and may hold onto

negative aspects of the self.  Accepting the client as innately worthwhile does not mean

accepting all actions the client may exhibit.

2. Non-Judgmental Attitude:  Along with seeing the person as worthy, the therapist should

never pass judgment on the individual.  Roger's believed that people are competent in

seeing their mistakes and knowing what needs to change even if they may not initially

admit it.  He also believed that by judging a person, you are more likely to prevent

disclosure.

3. Disclosure:  Disclosure refers to the sharing of personal information.  Unlike

Psychoanalysis and many other approaches to therapy, Roger's believed that in order for

the client to disclose, the therapist must do the same.  Research has shown that we share

information at about the same level as the other person.  Therefore, remaining secretive

as a therapist, encourages the client to hold back important information.

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4. Reflection: Rogers believed that the key to understanding the self was not interpretation,

but rather reflection.  By reflecting a person's words in a different manner, you can

accomplish two things.  First, it shows the client that you are paying attention, thinking

about what he or she is saying, and also understanding the underlying thoughts and

feelings.  Second, it allows the client to hear their own thoughts in a different way.  Many

people have said that their beliefs become more real once they are presented back to them

by someone else.

By following these concepts, therapy becomes a self-exploration where the therapist is the guide

rather than the director.  The client, according to Rogers, has the answers and the direction.  It is

the therapist's job to help them find it.

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7.Alfred’s Adler’s Theory Of Personality

Inferiority

According to Adler's theory, each of us is born into the world with a sense of inferiority.  We

start as a weak and helpless child and strive to overcome these deficiencies by become superior

to those around us.  He called this struggle a striving for superiority, and like Freud's Eros and

Thanatos, he saw this as the driving force behind all human thoughts, emotions, and behaviors.

For those of us who strive to be accomplished writers, powerful business people, or influential

politicians, it is because of our feelings of inferiority and a strong need to over come this

negative part of us according to Adler.  This excessive feeling of inferiority can also have the

opposite effect.  As it becomes overwhelming and without the needed successes, we can develop

an inferiority complex.  This belief leaves us with feeling incredibly less important and deserving

than others, helpless, hopeless, and unmotivated to strive for the superiority that would make us

complete.

Parenting and Birth Order

Parenting Styles.  Adler did agree with Freud on some major issues relating to the parenting of

children and the long term effects of improper or inefficient child rearing.  He identified two

parental styles that he argued will cause almost certain problems in adulthood.  The first was

pampering, referring to a parent overprotecting a child, giving him too much attention, and

sheltering him from the negative realities of life.  As this child grows older, he will be ill

equipped to deal with these realities, may doubt his own abilities or decision making skills, and

may seek out others to replace the safety he once enjoyed as a child.

On the other extreme is what Adler called neglect.  A neglected child is one who is not protected

at all from the world and is forced to face life's struggles alone.  This child may grow up to fear

the world, have a strong sense of mistrust for others and she may have a difficult time forming

intimate relationships.

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The best approach, according to this theory, is to protect children form the evils of the world but

not shelter them from it.  In more practical terms, it means allowing them to hear or see the

negative aspects of the world while still feeling the safety of parental influence.  In other words,

don't immediately go to the school principal if your child is getting bullied, but rather teach your

child how to respond or take care of herself at school.

Birth Order.  Simply put, Adler believed that the order in which you are born to a family

inherently effects your personality.  First born children who later have younger siblings may

have it the worst.  These children are given excessive attention and pampering by their parents

until that fateful day when the little brother or sister arrives.  Suddenly they are no longer the

center of attention and fall into the shadows wondering why everything changed.  According to

Adler, they are left feeling inferior, questioning their importance in the family, and trying

desperately to gain back the attention they suddenly lost.  The birth order theory holds that first

born children often have the greatest number of problems as they get older.

Middle born children may have it the easiest, and interestingly, Adler was a middle born child. 

These children are not pampered as their older sibling was, but are still afforded the attention.  

As a middle child, they have the luxury of trying to dethrone the oldest child and become more

superior while at the same time knowing that they hold this same power over their younger

siblings.  Adler believed that middle children have a high need for superiority and are often able

to seek it out such as through healthy competition.

The youngest children, like the first born, may be more likely to experience personality problems

later in life.  This is the child who grows up knowing that he has the least amount of power in the

whole family.  He sees his older siblings having more freedom and more superiority.  He also

gets pampered and protected more than any other child did.  This could leave him with a sense

that he can not take on the world alone and will always be inferior to others.

Adler stressed a positive view of human nature. He believed that individuals can control their

fate. They can do this in part by trying to help others (social interest). How they do this can be

understood through analyzing their lifestyle. Early interactions with family members, peers, and

teachers help to determine the role of inferiority and superiority in their lives.

View of Human Nature

A Person’s Perceptions are based on His or Her View of Reality (Phenomenology)

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– Adler believed that we “construct” our reality according to our own way of

looking at the world.

– “I am convinced that a person’s behavior springs from this idea…because our

senses do not see the world, we apprehend it.” (Adler, 1933/1964)

Each person must be viewed as an individual from a holistic perspective.

– Adler suggested that dividing the person up into parts or forces (i.e., id, ego, and

superego) was counterproductive because it was mechanistic and missed the

individual essence of each person.

– In his view, understanding the whole person is different than understanding

different aspects of his life or personality.

Human Behavior is Goal Oriented (Teleological)

– People move toward self-selected goals. “The life of the human soul is not a

‘being’ but a ‘becoming.’” (Adler, 1963a)

– This idea requires a very different way of viewing humans than the idea that

behavior is “caused” by some internal or external forces or rewards and

punishments.

– Understanding the causes of behavior is not as important as understanding the

goal to which a person is directed. Since we have evolved as social creatures, the

most common goal is to belong.

Determinism

– Moving through life, the individual is confronted with alternatives.

– Human beings are creative, choosing, self-determined decision-makers free to

chose the goals they want to pursue.

View of Human Nature

Conscious and unconscious are both in the service of the individual, who uses them to

further personal goals (Adler, 1963a)

Striving for superiority to overcome basic inferiority is a normal part of life.

– Mosak(2000) reports that Adler and others have referred to this central human

striving in a number of ways: completion, perfection, superiority, self-realization,

self-actualization, competence, and mastery.

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Social Interest and a Positive involvement in the community are hallmarks of a healthy

personality.

– All behavior occurs in a social context. Humans are born into an environment

with which they must engage in reciprocal relations.

– Adler believed that social interest was innate but that it needed to be nurtured in a

family where cooperation and trust were important values.

Adlerian Core Concepts and Explanation of Behavior

Style of life or Lifestyle

– A way of seeking to fulfill particular goals that individuals set in their lives.

Individuals use their own patterns of beliefs, cognitive styles, and behaviors as a

way of expressing their style of life. Often style of life or lifestyle is a means for

overcoming feeling of inferiority.

Four areas of lifestyle:

1. The self-concept

the convictions about who I am.

2. The self-ideal

convictions about what I should be.

3. The Weltbild, or “picture of the world”

convictions about the not-self and what the world demands of me.

4. The ethical convictions

The personal “right-wrong” code.

Adlerian explanation of Behavior

(Theory of Personality)

Family Constellation and Atmosphere:

– The number and birth order, as well as the personality characteristics of members

of a family. Important in determining lifestyle.

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– The family and reciprocal relationships with siblings and parents determine how a

person finds a place in the family and what he learns about finding a place in the

world.

– Adlerian Theory of Personality

Social Interest:

– The caring and concern for the welfare of others that can serve to guide people's

behavior throughout their lives. It is a sense of being a part of society and taking

responsibility to improve it.

Superiority

– The drive to become superior allows individuals to become skilled, competent,

and creative.

Superiority Complex:

– a means of masking feelings of inferiority by displaying boastful, self-centered, or

arrogant superiority in order to overcome feelings of inferiority.

Inferiority:

– Feelings of inadequacy and incompetence that develop during infancy and serve

as the basis to strive for superiority in order to overcome feelings of inferiority.

Inferiority complex:

– A strong and pervasive belief that one is not as good as other people. It is usually

an exaggerated sense of feelings of inadequacy and insecurity that may result in

being defensive or anxious.

Adlerian explanation of Behavior

Birth order:

– The idea that place in the family constellation (such as being the youngest child)

can have an impact on one's later personality and functioning.

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Early recollections:

– Memories of actual incidents that clients recall from their childhood. Adlerians

use this information to make inferences about current behavior of children or

adults.

Basic mistakes:

– Self-defeating aspects of individuals' lifestyle that may affect their later behavior

are called basic mistakes. Such mistakes often include avoidance of others,

seeking power, a desperate need for security, or faulty values.

Assets:

– Assessing the strengths of individuals' lifestyle is an important part of lifestyle

assessment, as is assessment or early recollections and basic mistakes.

TECHNIQUES FOR CHANGE

A lifestyle analysis helps the Adlerian therapist to gain insights into client problems by

determining the clients' basic mistakes and assets. These insights are based on assessing

family constellation, dreams, and social interest. To help the client change, Adlerians

may use a number of active techniques that focus to a great extent on changing beliefs

and reorienting the client's view of situations and relationships.

Life tasks:

– There are five basic obligations and opportunities: occupation, society, love, self

development, and spiritual development. These are used to help determine

therapeutic goals.

Interpretation:

– Adlerians express insights to their clients that relate to clients' goals.

Interpretations often focus on the family constellation and social interest.

Immediacy:

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– Communicating the experience of the therapist to the client about what is

happening in the moment.

Encouragement:

– An important therapeutic technique that is used to build a relationship and to

foster client change. Supporting clients in changing beliefs and behaviors is a part

of encouragement.

Acting as if:

– In this technique, clients are asked to "act as if" a behavior will be effective.

Clients are encouraged to try a new role, the way they might try on new clothing.

Catching oneself:

– In this technique, patients learn to notice that they are performing behaviors

which they wish to change,. When they catch themselves, they may have an

"Aha" response.

Aha response:

– Developing a sudden insight into a solution to a problem, as one becomes aware

to one's beliefs and behaviors.

Avoiding the tar baby:

– By not falling into a trap that the client sets by using faulty assumptions, the

therapist encourages new behavior and "avoids the tar baby" (getting stuck in the

client's perception of the problem).

The Question:

– Asking "what would be different if you were well?" was a means Adler used to

determine if a person's problem was physiological or psychological

– TECHNIQUES FOR CHANGE

Paradoxical intention:

– A therapeutic strategy in which clients are instructed to engage and exaggerate

behaviors that they seek to change. By prescribing the symptom, therapists make

clients more aware of their situation and help them seek to change. By prescribing

the symptom, therapists make clients more aware of their situation and help them

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achieve distance from the symptoms. For example, a client who is afraid of mice

may be asked to exaggerate his fear of mice, or a client who hoards paper may be

asked to exaggerate that behavior so that living becomes difficult. In this way

individuals can become more aware of and more resistant from their symptoms.

Spitting in the client's soup:

– Making comments to the client to make behaviors less attractive or desirable.

Homework:

– Specific behaviors or activities that clients are asked to do after a therapy session

Push-button technique:

– Designed to show patients how they can create whatever feelings they what by

thinking about them, the push-button technique asks clients to remember a

pleasant incident that they have experienced, become aware of feelings connected

to it, and then switch to an unpleasant image and those feelings. Thus clients learn

that they have the power to change their own feelings.

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8.Karen Horney's Feminine Theory and Theory of

Neurosis

Feminine Psychology

Perhaps the most important contribution Karen Horney made to psychodynamic thought was her

disagreements with Freud's view of women.  Horney was never a student of Freud, but did study

his work and eventually taught psychoanalysis at both the Berlin and New York Psychoanalytic

Institute.  After her insistence that Freud's view of the inherent difference between males and

females, she agreed to leave the institute and form her own school known as the American

Institute for Psychoanalysis.

In many ways, Horney was well ahead of her time and although she died before the feminist

movement took hold, she was perhaps the theorist who changed the way psychology looked at

gender differences.  She countered Freud's concept of penis envy with what she called womb

envy, or man's envy of woman's ability to bear children.  She argued that men compensate for

this inability by striving for achievement and success in other realms.

She also disagreed with Freud's belief that males and females were born with inherent

differences in their personality.  Rather than citing biological differences, she argued for a

societal and cultural explanation.  In her view, men and women were equal outside of the cultural

restrictions often placed on being female.  These views, while not well accepted at the time, were

used years after her death to help promote gender equality.

Neurosis and Relationships

Horney was also known for her study of neurotic personality.  She defined neurosis as a

maladaptive and counterproductive way of dealing with relationships.  These people are unhappy

and desperately seek out relationships in order to feel good abut themselves.  Their way of

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securing these relationships include projections of their own insecurity and neediness which

eventually drives others away.

Most of us have come in contact with people who seem to successfully irritate or frighten people

away with their clinginess, significant lack of self esteem, and even anger and threatening

behavior.  According to Horney, these individuals adapted this personality style through a

childhood filled with anxiety.  And while this way of dealing with others may have been

beneficial in their youth, as adults it serves to almost guarantee their needs will not be met.

She identified three ways of dealing with the world that are formed by an upbringing in a

neurotic family: Moving Toward People, Moving Against People, and Moving Away From

People.  

