Last
Updated Mental Retardation
Introduction Mental retardation is not a single, isolated disorder. It is a term used to describe a condition affecting individuals who are limited in mental functioning to a level that affects many aspects of life, including basic skills such as communicating, taking care of personal needs, and social interaction. The national prevalence rate for mental retardation has been cited at approximately one percent (Developmental Disabilities Act, 1994). In Fiscal Year 1999-2000, there were 15,947 children in Virginia ages 3 to 22 in special education who had received a mental retardation diagnosis (Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services, 2001). The first signs of mental retardation are usually displayed in early childhood, often within the first or second year of a child’s life. The child tends to lag behind his peers in milestones such as sitting up, walking, and talking. He also demonstrates lower than normal levels of interest in his environment and responsiveness to others (Gale Encyclopedia of Childhood and Adolescence, 1998). It is important that parents, pediatricians, and service providers are familiar with and recognize these signs, as early intervention serves as a crucial component to ensure that the development and quality of life of these children are maximized. The Diagnostic and Statistical Manual of Mental Disorders - 4th Edition (DSM-IV), published by the American Psychiatric Association, provides the standard criteria for a diagnosis of mental retardation which are used in the diagnosis of children, as well as adults. The disorder is characterized by “significantly subaverage intellectual functioning,” which must be supported by three factors: intellectual impairment, significant difficulty in adaptive functioning, and onset before the age of 18 (APA, 1994). The first required element of the diagnosis¾intellectual impairment¾is typically measured by cognitive testing instruments. Normal IQ measurements on standardized, individually administered tests such as the Wechsler Intelligence Scale or the Stanford-Binet test generally fall between 80 and 135 and, for this diagnosis, the child must have an intelligence quotient (IQ) that falls below 70 or 75 (Szymanski & King, 1999). The threshold for mental retardation is typically set at 70, and experts generally agree that scores of 71-75 are only consistent with mental retardation when significant deficits in adaptive behavior are present (Szymanski & King). Normal IQ measurements on these tests generally fall between 80 and 135. In addition, all children receiving the diagnosis must also demonstrate significant impairment in two or more of the following adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work (DSM-IV). There are standardized scales to measure these behaviors, but they often do not capture all of the functional domains, and therefore this element of diagnosis is typically measured after a clinical assessment of the child (Szymanski & King, 1999). The DSM-IV also requires that the onset of symptoms occur prior to the age of 18. It is important to note, however, that experts warn that children under the age of two 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, such as Downs Syndrome. Instead, service providers should acknowledge the cognitive or behavioral deficit as a form of developmental disability and leave room for further diagnosis as the child gets older (Biasini et al., in press; Sattler, 1992). “Mental retardation” should not be used interchangeably with the term “developmental disability.” A developmental disability is not a medical term, but is instead a legislative concept referring to a broad spectrum of disorders, including mental retardation, epilepsy, and autism. A diagnosis
of mental retardation has been further classified based on the child’s
level of impairment. The four categories adopted by the DSM-IV are: mild (IQ between 50/55 and 70), moderate (IQ between 35
and 50), severe (IQ between 20 and 35), and profound (IQ below 20).
Studies have found that 80 to 85 percent of those with the diagnosis fall
within the mild mental retardation range, while less than six percent are
diagnosed with severe or profound mental retardation (Szymanski &
King, 1999). Etiology There are numerous causes for mental retardation. Those most frequently cited include external factors such as infections, trauma, toxins, premature births and delivery problems. Genetic disorders have also been cited as a frequent cause of mental retardation, accounting for approximately one third of cases (Szymanski & King, 1999). It is important for the causes of retardation to be identified if possible, in order to clarify the prognosis and tailor treatment efforts (Szymanski & King). Furthermore, the identification of causation may be valuable in alerting the clinician to possible medical and behavioral complications that occur more frequently in certain conditions (Szymanski & King). However, research has shown that in 58 to 78 percent of the cases of mild retardation and in 23 to 43 percent of severe cases, no official cause has been determined (Szymanski & King). A
multidisciplinary team that may include psychologists, psychiatrists,
pediatricians, and clinical geneticists typically conducts the assessment
for mental retardation. All assessments should be comprehensive, and
should include standardized intelligence testing, evaluation of adaptive
skills through testing or clinical evaluation, biomedical and family
history evaluation, and psychological and behavioral testing (Szymanski
& King, 1999). Comorbidity
with Mental Illnesses Individuals who receive a diagnosis of mental retardation frequently suffer from additional mental disorders as well (Masi, 1998). Clinicians and researchers have explained this high prevalence of comorbidity as the result of the psychological vulnerability of children with mental retardation. This can have a significant impact on a child’s coping skills and mental health, and it may be one of the primary factors limiting the functioning, quality of life, and adaptation of mental retardation to community life (Masi). The
prevalence of comorbidity of mental illnesses has been found to range from
27 to 71 percent in children with mental retardation (Bregman, 1991).
