Students with Mental Students with Mental Retardation and Depression: Retardation and Depression: Providing Understanding and Providing Understanding and

AssistanceAssistance

Presented by Paula J. McCall, PhD, NCSPPresented by Paula J. McCall, PhD, NCSP

National Association of School PsychologistsNational Association of School Psychologists

February 2011 Annual ConventionFebruary 2011 Annual Convention

AgendaAgenda

Prevalence and symptoms of Prevalence and symptoms of depression in individuals with depression in individuals with intellectual disabilitiesintellectual disabilities

Possible factors of depression in Possible factors of depression in this populationthis population

Effective treatment approachesEffective treatment approaches Research resultsResearch results Implications for school Implications for school

psychologistspsychologists

Prevalence of Depression Prevalence of Depression with Intellectual with Intellectual

DisabilityDisability 4-9% of adults with mental retardation 4-9% of adults with mental retardation

((Stavrakaki & Lunsky, 2007Stavrakaki & Lunsky, 2007)) Depression most common diagnosis Depression most common diagnosis

for all levels of mental retardation – up for all levels of mental retardation – up to 42% (to 42% (Hurley, Folstein, & Lam, 2003Hurley, Folstein, & Lam, 2003))

Rates underestimated due to problems Rates underestimated due to problems with communication of internalized with communication of internalized symptomssymptoms

Rates at least approach – if not exceed Rates at least approach – if not exceed – those of depression in the general – those of depression in the general populationpopulation

Prevalence: Prevalence: Children & AdolescentsChildren & Adolescents

1.5 to 13.7% - similar rates as 1.5 to 13.7% - similar rates as nondisabled peers (nondisabled peers (Whitaker & Read, 2006Whitaker & Read, 2006))

16.7% with significant depressive 16.7% with significant depressive symptoms in adolescents with symptoms in adolescents with mild mental retardation (mild mental retardation (McCall, 2006McCall, 2006))

Symptoms: Mild to Symptoms: Mild to ModerateModerate

Mental RetardationMental Retardation Full range of depressive symptoms as Full range of depressive symptoms as

nondisabled peersnondisabled peers Common symptoms: sad appearance, Common symptoms: sad appearance,

depressed mood, irritability, fatigue, depressed mood, irritability, fatigue, hopelessness, guilt, loss of interest in hopelessness, guilt, loss of interest in activitiesactivities

Suicidal ideation and attempts 17 to 23% Suicidal ideation and attempts 17 to 23% ((Lunsky, 2004Lunsky, 2004))– Sample of 42 adolescents with MiMR Sample of 42 adolescents with MiMR

showed 38% thought about killing showed 38% thought about killing themselves while nearly 5% wanted to do themselves while nearly 5% wanted to do itit (McCall, 2006)(McCall, 2006)

Symptoms: Moderate to Symptoms: Moderate to Severe Mental Severe Mental

RetardationRetardation Common symptoms: changes in sleep Common symptoms: changes in sleep

patterns, depressed affect, withdrawal patterns, depressed affect, withdrawal Manifestation may differManifestation may differ

– Loss of interest as withdrawal from Loss of interest as withdrawal from reinforcersreinforcers

– Feelings of worthlessness as statements Feelings of worthlessness as statements about being “retarded”about being “retarded”

– Recurrent thoughts of death or suicide as Recurrent thoughts of death or suicide as perseveration on deaths, funerals of loved perseveration on deaths, funerals of loved onesones

(see Reudrich, Noyers-Hurley, & Sovner, 2001)(see Reudrich, Noyers-Hurley, & Sovner, 2001)

Factors of Depression in Factors of Depression in Individuals with Intellectual Individuals with Intellectual

DisabilityDisability Biological and Etiological (i.e., Down Biological and Etiological (i.e., Down

syndrome)syndrome) Cognitive (i.e., automatic negative Cognitive (i.e., automatic negative

thoughts)thoughts) Educational: Learned Helplessness, Educational: Learned Helplessness,

Outerdirectedness, InattentionOuterdirectedness, Inattention Life Events:Life Events:

– Negative social conditions Negative social conditions (ridicule, rejection, etc.)(ridicule, rejection, etc.)