Moving Toward People.  Some children who feel a great deal of anxiety and helplessness move

toward people in order to seek help and acceptance.  They are striving to feel worthy and can

believe the only way to gain this is through the acceptance of others.   These people have an

intense need to be liked, involved, important, and appreciated.  So much so, that they will often

fall in love quickly or feel an artificial but very strong attachment to people they may not know

well.  Their attempts to make that person love them creates a clinginess and neediness that much

more often than not results in the other person leaving the relationship.

Moving Against People.  Another way to deal with insecurities and anxiety is to try to force

your power onto others in hopes of feeling good about yourself.  Those with this personality

style come across as bossy, demanding, selfish, and even cruel.  Horney argued that these people

project their own hostilities (which she called externalization) onto others and therefore use this

as a justification to 'get them before they get me.'  Once again, relationships appear doomed from

the beginning.

Moving Away From People.  The final possible consequence of a neurotic household is a

personality style filled with asocial behavior and an almost indifference to others.  If they don't

get involved with others, they can't be hurt by them.  While it protects them from emotional pain

of relationships, it also keeps away all positive aspects of relationships.  It leaves them feeling

alone and empty.

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9. Sullivan’s Interpersonal theory

Sam I am, good or bad

Harry Stack-Sullivan was trained in psychoanalysis in the United States, but soon drifted from

the specific psychoanalytic beliefs while retaining much of the core concepts of Freud. 

Interestingly, Sullivan placed a lot of focus on both the social aspects of personality and

cognitive representations.  This moved him away from Freud's psychosexual development and

toward a more eclectic approach.

Freud believed that anxiety was an important aspect in his theory because it represented internal

conflict between the id and the superego.  Sullivan, however, saw anxiety as existing only as a

result of social interactions.  He described techniques, much like defense mechanisms, that

provide tools for people to use in order to reduce social anxiety.  Selective Inattention is one

such mechanism.

According to Sullivan, mothers show their anxiety about child rearing to their children through

various means.  The child, having no way to deal with this, feels the anxiety himself.   Selective

inattention is soon learned, and the child begins to ignore or reject the anxiety or any interaction

that could produce these uncomfortable feelings.  As adults, we use this technique to focus our

minds away from stressful situations.

Personifications

Through social interactions and our selective attention or inattention, we develop what Sullivan

called Personifications of ourselves and others.  While defenses can often help reduce anxiety,

they can also lead to a misperception of reality.  Again, he shifts his focus away from Freud and

more toward a cognitive approach to understanding personality.

These personifications are mental images that allow us to better understand ourselves and the

world.  There are three basic ways we see ourselves that Sullivan called the bad-me, the good-me

and the not-me.  The bad me represents those aspects of the self that are considered negative and

are therefore hidden from others and possibly even the self.  The anxiety that we feel is often a

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result of recognition of the bad part of ourselves, such as when we recall an embarrassing

moment or experience guilt from a past action. 

The good me is everything we like about ourselves.  It represents the part of us we share with

others and that we often choose to focus on because it produces no anxiety.  The final part of us,

called the not-me, represents all those things that are so anxiety provoking that we can not even

consider them a part of us.  Doing so would definitely create anxiety which we spend our lives

trying to avoid.  The not-me is kept out of awareness by pushing it deep into the unconscious.

Developmental Epochs

Another similarity between Sullivan's theory and that of Freud's is the belief that childhood

experiences determine, to a large degree, the adult personality.  And, throughout our childhood,

the mother plays the most significant role.  Unlike Freud, however, he also believed that

personality can develop past adolescence and even well into adulthood.  He called the stages in

his developmental theory Epochs.  He believed that we pass through these stages in a particular

order but the timing of such is dictated by our social environment.  Much of the focus in

Sullivan's theory revolved around the conflicts of adolescence.  As you can see from the chart

below, three stages were devoted to this period of development and much of the problems of

adulthood, according to Sullivan, arise from the turmoil of our adolescence.

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Sullivan's Developmental Epochs

Infancy 

Age birth to 1 year

From birth to about age one, the child begins the process of

developing, but Sullivan did not emphasize the younger years to

near the importance as Freud.

Childhood

Ages 1 to 5

The development of speech and improved communication is key in

this stage of development.

Juvenile

Ages 6 to 8

The main focus as a juvenile is the need for playmates and the

beginning of healthy socialization

Preadolescence

Ages 9 to 12

During this stage, the child's ability to form a close relationship

with a peer is the major focus.  This relationship will later assist the

child in feeling worthy and likable.  Without this ability, forming

the intimate relationships in late adolescence and adulthood will be

difficult.

Early

Adolescence

Ages 13 to 17

The onset of puberty changes this need for friendship to a need for

sexual expression.  Self worth will often become synonymous with

sexual attractiveness and acceptance by opposite sex peers.

Late Adolescence

Ages 18 to 22 or

23

The need for friendship and need for sexual expression get

combined during late adolescence.  In this stage a long term

relationship becomes the primary focus.  Conflicts between

parental control and self-expression are commonplace and the

overuse of selective inattention in previous stages can result in a

skewed perception of the self and the world.

Adulthood

Ages 23 on

The struggles of adulthood include financial security, career, and

family.  With success during previous stages, especially those in

the adolescent years, adult relationships and much needed

socialization become more easy to attain.  Without a solid

background, interpersonal conflicts that result in anxiety become

92

more commonplace. 

10. Maslow’s Humanistic Theory

King of the Mountain

Perhaps the most well known contribution to humanistic psychology was introduced by Abraham

Maslow.  Maslow originally studied psychology because of his intrigue with behavioral theory

and the writings of John B. Watson.

Maslow grew up Jewish in a non-Jewish neighborhood.  He spent much of his childhood alone

and reported that books were often his best friends.  Despite this somewhat lonely childhood, he

maintained his belief in the goodness of mankind.  After the birth of his first child, his devotion

to Watson's beliefs began a drastic decline.  He was struck with the sense that he was not nearly

in control as much as Watson and other behaviorists believed.  He saw more to human life than

just external reinforcement and argued that human's could not possibly be born without any

direction or worth.

At the time when he was studying psychology, behaviorism and psychoanalysis were considered

the big two.  Most courses studies these theories and much time was spent determining which

theory one would follow.  Maslow was on a different path.  

He criticized behaviorism and later took the same approach with Freud and his writings.   While

he acknowledged the presence of the unconscious, he disagreed with Freud's belief that the vast

majority of who we are is buried deep beyond our awareness.  Maslow believed that we are

aware of our motives and drives for the most part and that without the obstacles of life, we would

all become psychologically healthy individuals with a deep understanding of ourselves and an

acceptance of the world around us.  Where Freud saw much negativity, Maslow focused his

efforts on understanding the positives of mankind.  It could be said that psychoanalytic thought is

based on determinism, or aspects beyond our control, and humanistic thought is based on free

will.

Maslow's most well known contribution is the Hierarchy of Needs and this is often used to

summarize the belief system of humanistic psychology.  The basic premise behind this hierarchy

is that we are born with certain needs.  Without meeting these initial needs, we will not be able to

continue our life and move upward on hierarchy.  This first level consists of our physiological

93

needs, or our basic needs for survival.  Without food, water, sleep, and oxygen, nothing else in

life matters.

Once these needs are met, we can move to the next level, which consists of our need for safety

and security.  At this level we look seek out safety through other people and strive to find a

world that will protect us and keep us free from harm.  Without these goals being met, it is

extremely difficult to think about higher level needs and therefore we can not continue to grow.

When we feel safe and secure in our world then we begin to seek out friendships in order to feel

a sense of belonging.  Maslow's third level, the need for belonging and love, focuses on our

desire to be accepted, to fit in, and to feel like we have a place in the world.   Getting these needs

met propels us closer to the top of this pyramid and into the fourth level, called esteem needs.  At

this level we focus our energy on self-respect, respect from others, and feeling that we have

made accomplishments on our life.  We strive to move upward in careers, to gain knowledge

about the world, and to work toward a sense of high self-worth.

The final level in the hierarchy is called the need for self-actualization.  According to Maslow,

may people may be in this level but very few if anybody ever masters it.  Self-actualization refers

to a complete understanding of the self.  To be self-actualized means to truly know who you are,

94

where you belong in the greater society, and to feel like you have accomplished all that you have

set out to accomplish.  It means to no longer feel shame or guilt, or even hate, but to accept the

world and see human nature as inherently good.

Application to Real Life

As you read through the section above, many likely tried to place themselves on one of the five

levels of the pyramid.  This may be an easy task for some, but many struggle with the ups and

downs of life.  For many of us, life is not that straight forward.  We often have one foot in one

level, the other foot in the next level, and are reaching at times trying to pull ourselves up while

making sure we don't fall backward at other times.

As we climb the pyramid, we often make headway but also notice that two steps forward can

mean one step back.  Sometimes it even feels like two steps forward means three steps back. 

The goal of mankind, however, is to keep an eye on the top of the pyramid and to climb as

steadily as possible.  We may stumble at times and we may leap forward at times.   No matter

how far we fall backward, however, the road back up is easier since we already know the way.

95

11. Glasser’s Control or Choice Theory

William Glasser, in his 'Control Theory' (later renamed to 'Choice Theory') detailed five needs

that are quite close to Maslow's Hierarchy, but with some interesting twists.

1. Survival

This is similar to Maslow's Physiological and Safety level. They are basic needs which are of

little interest unless they are threatened.

2. Love and belonging

This is the same as Maslow's Belonging need and recognises how important it is for us as a tribal

species to be accepted by our peers.

3. Power or recognition

This maps to some extent to Maslow's Esteem need, although the Power element focuses on our

ability to achieve our goals (which is perhaps a lower-level control need).

4. Freedom

This is the ability to do what we want, to have free choice. It is connected with procedural justice

where we seek fair play.

5. Fun

An interesting ultimate goal. When all else is satisfied, we just (as Cyndi Lauper sang) 'want to

have fun'.

Relationships and our Habits:

Seven Caring Habits Seven Deadly Habits

1.Supporting 1.Criticizing

2.Encouraging 2.Blaming

3.Listening 3.Complaining

4.Accepting 4.Nagging

5.Trusting 5.Threatening

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6.Respecting 6.Punishing

7.Negotiating differences 7.Bribing, rewarding to control 

The Ten Axioms of Choice Theory

A. The only person whose behavior we can control is our own.

B. All we can give another person is information

C. All long-lasting psychological problems are relationship problems.

D. The problem relationship is always part of our present life.

E. What happened in the past has everything to do with what we are today, but we

can only satisfy our basic needs right now and plan to continue satisfying them in

the future.

F. We can only satisfy our needs by satisfying the pictures in our Quality World.

G. All we do is behave.

H. All behaviors are Total Behaviors and are made up of four components: acting,

thinking, feeling and physiology. All Total Behaviors are chosen, but we only

have direct control over the acting and thinking components.

I. We can only control our feeling and physiology indirectly through how we choose

to act and think.

J. All Total Behavior is designated by verbs and named by the part that is the most

recognizable.Whoops that's ELEVEN?? - Glasser couldn't count!

97

12. Fowler's Faith Stage Theory

James Fowler investigated and developed a stage theory for the development of religious faith.

In practice, it is also applicable to other areas of general beliefs.

Kirst-Ashman and Zastrow (2004) add a 'Primal or Undifferentiated' stage prior to stage 1. This

includes Lacan's early stages and entry into the Symbolic Register. 

Level ~Ages Name Characteristics

Stage 1 3-7 Intuitive-predictive

Egocentric, becoming aware of time.

Forming images that will affect their

later life.

Stage 2 6-12 Mythical-literal

Aware of the stories and beliefs of the

local community. Using these to give

sense to their experiences.

Stage 3 12- Synthetic-conventional

Extending faith beyond the family

and using this as a vehicle for

creating a sense of identity and

values.

Stage 4early

adultIndividuative-reflective

The sense of identity and outlook on

the world are differentiated and the

person develops explicit systems of

meaning.

Stage 5 adult Conjunctive

The person faces up to the paradoxes

of experience and begins to develop

universal ideas and becomes more

oriented towards other people.

Stage 6 adult Universalizing

The person becomes totally altruistic

and they feel an integral part of an

all-inclusive sense of being. This

stage is rarely achieved.

98

C. Biographical Data

Patient is J. He is 22 years old, single. He is a Filipino and a Roman Catholic. He is the eldest among 9 siblings. He lives at Sorsogon, Sorsogon. He was born on August 11, 1987 in Northern Samar.

J is currently hospitalized at National Center for Mental Health (NCMH) since November 6, 2009.

99

D. Nursing History

1. Chief Complaint

“Hindi ko po alam,”, as verbalized by the patient.

“Mabuti naman.” , as verbalized by the patient.

As verbalized by the informant (patient’s mother):

“nambabato ng bahay”

“nananakit”

“nagwawala”

“tinadyakan ang lola”

2. History of present Illness

While working as a plastic bag vendor in a market 12 days prior to admission, the patient

suddenly went home crying and anxious. He was restless, assaultive to his siblings when

apprehended. He sleeps poorly. He hides under the table. J became non-functional at home.

3. Previous Illness

J suffered from common illnesses like colds, cough, fever and flu.

4. Past Personal History

J was previously admitted at a Hospital in Sorsogon because of his mental illness. He

took up Grade 1 twice and repeated Grade 2 twice also. He is a former plastic bag vendor in a

market in their province. He is disoriented with time, place and person. He has no special

someone since birth. J is not sexually active. Eating gives him pleasure.