There is a substantial range of variation in the prevalence rates found in
prior studies due to differences in methodology, diagnostic definitions,
and population sampling strategies among the different studies. The most
common comorbid conditions are described in more detail below: ·
General Medical
Conditions –
Seizure disorders are present in 15 to 30 percent of individuals with
severe or greater mental retardation, and motor handicaps (20 to 30
percent) and sensory impairments (10 to 20 percent) are also frequently
reported (Szymanski & King, 1999). ·
Pervasive Developmental
Disorders
– Mental retardation is extremely common in children with pervasive
developmental disorders. Approximately 75 percent of autistic children are
also diagnosed with mental retardation (Fombonne, 1997). However, a
reciprocal relationship has not been reported; the majority of children
with mental retardation do not display significant impairments in
reciprocal social interaction that are typically present in pervasive
developmental disorders such as autism. ·
Attention Deficit
Disorders (ADD and ADHD) – The incidence of Attention Deficit Disorder
(ADD) is more frequent in persons with mental retardation (18 percent)
than in the general population (9 percent) (DSM-IV).
Attention Deficit Hyperactivity Disorder (ADHD) is also
particularly frequent, with a range of 4 to 11 percent of persons with
mental retardation affected by this disorder (Feinstein & Reiss,
1996). Experts have attributed the frequency of these diagnoses in the
mentally retarded to the fact that inattention is often a component of
intellectual impairment. ·
Conduct Disorder
– It has been reported that approximately one third of children and
adolescents with mental retardation display the characteristics of conduct
disorder (Richardson et al., 1985). However,
experts caution that it is important to consider the child’s
circumstances, ability to understand social rules, and possession of
sufficient skills to communicate opposition when proposing such a
diagnosis (Szymanski & King, 1999). ·
Behavior Disorders
– Children with greater degrees of mental retardation have been found to
display increased aggressiveness, feeding disorders, stereotyped movements
and self-injurious behavior (Masi, 1998). Self-injurious behavior is
particularly common, with approximately 10 to 15 percent of persons with
mental retardation displaying these characteristics (Oliver et al., 1987).
The tendency to self injury is particularly common in certain mental
retardation syndromes, such as Lesch-Nyhan, Prader-Willi, as well as in
patients with mental retardation who experience mood disorders (depressive
and manic), schizophrenia, personality disorders, and anxiety disorders
(especially obsessive compulsive disorder) (Masi). ·
Mood Disorders
– Mood disorders, especially of the depressive nature, are quite common
in persons having mental retardation and are believed to be significantly
underdiagnosed (Szymanski & King, 1999). Social isolation,
stigmatization, and poor social skills put children with mental
retardation at increased risk for depression (Reiss & Benson, 1985).
The symptoms are often triggered by external stressful events, but
ordinary life changes can also be responsible (Masi, 1998). Bipolar mood
disorders are also present in the mentally retarded, but are more
difficult to recognize. They have been found to involve dysphoria coupled
with periods of irritability, aggressiveness, or self-injury, rather than
the more typical manic episode (Masi). ·
Anxiety Disorders
– While it is likely that these disorders are highly prevalent in
persons with mental retardation, they are believed to be underreported due
to the difficulty diagnosing persons of limited intelligence (Masi, 1998).
Research indicates that the most frequent manifestations of anxiety
disorders in this population include acute episodes of anger, flight, and
crying or compulsions (repetitive, ritualistic behaviors) (Masi).