– Negative events without supportNegative events without support– Common life transitions Common life transitions

(i.e., puberty, high school graduation)(i.e., puberty, high school graduation)

Factors of Depression in Factors of Depression in Individuals with Intellectual Individuals with Intellectual

DisabilityDisability Social Skills and SupportSocial Skills and Support

– Negative experiences (i.e., stigmatization, ridicule, Negative experiences (i.e., stigmatization, ridicule, infantilization) maintain negative cognitive patternsinfantilization) maintain negative cognitive patterns

– Lack of social, adaptive behavior skillsLack of social, adaptive behavior skills– Lack of social support/lonelinessLack of social support/loneliness– Lower levels of self-control have significantly predicted Lower levels of self-control have significantly predicted

depressive symptoms in a group of 42 adolescents with depressive symptoms in a group of 42 adolescents with mild mental retardation mild mental retardation (McCall, 2006)(McCall, 2006)

– Males: significant correlations between cooperation, Males: significant correlations between cooperation, assertion, and total social skills with depressive assertion, and total social skills with depressive symptoms symptoms (McCall, 2006)(McCall, 2006)

– Females: significant correlation with depressive Females: significant correlation with depressive symptoms and self-control symptoms and self-control (McCall, 2006)(McCall, 2006)

– Higher means of depressive symptoms for students with Higher means of depressive symptoms for students with MiMR in grades 11-12 but social skills correlations (self-MiMR in grades 11-12 but social skills correlations (self-control, cooperation, and overall) only for grades 9-10 control, cooperation, and overall) only for grades 9-10 (McCall, 2006)(McCall, 2006)

Factors of Depression in Factors of Depression in Individuals with Intellectual Individuals with Intellectual

DisabilityDisability

Self-AwarenessSelf-Awareness– ““They can tell when others look They can tell when others look

down upon them, they are hurt down upon them, they are hurt emotionally when people ridicule emotionally when people ridicule them, and they realize that their them, and they realize that their opportunities are restricted because opportunities are restricted because others think they are incapable” others think they are incapable” (Reiss & Benson, (Reiss & Benson, 1984, p. 90)1984, p. 90)

Treatments and Treatments and InterventionsInterventions

PsychotherapyPsychotherapy– Can be successful with modificationsCan be successful with modifications– Play media, art, dramaPlay media, art, drama– Focus on present, goals, impact of Focus on present, goals, impact of

MRMR– Individual, group, and familyIndividual, group, and family– Has been used successfully with Has been used successfully with

clients with MR but limited studiesclients with MR but limited studies

Psychotherapy Psychotherapy ModificationsModifications

Concrete, structured formatConcrete, structured format Simplified concrete languageSimplified concrete language Therapist with more direct roleTherapist with more direct role Slower pace, shorter sessionsSlower pace, shorter sessions Frequent checks for understanding, repetitionFrequent checks for understanding, repetition Repeated, clear permission to express Repeated, clear permission to express

emotions emotions Recognize, address impact of disability, Recognize, address impact of disability,

repeated negative life experiences, external repeated negative life experiences, external systems (Levitas & Gilson, 1989; Lynch, 2004)systems (Levitas & Gilson, 1989; Lynch, 2004)

Psychotherapy Psychotherapy PrecautionsPrecautions

Play media must be age-appropriatePlay media must be age-appropriate– Act out TV show vs. playing with dollsAct out TV show vs. playing with dolls– Role play Role play

Increased dependency on therapistIncreased dependency on therapist Inappropriate “rescue” mentalityInappropriate “rescue” mentality Goals ignoring the individualGoals ignoring the individual

– Tailor to reality and experiences, including Tailor to reality and experiences, including disabilitydisability

– Encourage independence in setting, Encourage independence in setting, meetingmeeting

Group PsychotherapyGroup Psychotherapy

Effective for multiple purposes across levels Effective for multiple purposes across levels of mental retardationof mental retardation

6-8 individuals w/ similar cognitive and verbal 6-8 individuals w/ similar cognitive and verbal abilities, motivation, needs abilities, motivation, needs (Monfils, 1989)(Monfils, 1989)

Develop relationship, encourage self-Develop relationship, encourage self-disclosuredisclosure

Discussion, problem solving, role play, Discussion, problem solving, role play, reinforcement, feedback, social outingsreinforcement, feedback, social outings

Goals: improve self-image, acceptance of Goals: improve self-image, acceptance of disability, understanding of disability, coping disability, understanding of disability, coping skillsskills

Group Psychotherapy: Group Psychotherapy: AdvantagesAdvantages

Share common experiences of disabilityShare common experiences of disability Healthy emotional release with support, Healthy emotional release with support,

encouragement of othersencouragement of others Strong sense of group cohesionStrong sense of group cohesion Secure environment to explore feelings, Secure environment to explore feelings,

problemsproblems Increased self-esteem, self-image, life Increased self-esteem, self-image, life

strategiesstrategies

An Example of Group An Example of Group PsychotherapyPsychotherapy

Adolescents with mental retardation Adolescents with mental retardation (Thurneck, Warner, & Cobb, 2007)(Thurneck, Warner, & Cobb, 2007)

Improve coping strategies for failureImprove coping strategies for failure Group listening games, discussion of Group listening games, discussion of

negative experiencesnegative experiences Visits by students w/out disabilities to Visits by students w/out disabilities to

share experiences – commonalityshare experiences – commonality Increased sense of belongingIncreased sense of belonging