100

5. Family History

His mother is the most important person while he grows up. There is no concrete

evidence of sexual abuse or physical abuse but then, the patient verbalized that he was put into

“jail” by his mother, tied his hand, chained and was hit by a wood.

6. Social History

The patient belongs to a nuclear structured and patriarchal type of family. He is the eldest

among 9 siblings. J reached Grade 2. He has worked as a plastic bag vendor in a market at their

place.

101

CHAPTER

IIPresentation,

Interpretation

&Analysis

of Data

102

(Daily Account of Observed Behavior)

Psychiatric Nursing History and

Mental Status Assessment

GENERAL ADMISSION INFORMATION

Name: “J”

Age/Gender: 22 y/o, Male Marital Status: Single

Racial and Ethnic Data: Filipino, Bisaya

Number and Ages of Children/Siblings: 9 siblings

Living Arrangements:

Educational Attainment: unfinished Grade 2

Occupation: none

Religious Affiliations: Roman Catholic

CONDITIONS OF ADMISSION

Voluntary: __________ Involuntary:

Accompanied to Facility by (Family Friend Police Other): mother

Route of Admission (ambulatory, wheelchair, stretcher): ambulatory

Admitted from: (home, other facility, street, place of destination): home

I. PRESENTING PROBLEMA. Statement in the client’s own words of why he or she is hospitalized or seeking help

According to the Patient:

“mabuti naman”

103

According to the Informant:

“nambabato ng bahay”

“nananakit”

“nagwawala”

“tinadyakan ang lola”

B. Recent difficulties/alterations in1. Relationships 2. Usual level of functioning3. Behavior4. Perceptions or cognitive abilities

C. Increased feelings of1. Depression2. Anxiety3. Hopelessness4. Being overwhelmed5. Suspicious6. Confusion

D. Somatic changes, such as1. Constipation2. Insomnia3. Lethargy4. Weight loss or gain5. Palpitations

II. RELEVANT HISTORY – PERSONAL:A. Previous hospitalizations and illness: Provincial Hospital in Sorsogon/mental illnessB. Educational background : Grade 1 (2x), Grade 2 (2x)C. Occupational background : former plastic bag vendor

1. if employed, where? : in a market at Sorsogon2. How long at the job? ___________________________________________3. Previous positions and reasons for leaving __________________________4. Special skills _________________________________________________

D. Social patterns1. Describe friends : disoriented with fellow patients2. Describe a usual day __________________________________________

E. Sexual patterns1. Sexually active? : not2. Sexual orientation ___________________________________3. Sexual difficulties ___________________________________4. Practice safe sex or birth control ________________________

F. Interest and abilities1. What does the client do in his or her spare time: sleep, rest2. What is the client good at? ______________________________________3. What gives the client pleasure? : eating

G. Substance use and abuse1. What medication does the client take? : haloperidol How often: once a day, at night How much? : 10mg

2. Any herbal or-the-counter medicati ons?__________________________ How often? ________________ How much? __________________

3. What psychotropic drugs does the client take? ____________________ How often? _______________ How much? ___________________

4. How many drinks of a alcohol does the client take? _______________ per day? ___________ Per week? _________________

104

5. Does the client identify use of drugs as a problem? _______________H. How does the client cope with stress? ___________________________

1. What does the client do when he or she gets upset? _________________________________________________________________________

2. Whom can the client talk to? __________________________________3. What usually helps to relieve stress? ____________________________4. What did the client try this time? _______________________________

III. RELEVANT HISTORY – FAMILYA. Childhood

1. Who was important to the client growing up? mother2. Was there physical or sexual abuse? ________________________________3. Did the parents drink or use drugs? _________________________________4. Who was in the home when the client was growing up? Mother, father

B. Adolescence

1. How would be client describe his or her feelings in adolescence? __________________________________________________________________________

2. Describe the client’s peer group at the time. ___________________________

C. Use of drugs

1. Was there use or abuse of drugs by any family member? _________________Prescription _________________ Street __________ By whom? _________

2. What was effect on the family? ______________________________________ D. Family physical or mental problems

1. Is there any family history of violence or physical/sexual abuse? ______________2. Who in the family had physical or mental problems? _______________________3. Describe the problem ________________________________________________4. How did it affect the family? __________________________________________

E. Was there an unusual or outstanding event the client would like to mention ________

____________________________________________________________________

IV. SPIRITUAL ASSESSMENTA. What importance does religion or spirituality have in your life? _______________

__________________________________________________________________

B. Do your religious or spiritual beliefs influence the way you take care of yourself or your illness?

How? __________________________________________________

C. Who or what supplies you with hope? ___________________________________

V. CULTURAL INFLUENCESa. With what cultural group do you identify? Bisayaa. Have you tried any cultural remedies or practices for your condition? If so, what?

________________________________________________________________

a. Do you use any alternative or complimentary medicines/herbs/practices?

105

_______________________________________________________________

/- observedX- not observed

MENTAL STATUS EXAMINATION

General Appearance Day

1 2 3 4 5

Facial Expression

Animated

Fixed or Immobile

Sad or Depressed

Angry

Pale

Reddened

Posture

Slouched

Stooped

Upright (erect)

Stiff

Gait

Smooth Rhythmic

Shuffling

Staggering

Dress

Appropriately Dressed

Inappropriately Dressed

Pressed

Wrinkled

Grooming

Well Groomed

x

/

x

x

/

x

/

/

x

/

/

x

x

/

x

/

x

/

x

/

x

x

/

x

/

/

x

/

/

x

x

/

x

/

x

/

x

/

x

x

/

x

/

/

x

x

/

x

x

/

x

/

x

/

x

/

x

x

/

x

/

/

x

/

/

x

x

/

x

/

x

/

/

x

x

x

/

x

/

/

x

x

/

x

x

/

x

/

x

/

106

Unkempt

Hygiene

Clean

Untidy

Odor (Body / Breath)

None

Alcohol

Acetone

Pungent

Cigarette Smoke

Foul Smelling

Physical Deformity: (specify)_____________________

Eye Contact

Maintains Good Eye Contact

Poor Eye Contact (Lacks Eye Contact)

Eye Cast (Client squints his eyes, pupils dilated)

x

/

x

/

x

x

x

x

x

x

/

x

x

/

x

/

x

x

x

x

x

/

x

x

x

/

x

/

x

x

x

x

x

/

x

x

x

/

x

/

x

x

x

x

x

/

x

x

x

/

x

/

x

x

x

x

x

/

x

x

The patient has a fixed facial expression. He is 5’4” and weighs 56 kg. He has a stooped

posture. J has smooth rhythmic gait. He is appropriately dressed and well groomed. He is clean.

He has no body or breath odor. There is a scar on both patella and on both wrists. Eye contact

was established.

MOTOR BEHAVIOR

Gestures, stereotyped behavior, pacing, any purposeless activity should be described.

Day

1 2 3 4 5

Purposeful and Coordinated Movement

Catatonia

Echopraxia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

107

Tics

Spasm

Compulsive

Waxy Flexibility

Parkinson-like symptoms

Akathisia

Dyskinesia

Apraxia

Catatonic Stupor

Catatonic Excitement

Hyperkinesia

Catalepsy

Cataplexy

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

The patient at times has a waxy flexibility.

Speech

How the client is communicating, rather than what the client is telling you. Rate, volume, modulation and flow

Day

1 2 3 4 5

Rate

Rapid

Slow

Volume

Loud

Soft/mumbled

Quantity

Paucity

Muteness

Voluminous

Quality

/

x

x

/

/

x

x

/

x

x

/

/

x

x

/

x

x

/

/

x

x

/

x

x

/

/

x

x

/

x

x

/

/

x

x

108

Articulate

Congruent

Spontaneous

Monotonous

Talkative

Repetitious

Pressured Speech

x

x

x

/

x

/

x

x

x

x

/

x

/

x

x

x

x

/

x

/

x

x

x

x

/

x

/

x

x

x

x

/

x

/

x

J has somnolence. There is clouding and stupor. He is disoriented to time, place and person.

He is unrespondent to some querries. He has a difficulty to recall personal information and is

often confused.

Perceptions

Process by which physical stimuli are brought to mental awareness

Day

1 2 3 4 5

Hallucinations

Auditory

Visual

Tactile

Gustatory

Olfactory

Illusions

Depersonalization

Derealization

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

Patient has an auditory hallucination.

Thinking Day

109

The waythe person functttions intellectually; the process or way of thinking or analysis of the world: the way of connecting or associating thoughts; the overall organization of thoughts.

1 2 3 4 5

(1) Thought Content-What a client is thinking

1.1 Delusionsa. Delusions of Grandeurb. Delusions of Referencec. Delusions of Persecutiond. Religious Delusione. Somatic Delusionf. Paranoid Delusion

1.2 Phobia: Specify _________________________

(2) Thought Process - How a person thinksa. Flight of Ideas

b. Looseness of Association

c. Blocking

d. Confabulation

e. Tangetiality

f. Neologism

g. Circumstantiality

h. Perserveration

i. Confabulation

j. Word Salad

x

x

x

x

/

/

/

/

x

x

x

/

/

/

x

x

x

x

/

/

/

/

x

x

x

/

/

/

x

x

x

x

/

/

/

/

x

x

x

/

/

/

x

x

x

x

/

/

/

/

x

x

x

/

/

/

x

x

x

x

/

/

/

/

x

x

x

/

/

/

Patient   is   mumbling   to   self.   He   has   flight   of   ideas,   looseness   of   association,   blocking,   and 

perseveration. He has faulty judgment and has a poor insight to his illness. Echolalia can be observed as 

well as mutism at times. 

Emotional State (Mood/Affect)

Expression of emotion as seen by others;what examiner infers from patient’s facial expression/behavior

Day

1 2 3 4 5

Appropriate

Inappropriate

Flat

x

/

/

x

/

/

x

/

/

x

/

/

/

x

x

110

Pleasurable Affect

Euphoria

Exaltation

Ecstacy

Unpleasurable

Depression

Anxiety

Fear

Agitation

Ambivalence

Aggression

Mood Swings

Lability

Panic

Anger

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

x

x

x

x

/

x

x

x

x

x

x

x

x

Mood is ethylic and has an inappropriate affect which in most of the times is flat. He is

anxious.

111

CHAPTER

3DIAGNOSIS

112

E. Predisposing Factors

Prenatal Alcohol Syndrome

Traumatic injury to the brain

Intrauterine malnutrition

Central Nervous System Malignancy

fragile X syndrome

Phenylketonuria (PKU)

F. Psychodynamics / Psychopathology

The mental retardation generally results from either of the two causes. The one is chromosomal

abnormality and the second is deficiency of certain bio chemicals or neurotransmitters due to the

lack of minerals required for that specific function and a third cause can be brain injuries.

The DSM (Diagnostic and Statistical Manual) divides the retardation into four categories as mild

MR, Moderate MR, severe MR, and profound MR. The level of mental retardation is usually

determined with reference to the IQ (Intelligence Quotient)

About 30% of cases of mental retardation are caused by hereditary factors. Mental retardation

may be caused by an inherited genetic abnormality such as fragile X syndrome, Phenylketonuria

(PKU), Down syndrome. etc.

Fetal alcohol syndrome (FAS), drug exposure, hyperthyroidism are some of the other causes.

Every mental activity involves a series of active involvement of the neurotransmitters, mental

waves, and other complex processes in the nervous system. Insufficient physiological process in

the nervous system results in the retarded mental functioning.

113

PKU

(enzyme phenylalanine hydroxylase normally converts the amino acid phenylalanine into the amino acid tyrosine)

phenylalanine accumulates

tyrosine is deficient

excessive phenylalanine

metabolism of phenylketones

transaminase pathway with glutamate

Metabolites formed

(phenylacetate, phenylpyruvate and phenethylamine)

Saturation of blood-brain barrier (BBB)

decreased levels of other large neutral amino acid (LNAAs) transporter in the brain

decreased synthesis of proteins and neurotransmitters

disrupts brain development

mental retardation

* Delays in oral language development

* Deficits in memory skills

* Difficulty learning social rules

* Difficulty with problem solving skills

* Delays in the development of adaptive behaviors such as self-help or self-care skills

* Lack of social inhibitors

114

G. Related Literature

DRUG REVERSES MENTAL RETARDATION CAUSED BY GENETIC DISORDER

Published: Sunday, June 22, 2008 - 12:35 in Health & Medicine

Source: University of California - Los Angeles

UCLA researchers discovered that an FDA-approved drug reverses the brain dysfunction

inflicted by a genetic disease called tuberous sclerosis complex (TSC). Because half of TSC

patients also suffer from autism, the findings offer new hope for addressing learning disorders

due to autism. Nature Medicine publishes the findings in its online June 22 edition. Using a

mouse model for TSC, the scientists tested rapamycin, a drug approved by the FDA to fight

tissue rejection following organ transplants. Rapamycin is well-known for targeting an enzyme

involved in making proteins needed for memory. The UCLA team chose it because the same

enzyme is also regulated by TSC proteins.