Clinicians have found that psychosocial stress factors, including fragile
self-esteem, fears of failing, and loss of caregivers are likely
contributors to the psychological difficulties of this population
(Szymanski & King, 1999). ·
Posttraumatic Stress
Disorder (PTSD) – PTSD is also believed to be significantly
under-diagnosed in this population (Szymanski & King, 1999). Mentally
retarded children are particularly vulnerable to abuse given their high
level of dependency and their tendency to want to please others, as well
as lack of understanding of their rights. They may also be targeted
because of their lack of communication skills, which may prevent
reporting. ·
Schizophrenia
– The incidence of schizophrenic disorders has been found to be higher
in children diagnosed with mental retardation than in the general
population (Heaton-Ward, 1977). All
forms of psychotic disorders have been identified in mentally retarded
persons (Masi, 1998). The
diagnostic evaluation for psychiatric disorders is principally the same
for patients with mental retardation, child and adult, as it is in the
general population (Szymanski & King, 1999). It is important to
recognize, however, that the psychiatric diagnostic assessment of children
with mental retardation must be comprehensive and consider biological,
psychological, and social contexts, rather than being merely a
“medication evaluation” focused only on the choice of drug to suppress
a disruptive behavior. Furthermore, any additional mental health diagnosis
should be formal and specific, rather than a nonspecific description of
“behavior disorder” or “challenging behavior.”
It is important that the child’s assessment and resulting
diagnosis demonstrate that he is ill, rather than merely “bad” or
“noncompliant.” There are
certain specific limitations that affect the reliability of the dual
diagnosis in children and adolescents with mental retardation. First of
all, the level of communication skills that the child or adolescent
exhibits is strongly related to the reliability of the diagnosis
(Szymanski & King, 1999). Individuals with more severe cognitive
limitations are less likely to be given a dual diagnosis than children
with lower levels of impairment due to their inability to communicate
their symptoms and distress (Borthwick-Duffy & Eyman, 1990).
Evaluation of significantly impaired children requires the mental health assessor to depend on information
provided by the caregivers familiar with the child and direct behavioral
observations, which tend to be less informative and reliable. The
reliability of the diagnosis is also highly reliant on the availability of
information regarding the biological, psychological, and social history of
the child or adolescent (Biasini et al., in press). The child’s history
of behavior and symptoms are often crucial in making a diagnosis and, in
the absence of this information, the evaluator is placed in the difficult
position of making a diagnosis strictly on current symptoms and behavior
without being fully informed of a child’s treatment history. This
information is particularly crucial in the evaluation of children with
profound and severe mental retardation. Many psychologists and
psychiatrists rely heavily on biological markers, observable signs, and
patterns of family psychopathology to diagnose these severely impaired
children (Sturmey, 1995). The strength
and accuracy of a diagnosis is also directly affected by the experience
and training of the clinician conducting the evaluation (Szymanski &
King, 1999). It is crucial that the assessment be conducted by an
individual specially trained in the evaluation and treatment of children
with mental retardation. Furthermore, clinicians must recognize that there
are often mismatches between the behaviors scripted in the DSM-IV for certain diagnoses and the symptoms presented in children
with mental retardation (Biasini et al., in press). These differences can
lead to under-diagnosis; therefore evaluators must be comprehensive in
their approach and think outside the usual formulas when diagnosing
mentally retarded children (Sturmey,
1995). Treatment The
treatment of children with mental retardation is based on two guiding
principles: normalization and community-based care (Szymanski & King,
1999). Normalization requires that children with mental retardation live
under patterns and conditions of everyday life that are as close as
possible to mainstream society. The concept of community-based care flows
directly from this principle, calling for the treatment and integration of
mentally retarded children within the community to the maximum extent
possible. No more than 10 percent of persons with mental retardation in
this country have ever lived in institutional settings, and most can be
found either living with their families or in community-based out-of-home
placements such as foster care, group homes, and independent living
programs (Szymanski & King). Service providers have found that, with
proper services, the majority of children with mental retardation do well
in the community. Those children with mental retardation who are admitted
to an institutional setting typically display symptoms of severe mental
disorder or intensive or massive medical needs in conjunction with mental
retardation. The primary
goal of service providers specializing in mental retardation is
prevention, as there is no cure for the condition once the damage has
occurred (Szymanski & King, 1999). Whenever possible, providers hope
to prevent conditions that may result in mental retardation in children by
educating women and families about the need for behaviors such as
abstinence from alcohol during pregnancy and frequent child immunizations.
