History taking - clinical and neuropsychology

1. Internship in Clinical and
Neuropsychology
Day 1

2. Intellectual Disability in the context of
RPWD act, 2016

3. Defining ID as per RPWD act, 2016
• Intellectual disability, a condition characterized by significant
limitation both in intellectual functioning (reasoning, learning, and
problem-solving) and in adaptive behavior which covers a range of
day-to-day, social, and practical skills

4. Intellectual Functioning as per RPWD act, 2016
• Like ICD-10, it has adopted the IQ cutoff of 70 for ID, and the same
terminology to denote severity levels, but with different cutoffs.
• The severity levels are based on the scores of the Vineland Social
Maturity Scale (a standardized, normative measure adaptive behavior
scale)
• Profound disability=0-20 (100%)
• Severe=21-35 (90%)
• Moderate=36-54 (75%)
• Mild=55-69 (50%)
• Borderline=70-84 (25%)

5. Adaptive behaviour as per RPWD act, 2016
• Adaptive behavior is not defined but is understood to cover a range of
day-to-day, social, and practical skills Scores on Vineland Social
Maturity scale (a standardized, normative measure adaptive behavior
scale) are considered to define the severity of ID

6. Clinical presentation of
Intellectual disability

7. • Delayed milestones of development,
• Poor ability to learn new things,
• Poor speech and comprehension,
• Poor self-help skills, poor school performance, poor memory
• Behaviour problems such as restlessness, poor, concentration,
impulsivity. self
• injurious behavior, stereotypy, sleep/ appetitè disturbances

8. Goals of history taking in ID

9. • To establish whether Intellectual disability is present or not (If child is
lagging behind in his cognitive, social and developmental aspects).
• To ascertain the degree, cause, associated problems and family and
psycho-social factors in the child’s environment
• To plan assessment and interventions for the child.
• To foster the child’s socio-occupational functioning through
rehabilitation services.

10. Method of history taking

11. 1. Socio-demographic details
• Name
• Age
• Sex
• Fathers name
• Education
• Religion
• Mother tongue
• Residence
• SES
• Why??
• For MLC, Disability
certification.
• To plan assessment and
rehabilitation.
• To understand the socio-cultural
background of the child in order
to attempt to understand
etiological factors.

12. 2. Complains
• With duration and evolution of current
problems
• Eg:
Since 2 yrs
• Doesn’t respond to parents
• Unable to hold his head still
Since last 1 year
Unable to walk without support
Since last 6 months
Cannot speak in words
Irritation

13. 3. Family history
• 3 generations genetic diagram
• Family history of ID, Epilepsy
and other developmental
problems, early deaths etc.
• Family background
• Current living arrangements
• Details of stress and coping and
adaption by family

14. 4. Personal history
• pre-, peri, and postnatal details,
• Developmental milestones, &
developmental course or trajectory
(onset" of delay, dates of acquisition of
key milestones,
• Is it global (affecting all areas of
development, viz., motor, cognitive,
social, and language) or restricted (for
instance only motor or speech),
• Severity of delay,
• Schooling history, and menstrual history

15. 5. Psychiatric history
• Details of onset, evolution and
current status of behavioral and
other psychopathological
disturbances,
• ABC of behavioral problem.

16. Treatment history
• Past efforts by the family in
seeking help, nature, and
response
• Details past treatment, and
current medication

17. Current developmental attainments
• Current developmental
attainments in motor, cognitive,
language and social
• Areas, parents estimation of
mental age of the child

18. Associated (comorbid) psychiatric behavioral problems
• Recent onset changes in behavior, overall functioning, sleep and
appetite patterns, often point towards a comorbid psychiatric disorder.
• Intensity, frequency, context of occurrence of symptoms, precipitating
& relieving factors elicited
• Psychiatric disorders in children with ID are commonly under-
diagnosed or misdiagnosed.

19. Mental status testing

20. Preparing for Mental status testing

21. Setting for interview:
• Toys, Books, Pictures, Paper,
pencil
• Couch, child friendly furniture
• Safe from danger
• Space to move around

22. Process of Interviewing:
• Building rapport -Make the kid and parents comfortable: child on
mother's lap or in separate chair or to let the child move around.
• Learn the pet name, get the exact age. Be ready to get up from seat and
move around to interact with the child to engage in some activity.
• Offer toys, books, etc and quickly find out something the child is able
to do; appreciate and comment on it to the parents.

23. Build partnership with parents from the outset
• Value their opinions, and
impressions, and efforts;
• Appreciate parents for the right
things they have done.

24. Verbal interviewing: depends on language development and
conversational skills:
• Simple, structured, and brief;
• Use clear & concrete questions
• Avoid leading questions
• Use parents when necessary for interviewing

25. Clinical observation during mental status
testing

26. Basic Examination:
• Basic Examination: Vision,
hearing, locomotion, physical
health

27. Response to interview situation:
• Response to interview situation:
(excited, fearful and tense, shy,
inhibited, guarded,
uncooperative, defiant)
• Alertness: (over-aroused,
withdrawn)

28. Attachment to parents and response to separation:
• Attachment to parents and
response to separation: (clinging,
wanting to be carried all the
time, indifferent to separation)

29. Sociability:
• Sociability: check for Social
orientation, approachability,
Social responsiveness, ETE
contact, reciprocity or response
to overtures (solitary, withdrawn,
poor ETEC, over socialization)

30. Motor Activity level:
• Motor Activity level: Fidgetiness, restlessness, hyperactivity; lethargy
Course of motor behaviours during interview, response to firm
instructions: (quiet initially, but later restless, unresponsive to firm
instructions)

31. Impulse control:
• Impulse control: (snatching, spilling, falling, bumping, climbing,
interfering, temper tantrums; aggressive act_ such as biting; throwing,
beating, pulling hair, slapping)

32. Attention, concentration:
• Attention, concentration: goal directedness, task completion,
distractibility (short attention span, jumping from one activity to
another, easily distracted)

33. Speech, language & communication
• Speech, language &
communication: check for
verbal/non-verbal
comprehension& Expression,
vocabulary, articulation, and
flow

34. Mood, Play behaviour, Other inappropriate behaviors
• Mood: (inhibited, excessively
cheerful; whining and crying,
irritable,)
• Play behaviour: playful or not
• Other inappropriate behaviors:
(stereotypies, Self-Injurious
Behavior),

35. Impressions on current developmental
attainment:
• Impressions on current
developmental attainment: Hand
functions, self-help skills, use of
objects, general information,
capacity for new learning,
rational thinking, pre academic
& academic skills.

36. Parent child interactions:
• Parent child interactions: Quality
of engagement with child,
Communication patterns, Degree
and quality of control over the
child, Response to good and bad
behaviours, , Interaction between
parents.

37. Tentative summary of diagnosis
• Presence and degree of MR (mild.MR)
• Etiologic/ Syndromal diagnosis (fragile X syridrome)
• Associated medical problems (epilepsy) II.
• IV. Associated psychiatric problems (ADHD)
• V. Family&psycho-social axis (poor awareness, high strèss levels,
overexpectation)

38. Differentials
• Specific learning disability
• Pervasive developmental disorder
• Specific delay of speech and language development
• Visual and hearing impairment