"This is the first study to demonstrate that the drug rapamycin can repair learning deficits related

to a genetic mutation that causes autism in humans. The same mutation in animals produces

learning disorders, which we were able to eliminate in adult mice," explained principal

investigator Dr. Alcino Silva, professor of neurobiology and psychiatry at the David Geffen

School of Medicine at UCLA. "Our work and other recent studies suggest that some forms of

mental retardation can be reversed, even in the adult brain."

"These findings challenge the theory that abnormal brain development is to blame for mental

impairment in tuberous sclerosis," added first author Dan Ehninger, postgraduate researcher in

neurobiology. "Our research shows that the disease's learning problems are caused by reversible

changes in brain function -- not by permanent damage to the developing brain."

TSC is a devastating genetic disorder that disrupts how the brain works, often causing severe

mental retardation. Even in mild cases, learning disabilities and short-term memory problems are

common. Half of all TSC patients also suffer from autism and epilepsy. The disorder strikes one

in 6,000 people, making it twice as common as Huntington's or Lou Gehrig's disease.

Silva and Ehninger studied mice bred with TSC and verified that the animals suffered from the

same severe learning difficulties as human patients. Next, the UCLA team traced the source of

115

the learning problems to biochemical changes sparking abnormal function of the hippocampus, a

brain structure that plays a key role in memory.

"Memory is as much about discarding trivial details as it is about storing useful information,"

said Silva, a member of the UCLA Department of Psychology and UCLA Brain Research

Institute. "Our findings suggest that mice with the mutation cannot distinguish between

important and unimportant data. We suspect that their brains are filled with meaningless noise

that interferes with learning."

"After only three days of treatment, the TSC mice learned as quickly as the healthy mice," said

Ehninger. "The rapamycin corrected the biochemistry, reversed the learning deficits and restored

normal hippocampal function, allowing the mice's brains to store memories properly."

In January, Silva presented his study at the National Institute of Neurological Disorders and

Stroke meeting, where he was approached by Dr. Petrus de Vries, who studies TSC patients and

leads rapamycin clinical trials at the University of Cambridge. After discussing their respective

findings, the two researchers began collaborating on a clinical trial currently taking place at

Cambridge to examine whether rapamycin can restore short-term memory in TSC patients.

"The United States spends roughly $90 billion a year on remedial programs to address learning

disorders," noted Silva. "Our research offers hope to patients affected by tuberous sclerosis and

to their families. The new findings suggest that rapamycin could provide therapeutic value in

treating similar symptoms in people affected by the disorder."

116

Title: Mental Retardation

Source: nih.com

Thirty Years Ago

•

Haemophilus Influenzae Type B (Hib) was the leading cause of acquired mental retardation. In

the mid-1970s, no means existed to prevent infection from Hib, the cause of meningitis — a

serious infection of the membrane surrounding the brain and spinal cord. The disease strikes

children under 7 years of age, with most cases occurring in children from six months to two

years old. By the late 1980s, roughly 15-20,000 cases of Hib meningitis occurred each year.

Antibiotics could treat Hib infection, but couldn’t prevent its devastating consequences. On

average, 1 in 10 infected children died from Hib meningitis, 1 in 3 became deaf, and 1 in 3 was

left with mental retardation.

•

More than 10 million children had blood lead levels high enough to affect their cognitive

functioning. It was not known in the early 1970s that exposure to even small amounts of lead in

the environment — from paint and from automobile exhaust — could have an adverse effect on

the developing brain.

•

Many children of women with the metabolic disorder phenylketonuria (PKU) were born with

severe mental retardation — even though they did not have PKU themselves. PKU is a genetic

inability to process the nutrient phenylalanine. The disorder occurs once in every 10,000 to

20,000 births, affecting 250 children each year in the United States. Without treatment, a child

will suffer irreparable brain damage and require a lifetime of care in a nursing home facility. In

the 1960s, a blood test for PKU was developed and children with the disorder were identified at

birth. A low phenylanine diet spared them from brain damage. Because the diet is difficult to

adhere to, many children, including those that would go on to be mothers, discontinued the low

phenylalanine diet at approximately age 7 when the dangers of retardation are past.

Unfortunately, by the late 1970s, it was

apparent that children carried by moms with PKU were born with mental retardation.

• Infants lacking thyroid hormone were destined to a life of mental retardation. In the mid 1970s,

more than 1000 U.S. children each year became mentally retarded shortly after birth, because of

hypothyroidism

— failure to produce sufficient amounts of thyroid hormone. Thyroid hormone is essential for

growth, especially of the brain. Although the hormone could be supplied artificially, diagnosis of

the condition was usually not made until after an infant’s brain was permanently damaged.

117

Today

•

Meningitis from Hib has virtually been eliminated. In the 1970s, the search began for a vaccine

to prevent Hib meningitis. The Hib bacterium could hide from a young child’s immature immune

system by means of a protective sheath, or capsule, which shields its outer surface. In their first

attempt at a vaccine to prevent the infection, researchers at NIH isolated a complex

polysaccharide — a sugar molecule — from the bacterium’s covering. By itself, the

polysaccharide was not enough to prime the immune system to eliminate the Hib bacterium. The

researchers then chemically combined, or conjugated, the sugar molecule to a protein that was

easily recognized by the immune system. The protein and sugar “conjugate” became the basis for

a new vaccine, which virtually eliminated Hib meningitis from the developed world. In the

United States, there are now fewer than 10 cases of Hib meningitis each year.

•

Lead is no longer an ingredient in paint and gasoline. In 1979, researchers funded by NIH

showed that children whose baby teeth contained relatively high amounts of lead fared poorly on

a standard intelligence test when compared to children whose teeth contained much lower

amounts of lead. The finding eventually led to Federal laws that banned lead as an ingredient in

paint in 1974 and as an additive in gasoline in 1978. As a result, the number of children

National Institutes of Health Mental Retardation – 1

with elevated blood lead levels fell from 10 million in the 1970s to 434,000 in 2001. Although

the two most common sources of environmental lead exposure have been eliminated, many

children are still exposed to such sources of lead as paint in older homes, and contaminated soils.

•

Children of women with PKU can be protected from brain damage. In the 1960s, children with

PKU typically discontinued the low phenylalanine diet by the time they reached 7 years of age.

The diet’s special protein formulations are expensive, and many find the diet difficult to stick

with. To test whether a low phenylalanine diet would prevent mental retardation in the children

of women with PKU, the NIH began a large study. The study, which took 18 years to complete,

enrolled women from more than 120 clinics in the United States, Canada, and three foreign

countries. The study was completed in 2003 and found that limiting phenylalanine in the diets of

women with PKU beginning before pregnancy and continuing through pregnancy nearly

eliminated mental retardation in their children. Subsequent studies have shown that people with

PKU score higher on intelligence tests if they remain on the low-phenylalanine diets throughout

their lifetimes, rather than discontinuing it in childhood.

•

Infants who lack thyroid hormone can be identified in time to help them. Researchers funded by

the NIH developed a test to identify newborns that have insufficient thyroid hormones. A large

118

study funded by NIH in the early 1970s showed that hypothyroidism could be easily detected,

and treated within two weeks, before any brain damage resulted. Soon, every State required

thyroid hormone screening along with PKU screening. Each year in the United States, roughly

1000 cases of mental retardation due to insufficient thyroid hormone are prevented.

Tomorrow

• The NIH is supporting the development of new DNA microarray chips and other technologies

for newborn screening. The goal is to develop a fast, reliable, cost effective means to screen

newborns for a multitude of genetic conditions, including not only causes of mental retardation,

but of immune deficiency, blood disorders, nervous system disorders and muscle disorders. Such

a screening test would make it possible to begin treatment early, when chances for success are

greatest. Large numbers of infants who have disorders lacking effective treatments could also be

identified easily. Although treatment might not yet be available for their conditions, they could

be offered a chance to participate in studies of new treatments, so that eventually new therapies

could be developed for their disorders as well.

•

NIH-funded researchers hope to develop a drug that may one day treat the symptoms of Fragile

X Syndrome. The condition affects one in 6000 births, resulting in mental retardation, sleep

problems, attention deficit disorder, aggression, and compulsive behavior. NIH-funded scientists

working with mice having the same genetic mutation found in Fragile X Syndrome learned that

the mice have increased activity in the metabotropic glutamate receptor (mGluR), which sits atop

brain cells. Studies in mice and fruit flies show that chemically blocking the mGluR receptor

results in the animals displaying more normal behaviors. Researchers hope that drugs that block

the mGluR receptor might one day be used to lessen the disorder’s effects in humans.

•

Researchers have prevented brain damage in newborn infants deprived of oxygen at birth by

lowering body temperature. Accidents of birth — compression of the umbilical cord, or rupture

of the uterus, for example — can deprive an infant’s brain of blood and oxygen. Survivors of

such accidents may suffer lifelong brain damage and disability. Known scientifically as hypoxic

ischemic encephalopathy, or HIE, oxygen deprivation during birth is estimated to occur from 0.5

to 1 times per every thousand births. Researchers in an NIH network were able to reduce the

amount of death and disability of a group of infants with HIE, by lowering the infants’ body

temperature. The cooling treatment, known as hypothermia therapy, consisted of placing the

infants on a soft plastic blanket through which cool water circulates. When the infants were

examined at 18 to 22 months of age, 44 percent of those given hypothermia treatment had

developed a moderate to severe disability or had died, as compared to 62 percent of infants

119

receiving standard treatment for HIE. Because minor fluctuations in an infant’s body temperature

could result in serious harm, the hypothermia treatment requires personnel trained in life support

and the use of the cooling blanket. Researchers in the network are working to refine the therapy

so that it may one day be used routinely in newborn intensive care units.

3. Summary

The literature discussed the causes of mental retardation from early years until these were

eradicated, prevented and resolved. The following factors that were considered are Haemophilus

Influenza Type B, products with lead content, PKU, fetal injury from oxygen deprivation and

deficient thyroid hormone.

4. Reaction

I just want to commend the works and studies of the National Institutes of Health (NIH),

an agency of the United States Department of Health and Human Services and the primary

agency of the United States government responsible for biomedical and health-related research.

NIH research of acquiring new knowledge to help prevent, detect, diagnose, and treat

mental retardation is of really huge help and contribution to the world’s wellness especially for

the mentally incapacitated patients

120

D. Drug Study – HALOPERIDOL

121

122

DRUG CLASSIFICATIONDOSE/RATE/ROUTE

ACTION CONTRAINDICATION SIDE EFFECTSNURSING

CONSIDERATIONS

Generic Name:haloperidol

Brand Name:Haldol

Antipsychotics / Anti-vertigo Drugs

INDICATION: Restlessness Confusion Schizophreni

a Psychosis Organic

Psychoses acute

psychotic symptoms

Relieve hallucinations, delusions, disorganized thinking

severe anxiety

seizures

10 mg , PO, HS

Haloperidol blocks postsynaptic dopamine D1 and D2 receptors in the mesolimbic system and decreases the release of hypothalamic and hypophyseal hormones. It produces calmness and reduces aggressiveness with disappearance of hallucinations and delusions.Absorption: Readily absorbed from the GI tract (oral).Distribution: Crosses the blood-brain barrier; enters breast milk. Protein-binding: 92%.Metabolism: Hepatic via oxidative N-dealkylation and reduction of the ketone group; undergoes enterohepatic recycling.Excretion: Urine and faeces; 12-38 hr (elimination half-life).

Severe toxic CNS depression; pre-existing coma; Parkinson's disease; Lactation Glaucoma Seizures Elderly

Cardiovascular Effects:Tachycardia, hypotension, and hypertensionCNS:Insomnia, restlessness, anxiety, euphoria, agitation, drowsiness, depression, lethargy, headache, confusion, vertigo, grand mal seizures, exacerbation of psychotic symptoms including hallucinations, and catatonic-like behavioral statesHematologic Effects:mild and usually transient leukopenia and leukocytosis, minimal decreases in red blood cell counts, anemia, or a tendency toward lymphomonocytosis.Liver Effects:Impaired liver function and/or jaundiceDermatologic ReactionsMaculopapular and acneiform skin reactions and isolated cases of photosensitivity and loss of hair.Endocrine DisordersLactation, breast engorgement, mastalgia, menstrual irregularities, gynecomastia, impotence, increased libido, hyperglycemia, hypoglycemia and hyponatremia.Gastrointestinal EffectsAnorexia, constipation, diarrhea, hypersalivation, dyspepsia, nausea and vomiting.Autonomic ReactionsDry mouth, blurred vision, urinary retention, diaphoresis and priapism.Respiratory EffectsLaryngospasm, bronchospasm and increased depth of respiration.Special SensesCataracts, retinopathy and visual

• Assess mental status prior to and periodically during therapy.• Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG.• Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded.•Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration.• Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK.•Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea, and vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.

123

CHAPTER

IV

NURSING CARE PLAN

124

A.

Process

Recording

125

ORIENTATION PHASE

Description of Phase:

Problem defining phase

Starts when client meets nurse as stranger

Defining problem and deciding type of service needed

Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and

expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems and to use available

resources and services

Objectives:

After the orientation phase, the nurse will be able to:

Determine why the patient sought help

Establish trust, acceptance, and open communication

Mutually formulate a contract with the patient

Explore patient’s thoughts, feelings, and actions

Identify patient’s problems

Define goals with the patient

Date/ Time/ Venue: November 25, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

NURSE-PATIENT

INTERACTION

RATIONALE OF THE

NURSE’S

COMMUNICATION

TECHNIQUE

ANALYSIS OF THE

PATIENT’S RESPONSE

126

Nurse: Magandang umaga J.