Moreover, if an underlying condition that may lead to mental retardation
has been identified in a child, providers focus on the treatment of that
specific disorder in order to minimize potential brain injuries that could
increase the risk of mental impairment. However,
once a child has been diagnosed with mental retardation, providers begin
to pursue early intervention, education, and ancillary treatments, such as
physical, occupational, and language therapies (Szymanski & King,
1999). In addition, family support and other services are typically put
into place to ensure that the child is receiving comprehensive care in the
home, school, and community. The methods and intensity of treatment are adapted as the child progresses in age. In infants, exercises and special types of play are used to provide sensory and motor stimulation and enhance development (Gale Encyclopedia of Childhood and Adolescence, 1998). All states are required by law to offer early intervention programs for mentally retarded children from the time they are born. Once the child reaches the age of three, federal law requires that special education programs be made available for the child and family. These services concentrate on self-care, such as feeding, dressing, and toilet training, and also provide assistance with language and communication difficulties and physical difficulties. As the child gets older, the emphasis of special education programs changes to training in daily living skills as well as academic subjects. Treatment efforts will also include medical care for any comorbid physical conditions, such as seizure disorders, motor handicaps, and sensory impairments, as well as treatment of any psychosocial dysfunction and comorbid mental disorders. Several
factors may impact the choice of treatment method in children with mental
retardation. First, the child’s level of cognitive and communication
skills may cause a service provider to adapt the method of treatment. For
example, a child who lacks communication skills would be unable to benefit
from verbally-based treatments such as psychotherapy; consequently,
behavioral modification and educational accommodations would be more
effective. Another consideration is the impact of any concurrent general
medical disorders. An
effective treatment plan requires that the service provider recognize the
child’s physical limitations and synthesize physical, developmental, and
psychological needs and interventions (Szymanski & King, 1999). Furthermore,
the site of treatment may impact the methodology used.
In most cases, outpatient settings are appropriate if the necessary
services can be secured in the community. However, providers must be more
cautious when placing mentally retarded children in inpatient treatment
facilities. Clinicians have reported that not all of these facilities are
familiar with needs of children with mental retardation and many are not
equipped to provide these children with appropriate therapy, habilitative
or recreational programs and other necessary services (Szymanski &
King, 1999). Consequently, placements must be carefully made after the
provider has gained a wealth of knowledge regarding the services offered
and the methods used by the facility. An
additional factor that can have a significant impact on treatment efforts
is the willingness of the child and family members to participate and
comply with the therapeutic plan. Education and ongoing support are
essential, and detailed explanations must be given to family members to
ensure that they understand all of the behavioral and pharmacological
interventions that are being used to treat the child. Developmental and Educational
Services All states
are required by law to offer early intervention programs for children with
mental retardation from the time they are born. Infant/toddler services
can be home-based, center-based, or some combination of these two methods.
The nature of the services is determined based on an assessment of the
child and the family priorities. Under federal law, these considerations
must be used to develop an Individual Family Service Plan (IFSP) for the
child, which should include input from all parties participating in the
intervention. This plan is usually developed and coordinated by a case
manager who is available and acceptable to the family. The services that
are provided in response to this plan 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 (Biasini et al., in press). As the child
gets older, psychoeducational services must be provided. The Individuals
with Disabilities in Education Act (IDEA) (Public Law 94-142, Public Law
99-457, and Public Law 102-119) requires that children
with mental retardation or related developmental disorders receive a
free and appropriate education. Interventions are based on the needs of
the child as determined by a team of professionals. They should address
the priorities and concerns of the family and should be provided in the
least restrictive and most inclusive setting, allowing them to have every
opportunity to interact with nondisabled peers and to have access to the
community resources available to all other children. The services
provided to preschool children and school-aged children can be home-based,
but are more frequently center-based. As in the case of infants and
toddlers, an Individualized Education Plan (IEP) is developed through team
evaluation and parent input. This
plan describes the objectives for improving the child's skills and may
include family or parent-focused activities. It may include special
education services, child counseling, occupational therapy, physical
therapy, language therapy, recreational activities, school health
services, transportation services, and parent training or counseling.