CBT Approaches for CBT Approaches for Depression with Intellectual Depression with Intellectual

DisabilityDisability Self-InstructionSelf-Instruction

– Encourage use of positive self-statements Encourage use of positive self-statements with prompts, reinforcementwith prompts, reinforcement

– Internalized statements change cognitions Internalized statements change cognitions and behaviorand behavior

Problem SolvingProblem Solving– Direct instruction, practice, role playDirect instruction, practice, role play

ModelingModeling– Observe models, practice behaviorObserve models, practice behavior

CBT Approaches for CBT Approaches for Depression with Intellectual Depression with Intellectual

DisabilityDisability Behavioral TechniquesBehavioral Techniques

– Manipulation of setting eventsManipulation of setting events– Positive ReinforcementPositive Reinforcement– Teaching of alternative desired behaviorsTeaching of alternative desired behaviors– Token economies Token economies (see Ruedrich et al., 2001)(see Ruedrich et al., 2001)

Cognitive TechniquesCognitive Techniques– Positive self-statementsPositive self-statements– Self-monitoring of thoughts, mood Self-monitoring of thoughts, mood

(see Ruedrich et al., 2001)(see Ruedrich et al., 2001)

CBT Example for CBT Example for Depression with Depression with

Intellectual DisabilityIntellectual Disability 2 hours 1x/week for 5 weeks2 hours 1x/week for 5 weeks Group format: adults with mild-moderate Group format: adults with mild-moderate

MRMR Emphasis on meaning of depression, Emphasis on meaning of depression,

support networks, link between thoughts support networks, link between thoughts and emotions, development of positive and emotions, development of positive self-statements, role play for problem self-statements, role play for problem solving, development of realistic goalssolving, development of realistic goals

Improved symptoms, automatic thoughts; Improved symptoms, automatic thoughts; persisted 3 months afterpersisted 3 months after

McCabe, McGillivray, & Newton (2006)McCabe, McGillivray, & Newton (2006)

Skills Training Skills Training ApproachesApproaches

Social Skills: modeling, role play with Social Skills: modeling, role play with practice and feedbackpractice and feedback

Relaxation: deep breathing, guided Relaxation: deep breathing, guided imageryimagery

Assertiveness: instruction, modeling, Assertiveness: instruction, modeling, practicepractice– Differentiate from passivity, aggressionDifferentiate from passivity, aggression

Anger Management: coping statements, Anger Management: coping statements, problem solving, relaxationproblem solving, relaxation

Coping-Based Coping-Based TherapiesTherapies

BereavementBereavement– Unresolved grief, loss Unresolved grief, loss – Encouraged to hide emotions, not attend Encouraged to hide emotions, not attend

events events – Education about death, participation loss Education about death, participation loss

rituals and sharing, encouragement of rituals and sharing, encouragement of family contact, coping strategies, sharing family contact, coping strategies, sharing objects, journaling, writing letters, visiting objects, journaling, writing letters, visiting sites, sense of control over own lifesites, sense of control over own life

– Reduction of depressive symptoms across Reduction of depressive symptoms across all levels of MR all levels of MR (see Dowling, Hubert, White, & Hollins, 2006; Stoddart, (see Dowling, Hubert, White, & Hollins, 2006; Stoddart, Burke, & Temple, 2002)Burke, & Temple, 2002)

What is the Reality?What is the Reality?

62% of people with ID and mental 62% of people with ID and mental health needs do not receive services health needs do not receive services (Fletcher, 1988)(Fletcher, 1988)

75% of psychiatrists feel they do not 75% of psychiatrists feel they do not have sufficient training, 39% would have sufficient training, 39% would prefer not to treat prefer not to treat (Lennox & Chaplin, 1996)(Lennox & Chaplin, 1996)

Internal Barriers: communication, Internal Barriers: communication, finances, lack of self-referralfinances, lack of self-referral

External Barriers: fragmentation External Barriers: fragmentation between agencies, lack of between agencies, lack of professionals with training and desireprofessionals with training and desire

What About Schools?What About Schools?