Ako si Ran. Estudyante ako

mula sa Centro Escolar

University, Manila. Student

nurse mo ako ngayon.

Magkikita at mag-uusap tayo

simula Miyerkules hanggang

Biyernes sa susunod na

linggo, mula alas-siyete

hanggang alas-tres ng hapon.

Mag-uusap ulit tayo bukas ha.

Patient: Opo…Opo…Opo

(with nodding)

Nurse: Puwede ko bang

malaman ang buong pangalan

mo?

Patient: (stated the name)

Nurse: Ano ulit ang pangalan

ko J?

Patient: Ran po. (somnolence)

Nurse: Sige. Ako ang student

nurse mo tapos ikaw ang

pasyente.

Therapeutic:

Giving Information

Making available the facts

that the client needs

Use names

Using a person's name

makes her feel more

valued, and introducing

yourself is a basic step in

establishing a therapeutic

interaction.

Therapeutic:

Exploring

Encourages the speaker to

expand upon their

remarks/ question

Therapeutic:

Help to orient

Patient is conscious and

comprehending

Patient is responsive

Patient is drowsy and

comprehending

127

Patient: Opo.

Nurse: Mag-uusap tayo J ha.

Magkukwentuhan lang tayo.

Patient: Opo. Opo.

Nurse: Alam mo ba kung

anong petsa at araw ngayon?

Patient: Sabado

Nurse: J Huwebes ngayon.

November 26, 2009.

Patient: (stares only)

Nurse: Ano ulit ang petsa

ngayon J?

Patient: Sabado

Nurse: Huwebes ngayon,

November 26, 2009 J.

Illness and hospitalization

can be very disorienting

for patients, especially the

elderly.

Therapeutic:

Help to orient

Illness and hospitalization

can be very disorienting

for patients.

Therapeutic:

Presenting Reality

When it is obvious that the

patient is misinterpreting

reality, the nurse can

indicate that which is real.

He does this not by way of

arguing with the patient or

belittling his own

experiences, but rather by

calmly and quietly

expressing her own

perceptions or the facts

Therapeutic:

According to Jung,

perception involves all the

ways of becoming aware

of things, people,

happenings, or ideas.

Judgment involves all the

ways of coming to

conclusions about what

has been perceived. If

people differ

systematically in what

they perceive and in how

they reach conclusions,

then it is only reasonable

for them to differ

correspondingly in their

interests, reactions, values,

motivations, and skills.

Patient is responsive

He is analyzing the

information

Patient had

established/formed fixated

idea with regards

Patient is responsive

He has a difficulty to

recall personal information

128

Patient: Opo

Nurse: Ilang taon ka na pala J?

Patient: Napulo

Nurse: Anong taon nuong

ipinanganak ka?

Patient: Marso

Nurse: Ano ang birthday mo?

Kelan ka ipinanganak?

Patient: Hulyo, Agosto

Nurse: alam mo ba J kung ano

ang ginagawa mo dito?

Patient: (looses eye contact,

tumingin sa malayo)

Nurse: Anong lugar to J?

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Reframing the question:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Help to orient

Illness and hospitalization

can be very disorienting

for patients.

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

and is often confused.

He has a difficulty to

recall personal information

and is often confused.

Patient has difficulty in

memory skills

Disoriented to place

Misleading answer

129

Patient: (silence. Spits saliva)..

Ambot

Nurse: Saan ka pala nakatira

J?

Patient: sa bahay

Nurse: Saan ka galing na

probinsiya?

Patient: doon

Nurse: Saan yung doon na

sinasabi mo J? Yung lugar

kung saan ka dati nakatira

bago ka napunta dito?

Patient: Bitano

Nurse: Saan yung Bitano J?

Patient: Sorsogon

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Using Broad Opening

Statements The use of a broad

opening statement allows the

Trying to recall personal

information

Patient is responsive

Patient is responsive

Patient is responsive

130

Nurse: alam mo ba kung

nasaan ang Sorsogon?

Patient: sa Mindanao

Nurse: Naaalala mo pa ba ang

mga nangyari bago ka napunta

dito?

Patient: (looses focus, drowsy)

Nurse: Sino ang kasama mo

pagpunta mo dito?

Patient: (focus returned)

Nurse: J mag-usap pa tayo ha?

Patient: Opo.

Nurse: Okay ka pa?

patient to set the direction of

the conversation.

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Observation:

To help with awareness of

feelings, encourage

verbalization of feelings,

conveys concern and

interest.

Verbalizing Implied Thoughts

and Feelings

The nurse voices what the

patient seems to have

fairly obviously implied,

rather than what he has

actually said.

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Somnolence

The patient can’t justify

Piaget’s cognitive theory.

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

131

Patient: Opo.

Nurse: Inaantok ka ba J?

Patient: hindi po

Nurse: Napapagod ka na ba?

Patient: Hindi po.

Nurse: Nag-enjoy ka ba knina

J?

Patient: Opo (flat affect)

Nurse: Nag-exercise ka rin ba?

Patient: Opo

Nurse: Kamusta naman ang

pag-ehersisyo mo kanina J?

Patient: Okay lang po

Nurse: Sino pala ang kasama

no J pagpunta mo dito?

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should

recognize when to delve

further. If the patient

chooses not to elaborate,

the nurse should respect

the patient’s wishes.

Therapeutic:

Focusing:

It will help the client

expand on a topic

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties.

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should

recognize when to delve

further – she should refrain

from probing or prying. If

the patient chooses not to

elaborate, the nurse should

respect the patient’s

wishes. Probing usually

occurs when the nurse

processes to hypothetical

situations.

It is observable that the

patient has an

inappropriate affect

Some questions with

regards to personal

information can be

answered correctly by the

patient.

Flight of ideas

a nearly continuous flow

of rapid speech that jumps

from topic to topic, usually

based on discernible

associations, distractions,

or plays on words, but in

severe cases so rapid as to

132

Patient: Suseng

Nurse: Kaano-ano mo si

Suseng J?

Patient: nanay

Nurse: Nanay mo siya?

Patient: Opo

Nurse: Tapos ano ang

nangyari?

Patient: may red na bag, blue

Nurse: Tapos?

Patient: isang bag lang dala

ko, namin

Nurse: Ilang taon ka na dito?

Patient: lima

introduces a topic because

she is anxious.

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties.

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should

recognize when to delve

further – she should refrain

from probing or prying. If

the patient chooses not to

elaborate, the nurse should

respect the patient’s

wishes. Probing usually

occurs when the nurse

introduces a topic because

she is anxious.

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

be disorganized and

incoherent.

Patient is fixated with

certain numbers like 5 and

10.

When we feel safe and

secure in our world then

we begin to seek out

friendships in order to feel

a sense of belonging.

Maslow's third level, the

need for belonging and

love, focuses on our desire

to be accepted, to fit in,

and to feel like we have a

place in the world.

Persons may be called

both mentally retarded and

learning disabled, meaning

that their overall IQ is

lower than average, but

that they have strengths

and weaknesses on various

skills.

Cognitive development is

defined as thinking,

problem solving, concept

understanding, and

information processing

and overall intelligence.

133

Nurse: Si Suseng nasaan?

Patient: Doon

Nurse: Saan yung nanay mo J?

Patient: sa bahay, dun

Nurse: Sa Bitano?

Patient: Opo (nods)

Nurse: may mga gamot ka ba

na iniinom?

Patient: oo, kanina

Nurse: Ano daw yun J?

Patient: aspilit, isa lang

Patient: gamot, gamot,

(showed both arms)

Nurse: may asawa ka naba J?

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties.

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties

Therapeutic:

Acknowledging the patient’s

Feeling:

The nurse helps the patient

to know that his feelings

are understood and

accepted and encouraged

Many mentally retarded

clients have cognitive

weaknesses. Their overall

potential may be lower

than that of their peers and

siblings. They still have

patterns of strengths and

weaknesses in their

development and may do

very well with certain

types of learning.

Adaptive skills are the

skills needed for daily life

and include the ability to

produce and understand

language

(communication); home-

living skills; use of

community resources;

health, safety, leisure, self-

care, and social skills; self-

direction; functional

academic skills (reading,

writing, and arithmetic);

and work skills.

134

Patient: wala

Nurse: Nakatapos ka na ba ng

elementary o high school J?

Patient: oo, elementary

Nurse: Hanggang anong grade

natapos mo?

Patient: Grade 1

Nurse: ano pala palagi mo

ginagawa dito J?

Patient: Toothbrush (acting),

ligo, kain

Nurse: Tuwing umaga?

Patient: kain

Nurse: kapag hapon?

Patient: tulog

him to continue expressing

them. If communication is

to be successful, it is

essential that the nurse

accept the thoughts and

feelings her patient is

expressing.

Include the patient

You must remember that

patient care should be

collaborative and include

the patient in decision

making whenever

possible. The patient often

feels at the mercy of the

system, but you can help

him find ways to feel in

control.

135

Nurse: ano ang gusto mong

pagkain J?

Patient: monggo’

Nurse: ano ang kinain mo

kanina?

Patient: monggo

Nurse: Masarap ba J?

Patient: Opo

Nurse: ano ang mga ayaw mo

kainin?

Patient: monggo, kanin, apple

Nurse: Di ba sabi mo gusto

mo ng monggo knina?

Nurse: Usap ulit tayo bukas

ha!

Patient: Opo.

136

WORKING PHASE

Description of Phase:

At this point, the client’s problems are identified and solutions are explored,

applied and evaluated. The focus of the assessment and of the relationship is the client’s behavior

and the focus of the interaction is the client’s feelings.

Objective:

After the working phase, the nurse will be able to:

Explore relevant stressors for the patient

Promote patient’s development of insight and use of constructive coping

mechanisms

Overcome resistance behavior

Date/ Time/ Venue: November 26, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

NURSE-PATIENT

INTERACTION

RATIONALE OF THE

NURSE’S

COMMUNICATION

TECHNIQUE

ANALYSIS OF THE

PATIENT’S RESPONSE

Nurse: Magandang umaga sa

yo J!

Patient: Magandang umaga

din po.

Therapeutic:

Use names:

Using a person's name

makes her feel more

valued, and introducing

yourself is a basic step in

Patient is disoriented to

time, place and person

MEMORY AND

ATTENTION. Memory

137

Nurse: Ano ulit ang pangalan

ko J?

Patient: (Kran)

Nurse: Ran ako

Patient: Ran

Nurse: Kamusta naman ang

tulog mo J?

Patient: Maayos

Nurse: eh ang gising?

Patient: ayos

Nurse: Anong araw pala

ngayon J?

Patient: Martes

Nurse: J, Biyernes ngayon.

Ang petsa ay November 27,

2009.

establishing a therapeutic

interaction.

Therapeutic:

Help to orient

Illness and hospitalization

can be very disorienting

for patients.

Therapeutic:

Using Broad Opening

Statements:

The use of a broad

opening statement allows

the patient to set the

direction of the

conversation. Give the

patient an opportunity to

begin expressing himself.

In using a broad opening

statement, the nurse

focuses the conversation

directly on the patient and

communicates to him that

she is interested in him

and his problems. Upon

sensing that the patient

may have a need, the nurse

can use a broad opening

statement to initiate

discussion, while at the

same time allowing the

patient to determine what

will be discussed.

Therapeutic:

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

there is a lack in

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

The patient can’t justify

138

Nurse: Anong araw ang

sumunod sa Biyernes?

Patient: Martes

Nurse: Kung Biyernes ngayon,

ano ang araw bukas? Bukas

ay?

Patient: Martes

Nurse: Sabado bukas J.

Sundan mo ko ha.

Nurse: Lunes

Patient: Lunes

Nurse: Martes

Patient: Martes

Nurse: Miyerkules

Patient: Miyerkules

Giving Information

Studies have shown that a

major cause of anxiety or

discomfort in hospitalized

patients is lack of

information or

misconceptions about their

condition, treatment, or

hospital routines. When

the patient is in need of

information to relieve

anxiety, form realistic

conclusions, or make

decisions, this need will

often be revealed during

the interaction by

statements he makes. By

providing such

information as she

prudently can, admitting

and finding out what she

doesn’t know, or referring

the patient to someone

who can assist him, the

nurse can do much to

establish an atmosphere of

helpfulness and trust in her

relationship with the

patient.

Piaget’s cognitive theory

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

processes to hypothetical

situations.

139

Nurse: Huwebes

Patient: Huwebes

Nurse: Biyernes

Patient: Biyernes

Nurse: Sabado

Patient: Sabado

Nurse: Linggo

Patient: Linggo

Nurse: Anu-ano pala mga

ginawa mo ngayong umaga?

Patient: Kain, toothbrush, ligo

Nurse: Ano yung mga kinain

mo?

Patient: Spanish

Therapeutic:

Using Broad Opening

Statements:

The use of a broad

opening statement allows

the patient to set the

direction of the

conversation. Give the

patient an opportunity to

begin expressing himself.

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties.

Therapeutic:

Sharing Observations

The nurse shares with the

patient observations

regarding behavior. The

patient who has a need is

often unaware of the

source of this distress, or

reluctant to communicate

it verbally. However, the

tension or anxiety created

by his need creates energy

which is transformed into

some kind of behavior,

Patient is responsive.