These services must also be provided in the least restrictive setting
possible, such as a regular preschool program, Treatment of Comorbid
Conditions The general
principles of treatment are the same as those for children with other
mental disorders. However, treatment techniques may need to be modified in
order to adapt to the individual’s developmental level, particularly
with regards to communication skills. There are
two elements that have a significant impact on the effectiveness of
psychotherapy in children with mental retardation. First, the child must
exhibit a sufficient level of communication skills in order for this type
of therapy to be appropriate. Second, in order to maximize results,
treatment must be implemented across settings (classroom, home, and other
environments); and the therapist must collaborate with the other
interested parties in the child’s life, such as teachers, family
members, and other service providers (Szymanski & King, 1999). The
most effective forms of psychotherapy are: ·
Individual
therapy – This type of intervention has been found to be
beneficial for mentally retarded children with higher cognitive skills
(Harris, 1995). It is best conducted by a therapist specifically trained
in developmental disorders. Techniques and activities should be adapted to
the child’s chronological age and level of development (Szymanski &
King, 1999). ·
Family
therapy – Research supports the benefits of family
therapy for children with mental retardation (Harris, 1995). It typically
focuses on the caregiver’s identification and support of the child’s
strengths and independence, and the provision of opportunities for
success. It may also include educational and emotional support components.
The family should be seen as treatment team members, as they are essential
to recognizing the child’s strengths, avoiding guilt feelings and
overprotection, supporting the child’s pathways to independence, and
providing opportunities for success. This form of therapy has also been
found to be beneficial in assisting in locating resources, identifying
entitlement for services and providing advocacy, empathy, and concrete
advice in management of the child’s disability (Szymanski & King,
1999). ·
Group
therapy – Therapeutic efforts in a group environment
have been found to be particularly useful with adolescents who have
relatively good verbal skills, as they often benefit from peer interaction
and support (Szymanski & King, 1999; Harris, 1995).
Multiple family group therapy has also been found to be beneficial,
as it provides the family and child with support in a context similar to
society at large (Szymanski & Kiernan, 1983). ·
Behavior
modification – Behavioral modification
has been reported to be beneficial to children with mental retardation
that lack social skills or demonstrate problem behaviors such as
self-injury (Reiss, 1985). This intervention provides a consistent and
structured framework for teaching appropriate behavioral patterns, as well
as adaptive life skills. It should be generalized and consistent in all
settings, such as home and school, and should focus on teaching
appropriate skills and behaviors to replace maladaptive behaviors, rather
than merely suppressing them (Szymanski & King, 1999). ·
Social
skills training – Social skills training
has also been found to improve the integration of mentally retarded
children into the community (Hollins et al., 1994). Those who receive
social skills training are taught effective social interactions and
appropriate social behavior. ·
Cognitive
therapy – This form of therapy teaches children with
mild retardation to recognize situations in which they get into trouble
and to adopt alternative behaviors and solutions. It has only recently
been adapted for use with mentally retarded children, and therefore
research regarding its effectiveness is limited (Benson, 1992). Pharmacological Treatment The effects
of medication are not generally different in mentally retarded children
than in the general population (Szymanski & King, 1999). However,
certain issues related to pharmacology have been recognized exclusively in
the mentally retarded population. For example, clinicians have found that
medication is often prescribed to mentally retarded children for symptom
suppression without being integrated into the overall treatment plan
(Szymanski & King, 1999). The literature repeatedly advises that
medication should not be used for the convenience of caregivers or as a
substitute for appropriate services. An additional concern is that
follow-up behavioral data is infrequently collected and providers often
fail to monitor for side effects. This is especially important in mentally
retarded populations, because these patients may be unable to report
symptoms adequately. While
psychotropic drugs are not often used with mentally retarded children,
they are most often prescribed in patients who exhibit disruptive
behavior, including self-injury, stereo-typed behaviors (such as hand or
finger twisting, or complex whole body movements), and aggression
(Szymanski & King, 1999). Unproven Treatments The
effectiveness of diet restrictions in mentally retarded patients generally
is not supported by research (Szymanski & King, 1999). These types of
treatments include vitamin and mineral supplements and various dietary
restrictions, such as yeast and gluten-free regimens. Other Important Treatment
Elements Cultural
Considerations Any
assessment of adaptive behavior focuses on how well children can function
and maintain themselves independently and how well they meet the personal
and social demands imposed on them by their cultures. Because various
cultures may hold their own views regarding the level of
functioning/skills expected in children of certain ages, clinicians must
be culturally sensitive in diagnosing children with developmental delays
and retardation. In addition, the sociocultural background and native
language of the child should be considered in assessing intelligence and
level of impairment (Szymanski & King, 1999). Family
Involvement Service
providers must make every effort to include the family in all aspects of
treatment and planning. They must consider the level of knowledge and
understanding of the family regarding the disability of the child, and
must also be sure that the family is sufficiently informed of all service
and treatment options. If professionals fail to acknowledge parents as
partners in the process, they run the risk of alienating them in the
process. This can result in a lack of interest or participation in
necessary services. Availability
of Community Services and Supports The Arc, a
non-profit organization that supports the mentally retarded, has reported
that approximately 200,000 individuals nationwide are on waiting lists for
such essential supports and services as service coordination, housing,
employment, in-home supports, early intervention, transportation, and
respite care (The Arc, 1999). A report by the Research
indicates that lack of services can exacerbate the problems of children
with mental retardation, as it may allow for an increase in the severity
of the disability or learning delays (The Arc, 1999). Furthermore, the
lack of services may also lead to greater dependence, isolation, and a
decrease in self-esteem and productivity. Consequently, providers and
policy makers must make every effort to identify these children and
provide them with necessary services to ensure that they become productive
members of society. Sources American
Psychiatric Association. (1994). Diagnostic
and Statistical Manual of Mental Disorders -
4th edition
(DSM-IV). Benson,
B.A. (1992). Teaching anger management to persons with mental retardation.
Biasini,
F.J., Grupe, L.. Huffman, L. & Bray, N.W. Mental retardation: A
symptom and a syndrome. In Bregman,
J.D. (1991). Current developments in the understanding of mental
retardation, Part II: Psychopathology, Journal
of the American Academy of Child and Adolescent Psychiatry, 31, 861-72. Developmental
Disabilities Assistance and Bill of Rights Act Amendments of 1994, P.L.
103-230, Section 101(a)(1). Feinstein,
C. & Reiss, A.L. (1996). Psychiatric disorder in mentally retarded
children and adolescents: The challenges of meaningful diagnosis. Child
and Adolescent Psychiatric Clinics of Fombonne,
E. (1997). Epidemiology of autism and related conditions. In
Volkar, F.R., (ed.), Autism and
Pervasive Developmental Disorders. Gale Encyclopedia of Childhood and Adolescence.
Mental Retardation. Gale
Research, 1998. Harris,
J.C. (1995). Developmental
Neuropsychiatry, Vols. 1-2. Heaton-Ward,
A. (1977). Psychosis in mental handicap. British
Journal of Psychiatry, 130, 525-33. Hollins,
S., Sinason, V., & Thompson, S. (1994). Individual, group, and family
psychotherapy. In Bouras, N.
(ed.), Mental Health in Mental
Retardation, Masi,
G. (1998). Psychiatric illness in mentally retarded adolescents: Clinical
features. Adolescence, 33, 425-35. Oliver,
C., Murphy, G.H., & Corbett, J.A. (1987). Self-injurious behavior in
people with mental handicap: A total population study. Journal
of Mental Deficiency Research, 31,
147-62. Reiss,
S. (1994) Handbook of Challenging
Behavior: Mental Health Aspects of Mental Retardation. Reiss,
S. & Benson, B.A. (1985). Psychosocial correlates of depression in
mentally retarded adults: Minimal social support and stigmatization. American
Journal of Mental Deficiency, 89,
331-37. Sattler,
J. M. (1992). Assessment of Children
3rd Edition. Sturmey,
P. (1995). DSM-III-R and persons with dual diagnoses: Conceptual issues
and strategies for future research. Journal
of Intellectual Disability Research, 39,
357-364. Szymanksi,
L.S. & Kiernan, W.E. (1983). Multiple family group therapy with
developmentally disabled adolescents and young adults. International
Journal of Group Psychotherapy, 33, 521-34. Szymanski,
L.S. & King, B.H. (1999). Practice parameters for the assessment and
treatment of children, adolescents, and adults with mental retardation and
comorbid mental disorders, Journal
of the American Academy of Child and Adolescent Psychiatry, 38,
5S-31S. The
Arc, Availability of Community Services and Supports: Position Statement # 21.
(Oct. 1999). Additional
Resources/Organizations American Association on Mental Retardation
The Arc (formerly Association for Retarded Citizens),
website: http://www.thearc.org IDEA 1997 Statute on Implementing Regulations: contact the United States Department of Education at (202) 205-5465 or (202) 205-5507, or website: http://www.ed.gov/offices/OSERS/Policy/IDEA/
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