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

processes to hypothetical

situations.

140

Nurse: Spanish bread?

Patient: Opo

Nurse: masarap ba?

Patient: Opo

Nurse: pag-usapan natin ang

drawing mo kanina.

Patient: iskindi (ice candy)

Nurse: ice candy yung

drawing mo?

Patient: Opo.

Nurse: Anong meron sa ice

candy at yun ang dinrawing

mo?

Ang ice candy ay?

Patient: matamis, lamig

Nurse: ano pa?

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties

Reflecting:

In reflecting, all or part of the patient’s statement is repeated to encourage him to go on. Reflecting can be overused, and the patient is likely to become annoyed if his own words or statements are continually repeated to him

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should recognize when to delve further – she should refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect the patient’s wishes. Probing usually

Patient is responsive and answers questions with comprehension.

MEMORY AND

ATTENTION. Memory

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

there is a lack in

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

141

Patient: tigas, tamis

Nurse: may naalala ka ba sa

ice candy?

Patient: (silence)

Nurse: paborito mo ba ang ice

candy?

Patient: Opo.

Nurse: ano ang paborito mo na

lasa ng ice candy?

Patient: monggo

Nurse: Anu-ano pala ang mga

kulay ng ice candy? Diyan sa

drawing mo J?

Patient: (Points on the lines

while identifying its colors,

with some mistakes)

Nurse: (corrects the mistakes)

Nurse: okay J, very well.

occurs when the nurse introduces a topic because she is anxious

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

MEMORY AND

ATTENTION. Memory

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

there is a lack in

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

142

Magaling!

Nurse: Nagtitinda ka ba dati

ng ice candy J?

Patient: Hu..

Nurse: Pagod ka na ba J?

Patient: Opo.

Nurse: Okay sige. Pahinga ka

na J. Hintayin lana muna natin

ang iba na matapos ha.

Patient: Opo.

143

TERMINATION PHASE

Description of Phase:

The nurse terminates the relationship when the mutually agreed goals are met, the

patient is discharged or transferred or the rotation is finished. The focus of this stage is the

growth that has occurred in the client and the nurse helps the patient to become independent and

responsible in making his own decisions. The relationship and the growth or change that has

occurred in both the nurse and the patient is summarized.

Objective:

During the termination phase, the nurse will be able to:

Establish reality of separation

Review progress of therapy and attainment of goal

Mutually explore feelings of rejection, loss, sadness, and anger and related

behaviors

Date/ Time/ Venue: December 3, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

Nurse-Patient Interaction Rationale of the Nurse’s Communication Technique

Analysis of the Patient’s Response

Nurse: Magandang umaga sa yo J.

Patient: Gandang umaga din po.

Nurse: Kumusta ang tulog mo?

Patient: Ok lang.

Therapeutic:

Use names

Using a person's name

makes her feel more

valued, and introducing

yourself is a basic step in

establishing a therapeutic

interaction.

The patient is conscious.

The patient talks rapidly.

Adaptive skills are the

skills needed for daily life

and include the ability to

produce and understand

language

144

Nurse: Maayos ba naman ang gising?

Patient: Opo.

Nurse: Anu-ano ang mga ginawa mo kanina?

Patient: toothbrush, ligo, kain

Nurse: Ano ang kinain mo J?

Patient: tinapay

Nurse: masarap ba J?

Patient: Opo.

Nurse: nabusog ka ba?

Patient: (nods)

Nurse: Pag-usapan natin J yung tungkol sa niyog. Ano nga ang mga parte ng niyog?

Patient: dahon

Nurse: Ahh. Magbigay ka nga ng isang gamit ng dahon.

Patient: bubong

Nurse: Ano pa J? Magsabi ka pa nga ng isang parte pa ng puno ng niyog?

Patient: puno

Nurse: Anong gamit ng kahoy ng niyog J?

Therapeutic:

Using Broad Opening

Statements:

The use of a broad opening statement allows the patient to set the direction of the conversation. Give the patient an opportunity to begin expressing himself.

Therapeutic:

Focusing:

It will help the client

expand on a topic

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should

recognize when to delve

further – she should refrain

from probing or prying. If

the patient chooses not to

elaborate, the nurse should

respect the patient’s

wishes. Probing usually

occurs when the nurse

introduces a topic because

she is anxious.

Therapeutic:

Sequencing:

Helps to identify cause and

effect, recurring pattern of

(communication); home-

living skills; use of

community resources;

health, safety, leisure, self-

care, and social skills; self-

direction; functional

academic skills (reading,

writing, and arithmetic);

and work skills.

Cognitive development is

defined as thinking,

problem solving, concept

understanding, and

information processing

and overall intelligence.

Many mentally retarded

clients have cognitive

weaknesses. Their overall

potential may be lower

than that of their peers and

siblings. They still have

patterns of strengths and

weaknesses in their

development and may do

very well with certain

types of learning.

MEMORY AND

ATTENTION. Memory

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

145

Patient: bahay.

Nurse: Oo. Ginagamit nga to sa paggawa ng bahay.

Nurse: Puwede ka bang magkuwento ng tungkol sa mga magulang at mga kapatid mo J?

Patient: …

Nurse: Namimiss mo ba sila J?

Patient: …

Nurse: Ano ulit pangalan nung nanay mo?

Patient: Suseng

Nurse: Ano naman ang pangalan ng tatay mo J?

Patient: Mario

Nurse: Ang mga kapatid mo? Naaalala mo ba mga pangalan nila?

Patient: Ricoy, Marichu

Nurse: Nasaan na sila ngayon J?

Patient: Ambot.

Nurse: Napaano pala yang mga sugat mo sa kamay J?

interpersonal difficulties.

Therapeutic:

Focusing:

It will help the client expand on a topic

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Acknowledging the patient’s

Feeling:

The nurse helps the patient

to know that his feelings

are understood and

accepted and encouraged

him to continue expressing

them. If communication is

to be successful, it is

essential that the nurse

accept the thoughts and

there is a lack in

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

processes to hypothetical

situations.

146

Patient: kadena

Nurse: Sino ang nagkadena sa yo J?

Patient: nanay

Nurse: Ano daw ang dahilan ni Suseng dahil kinadena ka nya? May nagawa ka ba na kasalanan?

Patient: Ambot lang.

Nurse: Ano pa ang mga nangyari J. Sige magkuwento ka pa. Makikinig ako.

Patient: Kinulong ako.

Nurse: Kinulong ka J?

Patient: …

Nurse: Ano ang naramdaman mo?

Patient: Nagalit.

Nurse: Kanino ka nagalit?

Patient: Suseng

Nurse: Tapos ano na ang nangyari?

Patient: Ambot.

Nurse: J huling beses na pala kita makakausap ng ganito.

Patient: …

feelings her patient is

expressing.

MEMORY AND

ATTENTION. Memory

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

there is a lack in

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

147

Nurse: Socialization na bukas at huling araw na rin na pupunta ako dito bukas.

Patient: ….

Nurse: May gusto ka pa ba na sabihin o ikuwento sa akin?

Patient: Wala na.

Nurse: Sige J. Hintayin na lang natin ang iba na matapos.

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

processes to hypothetical

situations.

148

B. List of Prioritized Psychiatric Nursing Diagnosis

NURSING DIAGNOSIS RANK RATIONALE

Disturbed Thought Processes

related to developmental delay of

cognition as evidenced by

cognitive dissonance

1

Based on Carl Jung's Theory of

Psychological Types, perception involves all

the ways of becoming aware of things,

people, happenings, or ideas. Judgment

involves all the ways of coming to

conclusions about what has been perceived.

If people differ systematically in what they

perceive and in how they reach conclusions,

then it is only reasonable for them to differ

correspondingly in their interests, reactions,

values, motivations, and skills.

Impaired Verbal Communication

related to impaired cognitive

abilities as evidenced by loose

association of ideas

2

According to Karen Horney’s Theory on

Personality, moving away from people: The

final possible consequence of a neurotic is a

personality style filled with a social behavior

and an almost indifference to others. If they

don't get involved with others, they can't be

hurt by them. While it protects them from

emotional pain of relationships, it also keeps

away all positive aspects of relationships. It

leaves them feeling alone and empty.

Impaired Social Interaction

related to impaired thought

processes as evidenced by

dysfunctional interaction with

others

3

According to Sullivan’s Interpersonal

Theory, the need for friendship and need for

sexual expression get combined during late

adolescence. In this stage a long term

relationship becomes the primary focus.

Conflicts between parental control and self-

expression are commonplace and the overuse

of selective inattention in previous stages can

result in a skewed perception of the self and

149

the world.

Self-Care Deficit, Bathing and

Hygiene related to mental delay

as evidenced by inability to bathe

himself

4

Dorothea E. Orem's Self-Care Deficit

Nursing Theory states that nursing is

required because of the inability to perform

self-care as the result of limitations.

Risk for Injury related to delayed

developmental age5

Self-harm is listed in the Diagnostic and

Statistical Manual of Mental Disorders

(DSM-IV-TR) as a symptom of borderline

personality disorder and depressive

disorders.

Because of a delay on the gross and fine

motor skills, as well as how the patient

perceives things and events, the patient is at

great risk of physical injury.

150

PSYCHIATRIC NURSING CARE PLAN

Cues / CluesPsychiatric Nursing

Diagnosis

Psychodynamics

(RATIONALE)PLANNING Therapeutic Approach

RATIONALE

(with Theories)EVALUATION

Subjective Cue:

When asked about the day, the patient verbalized “Sabado”, mistaken it for Thursday, even if initially oriented.

Objective:

GA:

Loosing eye contact Inappropriate affect-

flatMotor Behavior:

Waxy flexibilitySensory & Cognition:

Conscious but disoriented to time, person & place

Impaired memory on personal information

Poor focus regarding specific topic

Attitude:

Disturbed Thought Processes related to

developmental delay of cognition as

evidenced by cognitive dissonance

Risk factors are socioeconomic &

biochemical

Neurologic developmental

failure

Alteration of function in

cognitive and perceptive fields

Inaccurate interpretation of

Short term outcome:

After 8 hours of nursing intervention, the pt will be able to :

Reduce disorientation to time, place, person, and situation.

Interact with others appropriately.

Assist in assuming self-care responsibilities to the limits of his ability.

Participate in social activities and group therapies

A. INDEPENDENT:1. Assess degree of

disorientation to time, place, person, and situation regularly and frequently.

2. Providing general leads

a. Approach the client in slow, calm, matter-of-fact manner

b. Maintain facial

1. This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills.

2. A calm approach helps to avoid distorting the client’s sensory perceptual field which helps could promote disturbed thoughts and perceptions. The client with disturbed thought process may have difficulty in interpreting correct

Outcome Achieved:

The patient reduced disorientation to time, place, person, and situation.

The patient interacted with others appropriately.

The patient assisted in assuming self-care responsibilities to the limits of his ability.

The patient participated in social activities and group therapies

151

handily cooperative Withdrawn Perplexed apathetic

Affect:

Flat affect Anxious

Thought Process: looseness of

association blocking perseveration

Altered perceptions of surrounding stimuli caused by impairment in the following cognitive processes:

Memory Judgment Comprehension Concentration

Inability to reason, problem solve, calculate, and conceptualize

incoming information

Disturbed thought process

expression and behaviors that are consistent with verbal statements

3. Giving information

a. Offer the client clear, simple explanations of environmental events, activities and the behaviors of other clients as necessary

B. COLLABORATIVE

1. Continue to administer and monitor the effects of the prescribed medication

haloperidol

meanings if the nurse misrepresents intent with a conflicting or double message.Peplau defined Psychodynamic Nursing as being able to understand one’s own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience.

3. Clear direct explanations of environment events help to lessen the client’s suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior. According to Sullivan, the strand of interpersonal theory is the principle of complementarities which contends that people in dyadic interactions negotiate the definition of their relationship through verbal and non-verbal cues.

Haloperidol may cause dehydration. Assessing I/O is important.

PSYCHIATRIC NURSING CARE PLAN

152

Cues / CluesPsychiatric Nursing

Diagnosis

Psychodynamics

(RATIONALE)PLANNING Therapeutic Approach

RATIONALE

(with Theories)EVALUATION

Subjective Cue: (conversation between the nurse and the patient)

Nurse: Ilang taon ka na pala J?

Patient: Napulo

Nurse: Anong taon nuong ipinanganak ka?

Patient: Marso

Nurse: Ano ang birthday mo? Kelan ka ipinanganak?

Patient: Hulyo, Agosto

Objective:

Impaired Verbal Communication

related to impaired cognitive abilities as evidenced by loose association of ideas

Risk factors are socioeconomic &

biochemical

Neurologic developmental

failure

Alteration of function in

cognitive and perceptive fields

Inaccurate interpretation of

incoming information

Short term outcome:

After 8 hours of nursing intervention, the pt will be able to :

Use a form of communication to get needs met and to relate effectively with persons and his or her environment.

Demonstrate congruent verbal and non-verbal communication

Participate in social activities and group therapies

C. INDEPENDENT:4. Assess degree of

disorientation to time, place, person, and situation regularly and frequently.

5. Giving information

b. Offer the client clear, simple explanations of environmental

4. This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills.

5. Clear direct explanations of environment events help to lessen the client’s suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior. According to Sullivan, the strand of interpersonal theory is the principle of complementarities which contends that people in dyadic interactions negotiate the definition of their relationship through verbal and non-verbal cues.

Outcome Achieved:

The patient used a form of communication to get needs met and to relate effectively with persons and his or her environment.

The patient demonstrated congruent verbal and non-verbal communication

The patient participated in social activities and group therapies

153

Sensory & Cognition:

Conscious but disoriented to time, person & place

Impaired memory on personal information

Poor focus regarding

specific topic

Attitude:

WithdrawnThought Process:

looseness of association

blocking perseveration inability to recall

familiar words, phrases, or names of known persons, objects, and places

impaired cognitive abilities

inability to recall familiar words,

phrases, or names of known persons, objects, and places

events, activities and the behaviors of other clients as necessary

6. Anticipate patient needs and pay attention to nonverbal cues.

7. Give the patient ample time to respond.

8. Face the patient when communicating with them, listen and watch them closely

9. Pay attention to their voice inflection and body cues

10. Always speak to the patient in a calm even voice

11. Allow the patient

6. The nurse should set aside enough time to attend to all of the details of patient care. Care measures may take longer to complete in the presence of a communication deficit. Peplau defined Psychodynamic Nursing as being able to understand one’s own behavior to help others identify felt difficulties and to apply principles of human relations to the problems that arise at all levels of experience.

7. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations.

8. 5to9. Humanistic Nursing Communication Theory (Theorist: Bonnie W. Duldt, Ph.D., R.N.) In an interpersonal relationship of trust, self-disclosure, and feedback, to the degree that dehumanizing communication attitudes are expressed by another, to that degree one tends to use assertiveness as a pattern of interaction. To the degree that assertiveness tends not to re-establish trust, self-disclosure, and feedback, and to the degree that dehumanizing attitudes are expressed by another, to that degree one tends to use assertiveness as a pattern of

154

time to complete what they are saying

12. Provide encouragement and reassurance to the patient at all times when they are attempting to communicate with you

COLLABORATIVE

Refer to speech therapy for assistance in understanding patient's speech patterns

To promote wellness and assistance.

PSYCHIATRIC NURSING CARE PLAN

Cues / CluesPsychiatric

Nursing Diagnosis

Psychodynamics

(RATIONALE)PLANNING Therapeutic Approach

RATIONALE

(with Theories)EVALUATION

Subjective Cue:

“Hindi ko sila kilala” (referring to his fellow patients), as verbalized

by the patient.

Impaired Social Interaction related to

impaired thought processes as evidenced by dysfunctional

Risk factors are socioeconomic &

biochemical

Short term outcome:

After 8 hours of nursing intervention, the pt will be able to :

D. INDEPENDENT1. Encourage client to verbalize

feelings of discomfort about social situations. Identify causative factors, recurring precipitation patterns, and barriers to using support systems

According to Hildegard Peplau, psychodynamic nursing involves the use of one's (the nurse) knowledge and understanding of one's own behavior to help others (patients) identify felt difficulties, and the application of

Outcome Achieved:

1. The patient established a therapeutic

155

Objective:

Sensory & Cognition:

Conscious but disoriented to time, person & place

Impaired memory on personal information

Poor focus regarding specific topic

Attitude:

WithdrawnAffect:

AnxiousThought Process:

looseness of association

blocking perseveration

interaction with others

Neurologic developmental failure

Alteration of function in cognitive and perceptive fields

Disturbed thought process

Dysfunctional interaction with

others

1. Establish a therapeutic relationship with the nurse.

2. Identify barriers in interpersonal relationships that interfere with socialization.

3. Participate in social activities and group therapies

2. Establish therapeutic relationship using positive regard for the client, active listening and providing safe environment for self-disclosure

human relations to problems that arise at all levels of experience (Carey, Noll, Rasmussen, Searcy, and Stark, 1989, p. 205). This interpersonal process is defined by Peplau in the context of four phases of the nurse-patient relationship-orientation, identification, exploitation, and resolution. Although each phase of this relationship is defined separately, Peplau recognized that considerable overlap existed between the phases.

Peplau: During the orientation phase of the nurse-patient relationship, the patient experiences a felt need and seeks professional assistance from the nurse. During this phase, the nurse tries to help the patient in both recognizing and understanding the problem that he or she is experiencing. During the orientation phase, also, the nurse attempts to determine exactly what help is needed by the patient.

Ida Jean Orlando, The Dynamic Nurse-Patient Relationship:The role of the nurse is to find out and meet the patient's immediate need for help. The patient's presenting behavior may be a plea for help; however, the help needed may not be what it appears to be. Therefore, nurses need to use their perception, thoughts about the perception, or the feeling engendered from their thoughts to explore with patients the meaning of

relationship with the nurse.

2. The patient identified barriers in interpersonal relationships that interfere with socialization.

3. The patient participated in social activities and group therapies

156

3. Review/list behaviors observed previously by caregivers, care workers, and so forth

4. Provide positive reinforcement for improvement in social behaviors

5. Encourage classes, reading materials, and lectures for self-help in alleviating negative self-concepts that lead to impaired social interaction

E. COLLABORATIVE6. Involve client in a music-based

program, if available

their behavior. This process helps the nurse find out the nature of the distress and what help the patient needs.

There is a direct correlation between the musical portion of the brain and the language area, and the use of this programs may result in better communication skills

157

CHAPTER

VPSYCHOTHERAPY

158

A. Play Therapy

Definition Kahulugan

Play therapy refers to a method of

psychotherapy in which a therapist uses the

symbolic meanings of his or her play as a

medium for understanding and communication

with the client.

Ang play therapy ay isang uri ng

psychotherapy kung saan ang partisipasyon ng

pasyente ay maaring gawing isang obserbasyon

ng nars at maaari din itong magsilbing tulay

upang makausap ng nars ang pasyente.

Purposes Mga Layunin

To improve social and emotional

adjustment of the patient

To reduce stress and anxiety

To improve the self-concept

To learn to trust

To learn to complete, cooperate and

collaborate

Mapaunlad ang pakikipagsalamuha ng

pasyente sa ibang tao.

Mabawasan ang stress at takot ng mga

pasyente.

Matulungan ang pasyente sa

pagpapabuti ng tingin sa sarili

Matuto ang pasyente na magtiwala sa

sarili at sa ibang tao

Matuto ang pasyente na

makipagtulungan sa iba

159

HOT POTATO

Standard Rules Mga Patakaran

1. It involves players gathering in a circle

and tossing a small object such as a

beanbag or tennis ball to each other while

music plays

2. The player who is holding the "hot

potato" when the music stops is out.

3. Play continues until only one player is

left.

1. Uupo ng paikot ang mga kasali ng laro.

Habang tumutugtog ang musika,

pagpapasapasahan ng mga kasali ang

bola ng paikot.

2. Kung sino ang makakahawak ng bola

sa pagtigil ng musika ay matatanggal sa

bilog.

3. Magpapatuloy ang laro hanggang sa isa

nalang ang matira. Ang natira ang

pangangalanang panalo.

TechniquesPamamaraan

1. The nurse must first explain to the

patient what particular activity they are

going to perform. Trust should be

developed during this stage.

2. The patient must be given an

opportunity to perform the activity.

3. During the activity, never forget to talk

to your patient using therapeutic ways

of communication.

1. Dapat ipaliwanag muna ng nars kung

anu-anong mga gawain ang kanilang

gagawin. Ang pagtitiwala ay dapat

mabuo sa panahong ito.

2. Ang pasyente ay dapat mabigyan ng

pagkakataong gawin ang gawain.

3. Huwag kalimutang kausapin ang

pasyente habang may gawain. Palaging

gumamit ng mga therapeutic na

pamamaraan ng pakikipag-usap.

ANALYSIS ANALISA

Patient is interacting with other

patients/playmates.

He has a flat affect during the

games’ implementation

Ang kliyente ay nakikipag-ugnayan

sa ibang kalahok sa laro.

Ang kliyente ay nagpakita ng hindi

ukmang emosyon.

INTERPRETATION INTERPRETASIYON

160

Flat and inappropriate affect is

really observable to patients with

mental retardation.

It is not obviously observed that the

patient enjoys what he is playing

even if he told it so.

Ang hindi ukmang emosyon ng

mukha ay normal na makikita sa

mga kliyenteng may kakulangan sa

pag-iisip.

Hindi masasabing masaya ang

kliyente kahit na sinabi pa niya na

natututwa siya.

161

B. Music & Art Therapy

Definition Kahulugan

Music Therapy is a research-based health

profession in which music activities are

designed to accomplish non-musical

therapeutic goals with clients of all ages

and abilities in a non-threatening

environment.

Ang music therapy ay isang propesyong

pangkalusugan na base sa pananaliksik

kung saan ang mga pangmusikang gawain

ay idinisenyo upang magawa ang mga di-

musika panterapeutikang hangarin sa mga

kliyenteng may iba’t ibang edad at

kakayahan sa isang hindi mapanganib na

kapaligiran

Purposes Layunin

cognitive stimulation 

coping skills 

enhanced development 

mood elevation 

to reduce pain and anxiety

increase compliance

reinforce progress

normalization of environment

reality orientation

rehabilitation of physical and

cognitive abilities

socialization 

pagbibigay-buhay sa pag-unawa

kasanayan na makaya

pinaghusay na pag-unlad

mapataas ang timpla ng damdamin

upang mabawasan ang sakit at

pagkabalisa

dagdagan ang pagsunod

mapalakas ang pag-unlad

normalisasyon ng kapaligiran

orientasyon sa realidad

pagbabagong-tatag ng mga pisikal

na pag-unawa at mga kakayahan

pagsasapanlipunan

Standard Rules Mga Patakaran

162

1. Provide planned schedule of

activities which aids patients in

dwelling personal problems.

2. Provide opportunity for gaining

attention in acceptable ways.

3. Provide an opportunity for the

development of healthy and

productive interest.

4. Provide planned acceptable outlet

for pension and hostility.

1. Magbigay ng mga pinlanong

gawain na makatutulong upang ang

pasyente ay makaya ang kanyang

mga personal na problema.

2. Magbigay ng pagkakataong

makakuha ng atensyon sa

katanggap-tanggap na paraan.

3. Magbigay ng pagkakataong

makabuo ng malusog at maunlad na

interes.

4. Magbigay ng katanggap-tanggap

na gawain kung saan kanilang

mailalabas ang kanilang mga sama

ng loob.

Technique Pamamaraan

1. The nurse must first explain to the

patient what particular activity they

are going to perform. Trust should

be developed during this stage.

2. The patient must be given an

opportunity to perform the activity.

3. During the activity, never forget to

talk to your patient using

therapeutic ways of communication.

4. Dapat ipaliwanag muna ng nars

kung anu-anong mga gawain ang

kanilang gagawin. Ang pagtitiwala

ay dapat mabuo sa panahong ito.

5. Ang pasyente ay dapat mabigyan ng

pagkakataong gawin ang gawain.

6. Huwag kalimutang kausapin ang

pasyente habang may gawain.

Palaging gumamit ng mga

therapeutic na pamamaraan ng

pakikipag-usap.

163

ART THERAPY

Definition Kahulugan

Art therapy is a form of expressive

therapy that uses art materials, such as

paints, chalk and markers. Art therapy

combines traditional psychotherapeutic

theories and techniques with an

understanding of the psychological aspects

of the creative process, especially the

affective properties of the different art

materials.

Ang art therapy ay isang anyo ng therapy

nagpapahayag na gumagamit ng mga

materyal sa sining, tulad ng mga pintura,

tisa at pang-marka. Ito ay nagsasanib ng

tradisyonal na teoryang psychotherapeutic

at pamamaraan ng pag-unawa sa

sikolohikal na aspeto ng malikhaing

proseso, lalo na sa emosyonal na pag-aari

ng iba’t ibang mga materyales na art.

Purposes Layunin

Self-discovery

Triggers an emotional catharsis

Personal fulfillment

Empowerment

Relaxation and stress relief

Symptom relief and physical

rehabilitation

Can help people visually express

emotions and fears that they cannot

express through conventional

means, and can give them some

Madiskubre ang sarili

Nagsasanhi ng isang emosyonal na

katarsis

Pangsariling Katuparan

Empowerment

Nagdadala ng ginhawa at

nagtatangal ng stress

Kaluwagan sa sintomas at pisikal na

rehabilitasyon

Maaari matulungan nito ang mga

tao sa pamamagitan ng biswal na

pagpapahayag ng damdamin at

takot na hindi nila maaaring

ipahayag sa pamamagitan ng

164

sense of control over these feelings pakikipagtalastasan at maaaring

magbigay sa kanila ng ilang pag-

unawa at kontrol sa kanilang mga

damdamin

Standard Rules Mga Patakaran

1. Art materials and techniques should

match the age and ability of the client.

Ang materyales at pamamaraan ay

dapat na tumugma sa edad at

kakayahan ng mga kliyente.

Technique Pamamaraan

1. The therapist may have an

introductory session with the client-

artist to discuss art therapy techniques

and give the client the opportunity to

ask questions about the process.

2. The therapist ensures that appropriate

materials and space are available for the

client-artist, as well as an adequate

amount of time for the session.

3. An appropriate workspace should

be available for the creation of art.

4. The artist should have adequate

time to become comfortable with and

explore the creative process.

1. Ang therapist ay maaaring

magkaroon ng isang pambungad na

introduksyon sa kliyente upang

talakayin ang mga pamamaraan sa art

therapy at bigyan ang client ng

pagkakataon upang magtanong tungkol

sa proseso.

2. Ang therapist ay tinitiyak na angkop

ang materyales at espasyo na gagamitin

ng kliyente. Sapat din dapat ang dami

ng oras para sa sesyon

3. Isang sapat na espasyo ang dapat

gamitin para sa paglikha ng sining.

4. Ang pintor ay dapat magkaroon ng

sapat na panahon upang maging

komportable at siyasatin ang mga

malikhaing proseso.

165

ANALYSIS ANALISA

The patient draws straight

lines with the colors of green,

black, red, orange and yellow

He said that those are ice

candies.

Gumuhit siya ng mga tuwid

na linyang may mga kulay na

berde, itim, pula, dalandan, at

dilaw.

Sabi niya na ito raw ay mga

ice candies.

INTERPRETATION INTERPRETASIYON

The patient may have a very

memorable experience with

regards to ice candies.

Red line indicates hostility,

black for anxiety, red and

yellow for spontaneous form

of expression and behaviour,

black represents repression,

depression and regression

The patient’s dominant

interpreted behaviour is being

anxious and depressed at that

moment

Maaaring mayroong isang

mahalagang pangyayari sa

buhay niya na kasama sa

memorya ang ice candies.

Base sa iginuhit ng pasyente,

malalaman na siya ay balisa.

166

C. Bibliotherapy

ENGLISH TAGALOG

  a. Definition

                        Bibliotherapy is a therapy

employed in which literature is used as a

stimulus to initiate expression of emotions.

b. Purpose

The printed word may be a means of

modifying or stimulating the emotions.

Reading may help lift the spirit of a depressed

patient, improve the attention span of the

individual with limited power of concentration,

relieve insomnia, stimulate the imagination,

and foster desirable attitudes and in patients.

c. Standard Rules

                        Principles in Selecting Reading

Materials for Psychiatric Patients:

                        a. Select literature in accordance

with the patient's educational preparation,

a.Kahulugan

Ang bibliotherapy ay ang paggamit ng

babasahin para makatulong sa pagpapalabas ng

mga emosyon.

Ang babasahin ay pwedeng gamitin upang

mabago o makapagpahayag ng emosyon. Ang

pagbabasa ay makakatulong sa pagpapataas ng

mababang emosyon ng tao, makatulong sa

pagkakaroon ng pokus, makakatulong kapag

hindi makatulog ang isang tao, mapalawak ang

imahinasyon at makatulong sa pagkakaroon ng

kanainis-nais na katangian ng isang pasyente.

-sa pagpili ng babasahin:

167

intellectual capacity and interest.

                        b. Size up the personality of the

patient and attempt to select materials which

you think may be interesting.

                        c. Avoid literature of

controversial nature or the type whose attempt

to stir up feeling of distress within the patient.

Literature concerning medicine, psychology,

psychiatric, politics, and tense murder

mysteries may do patients more harm than

good.

                        d. For educational reading,

choose books recommended by reliable

authorities.

                        e. History, travel, art, science,

biography, and literature concerning hobbies

are usually interesting subjects his most

patients.

d. Techniques/Mechanics

Literature, such as magazines, books and other

reading materials, is offered to the patient. Let

his view it and asks her what part catches his

attention most then the therapist to explore

more about the patient's emotions and feelings.

a. dapat pumili ng babasahin na angkop sa

kakayahang mental ng pasyente. Dapat ito

ibatay sa kakayahan ng pasyenteng

maintindihan ang nilalaman ng babasahin.

b. mamili ng babasahin na makakakuha ng

atensyon ng isang tao.

c. huwag pilliin ang babasahin na magdudulot

ng stress sa pasyente. Dapat ang nilalaman ay

hidi tungkol sa pulitika, mga kalamidad, mga

karahasan at iba pa dahil ito’y magdudulot ng

hindi maganda.

d. sa mapagkakatiwalaan lamang kumuha ng

babasahing gagamitin sa therapy

e. kasaysayan, paglalakbay, art, siyensya, mga

istorya ng buhay ng mga tao at literatura ay

mga kanais-nais na babasahin na gusto

karaniwan ng mga pasyente.

Ang mga babasahin ay ibinibigay sa pasyente.

Tatanungin sa pasyente kung ano ang kanyang

pananaw at kung ano ang kanyang masasabi

tungkol doon. Ang therapist ay maaaring

maunawan at makilala ang pasyente sa

pamamagitan nito dahil nakapaglalabas ang

pasyente ng kanyang emosyon.

168

ANALYSIS ANALISA

Not done Hindi naisagawa

INTERPRETATION INTERPRETASIYON

Not done Hindi naisagawa

169

D. Occupational Therapy

Definition: Kahulugan:

It is any productive, creative activity.

These activities are individualized

depending on the client’s need and may

range from individual or group tasks. The

major concern is the maximization of an

individual’s performance in relation to

cultural, social and work environment.

Ito ay ang mga gawaing maunlad at

malikhain. Ang mga gawaing ito ay

ibabase sa pangangailangan ng pasyente at

maaaring gawin ng mag-isa o ng grupo.

Ang layunin nito ay magamit ng indibidwal

ang pinakamataas na antas ng kanyang

makakaya na may relasyon sa kanyang

kultura, pakikisama sa ibang tao at

kapaligiran.

Purposes: Layunin:

1. To provide work training to the

patient.

2. To learn money management and

daily living skills.

3. To develop more positive group

training skills.

4. To help the patient succeed in the

chosen occupational role.

1. Upang makapagbigay ng mapag-

aaralang trabaho para sa pasyente.

2. Upang matutunan ang paghawak ng

pera at ng mga pang-araw-araw na

gawain.

3. Upang magkaroon ng panggrupong

pag-eensayo ng kakayahan na

positibo.

4. Upang matulungan ang pasyenteng

umunlad sa kanyang napiling

mapagkakakitaan.

170

5. To keep mind active and creative at

any rate.

6. To develop interpersonal

relationships with other patients.

7. To increase sense of

accomplishments, satisfaction and

control over one’s life.

8. To develop interdependence.

5. Upang mapanatiling aktibo at

malikhain ang pag-iisip.

6. Upang makabuo ng magandang

relasyon sa ibang pasyente.

7. Upang madagdagan ang pagiging

bilib sa sarili, pagiging kontento at

ang pagpapalakad ng sariling

buhay.

8. Upang magkaroon ng malusog na

pagdepende sa iba.

Standard Rules: Mga Patakaran:

5. Provide planned schedule of

activities which aids patients in

dwelling personal problems.

6. Provide opportunity for gaining

attention in acceptable ways.

7. Provide an opportunity for the

development of healthy and

productive interest.

8. Provide planned acceptable outlet

for pension and hostility.

5. Magbigay ng mga pinlanong

gawain na makatutulong upang ang

pasyente ay makaya ang kanyang

mga personal na problema.

6. Magbigay ng pagkakataong

makakuha ng atensyon sa

katanggap-tanggap na paraan.

7. Magbigay ng pagkakataong

makabuo ng malusog at maunlad na

interes.

8. Magbigay ng katanggap-tanggap

na gawain kung saan kanilang

mailalabas ang kanilang mga sama

ng loob.

Technique: Pamamaraan:

4. The nurse must first explain to the

patient what particular activity they

are going to perform. Trust should

be developed during this stage.

7. Dapat ipaliwanag muna ng nars

kung anu-anong mga gawain ang

kanilang gagawin. Ang pagtitiwala

ay dapat mabuo sa panahong ito.

171

5. The patient must be given an

opportunity to perform the activity.

6. During the activity, never forget to

talk to your patient using

therapeutic ways of communication.

8. Ang pasyente ay dapat mabigyan ng

pagkakataong gawin ang gawain.

9. Huwag kalimutang kausapin ang

pasyente habang may gawain.

Palaging gumamit ng mga

therapeutic na pamamaraan ng

pakikipag-usap.

ANALYSIS ANALISA

The patient cooperates with the

task given to him with moderate

assistance.

He tried to process how the

parts of the lantern will be

made.

Siya ay nakikipag-tulungan sa

studyante sa paggawa ng parol

at nakakagawa ng may sapat na

gabay ng studyante.

Sinubukan ng pasyente na

iproseso kung paano ang

paggawa ng parol na gamit ay

papel.

INTERPRETATION INTERPRETASIYON

It is clear, then, that there are

deficits in some aspects of

information processing in

individuals with mental

retardation.

Makikita na mayroong

kakulangangan sa ibang aspeto

ng pagproseso ng impormasyon

ang naobserbahan sa pasyente.

172

E. Remotivation Therapy

Definition: Kahulugan:

It is a simple group therapy which aims

to bridge the fantasy world of the

psychotics to the real world. It is a

technique of simple group therapy,

objective in nature, used with group of

patients in an effort to reach the

unwounded areas of each patient’s

personality and get them moving back into

reality

Isang simpleng gawaing panggrupo na

kung saan nilalayon nito na ipakita ang

realidad. Isa itong pamamaraan na

kadalasang napapatungkol sa kalikasan na

kung saan hindi nito naabala ang mga sugat

sa buhay ng isang tao bagkus ay pinapakita

nito ang realidad ng buhay.

Purposes: Layunin:

1. To stimulate patients to be fellow

explore the real world.

2. *To develop their ability t

pagkilalao communicated and share

ideas and experiences with the other

people.

3. *To develop feelings of acceptance.

4. *To promote group harmony and

identification.

9. upang mahikayat ang mga pasyente

na lakbayin ang tunay na mundo

10. upang madebelop ang abilidad na

makisalamuha sa mga tao at

maibahagi ang kanilang mga ideya

sa mga ito.

11. Upang madama ang pagtanggap

12. Para magkaroon ng maayos na

pakikisama sa sriling grupo at

magkaroon ng pagkilala sa sarili.

Standard Rules: Mga Patakaran:

173

1. .climate acceptance

2. bridge to reality- questions must be

short and easy to understand

3. sharing the world we live in-explore

the topic

4. appreciation of the works of the

world-application of the topic

5. Summarize the topic, subjects to be

covered:

Geography, history, Literature, Science,

Industry, Sports, Hobbies, Nature

6. Subjects not to be touched:Religion,

Politics, Family, Problem, Sex, love

9. Pagtanggap sa klima

10. Tulay sa relidad-. Ang mga tanong

ay nararapat na maikli at madaling

intindihan.

11. Pagbabahagi sa kanila ng mundong

ating tinitirhan – palawakin ang

paksa.

12. Pagkagalak sa mnga gawa ng

mundo- paggamuit ng paksa

13. Ibuod ang paksa , ang mga paksa na

maaring gamitin ay ang mga

sumusunod:

Heyograpiya, kasaysayan, panitikan ,

siyensiyna , kapaligiran, laro, hilig.

14. Mga paksang hindi nararapat na

talakayin:

Relihiyon, politika, pamilya, problema,

pakikipagtalik at pag-ibig

Technique: Pamamaraan

7. The nurse must encourage clients

feeling about the topic

8. The nurse must present the reality

to the client.

9. Be natural•

10. Approach in non-urging

relationship•

11. Don’t side-track into individual

conversation

1. Nararapat na iengganyo ang

pasyente sa paksang tatalakayin

2. Kailangang ipakita ang realidad sa

pasyente

3. Maging natural

4. Huwag silang pilitin

5. Huwag makielam sa isang usapan.

ANALYSIS ANALISA

The patient is not paying

attention to the speakers while

they are speaking sometimes

Hindi siya nakikinig minsan

Inuulit ng pasyente ang

anumang kakarinig niya lang

kapag siya ay tinanong

174

Echolalia was observed

Somnolence was observed

Inaantok ang pasyente

INTERPRETATION INTERPRETASIYON

Memory deficiencies interfere with

learning rote material such as days of

the week, months of the year, and times

tables. Basic facts are hard to remember

and there is a lack in knowledge of

general information. There are deficits

in attention and focus that interfere with

ability to focus and concentrate on

tasks.

Mahina ang memorya ng

pasyente. May kakulangan din

sa pagtuon ng atensiyon at

pokus ang pasyente.

175

APPENDICES

176

177

National Center for Mental HealthMandaluyong City

Pavilion 1

GRAND SOCIALIZATION DAY

Theme: “Building Bridges towards Holistic

Nursing Care”

_________________

177

Acknowledgement:

Food – Far Eastern University(Jay Nantin Ablao R.N)

Invitation- Centro Escolar University (Dovie Brabante R.N)

Sounds –Metropolitan Medical Center(Precy Samson R.N)

Decorations and Aftercare – LORMA Colleges

(Ever C. Garcia Jr. R.N, MSN)

Games – Capitol University(Honeylou Opanda R.N)

Perpetual Help University of Pangasinan

(Ignacia Mogro R.N)

PROGRAMME...

Doxology …………Metropolitan Medical Center Philippine National ……...Perpetual Help Anthem University of Pangasinan

Calisthenics …………… Capitol UniversityOpening Remarks ……………Ever C. Garcia, R.N. MSNYell and Dance ……………… All Schools PresentationGames ……………………Capitol UniversityDance for all……………….Closing Remarks ……………Evelyn Godines, Nurse Supervisor Pavilion 1