Lack of services overall for students Lack of services overall for students with mental health needswith mental health needs

Few effective programs, but even Few effective programs, but even these are mostly for typical students or these are mostly for typical students or externalizing behaviorsexternalizing behaviors

Children and adolescents receiving Children and adolescents receiving fewer services than adultsfewer services than adults

Only general guidelines existOnly general guidelines exist School psychologists as primary route School psychologists as primary route

to mental health servicesto mental health services

Services in the SchoolsServices in the Schools

Continuum of Services Continuum of Services (Pluymert, 2002)(Pluymert, 2002)– 11stst Level: Prevention (general education for all students) Level: Prevention (general education for all students)– 22ndnd Level: Risk Reduction (support groups for abuse, Level: Risk Reduction (support groups for abuse,

bereavement, coping skills)bereavement, coping skills)– 33rdrd and 4 and 4thth Levels: Early Intervention and Treatment for Levels: Early Intervention and Treatment for

individual needsindividual needs Key Components Key Components (Rones & Hoagwood, 2000)(Rones & Hoagwood, 2000)

– Involvement of parents, teachers, and peersInvolvement of parents, teachers, and peers– Multiple modalities (parent training, CBT, skills training)Multiple modalities (parent training, CBT, skills training)– Mental health awareness and education in general Mental health awareness and education in general

curriculumcurriculum– Adaptation of information, services to levels of studentsAdaptation of information, services to levels of students

Services in the Services in the SchoolsSchools

Majority of students who receive mental Majority of students who receive mental health services receive them in the schoolhealth services receive them in the school

Group therapy, cognitive therapy, coping Group therapy, cognitive therapy, coping skills training have decreased depressive skills training have decreased depressive symptoms in typical children and adolescents symptoms in typical children and adolescents (see Rones & Hoagwood, 2000)(see Rones & Hoagwood, 2000)

Most for ID focus on externalizing behaviorsMost for ID focus on externalizing behaviors– Effective techniques include individualized Effective techniques include individualized

assessment, contingency management, monitoring assessment, contingency management, monitoring of academic progress, guidance in transitions to of academic progress, guidance in transitions to new environments (Bijou, 1988)new environments (Bijou, 1988)

Services in the Schools: Services in the Schools: A Research StudyA Research Study

National survey of NASP database National survey of NASP database participants (participants (nn = 131); = 131); McCall, 2010McCall, 2010

Wider range of interventions used for Wider range of interventions used for students with only depression but did students with only depression but did not extend to use with students who not extend to use with students who also had IDalso had ID

Increased amounts of training Increased amounts of training correlated with increased use of many correlated with increased use of many interventions for students with interventions for students with depression both with and without IDdepression both with and without ID

Believed Effectiveness of Believed Effectiveness of InterventionsInterventions

High levels of believed effectiveness High levels of believed effectiveness for most interventions when used with for most interventions when used with students with only depressionstudents with only depression

Only the most commonly used Only the most commonly used interventions for students with ID were interventions for students with ID were believed to be effective either with or believed to be effective either with or without depression, and these tended without depression, and these tended to be academic interventions and to be academic interventions and teacher consultationteacher consultation

InterestInterest

Amount of Training significantly Amount of Training significantly predicted Interest when working with predicted Interest when working with populations with depression, both with populations with depression, both with and without the presence of IDand without the presence of ID

Training did not have predictive abilities Training did not have predictive abilities on Interest when working with ID onlyon Interest when working with ID only– Other factors, namely work experience, Other factors, namely work experience,

impacted interest in working with this impacted interest in working with this populationpopulation

Perceived EffectivenessPerceived Effectiveness

Training a consistent predictor of Training a consistent predictor of self-confidence in working with self-confidence in working with students with both sole and dual students with both sole and dual diagnosesdiagnoses

Strong relationship between Interest Strong relationship between Interest and Perceived Effectiveness and Perceived Effectiveness suggests indirect relationship suggests indirect relationship between Training and Interest between Training and Interest

InterventionsInterventions

Selected interventions and believed Selected interventions and believed effectiveness of them tended to reflect the core effectiveness of them tended to reflect the core areas of school psychology training: academic areas of school psychology training: academic interventions, behavioral/skills training, and interventions, behavioral/skills training, and teacher consultteacher consult

However, a wider range of interventions used However, a wider range of interventions used and believed to be effective for students with and believed to be effective for students with only depression suggests greater exposure to only depression suggests greater exposure to training in these interventions for this populationtraining in these interventions for this population– Indicates possible lack of training on modifications for Indicates possible lack of training on modifications for

people with MR and/or limited belief in the effectiveness people with MR and/or limited belief in the effectiveness of more cognitive-based approaches with individuals of more cognitive-based approaches with individuals who have MRwho have MR

Perceived Effectiveness of Perceived Effectiveness of InterventionsInterventions

Perceived Effectiveness in working with Perceived Effectiveness in working with ID and depression correlated with ID and depression correlated with Training, Interest, and Experience Training, Interest, and Experience variables for all three groups of studentsvariables for all three groups of students– Confidence in serving low incidence Confidence in serving low incidence

populations may be related to experience populations may be related to experience and training in multiple related areasand training in multiple related areas

– Psychologists feeling successful in working Psychologists feeling successful in working with comorbid conditions may seek out with comorbid conditions may seek out opportunities to work with each of the opportunities to work with each of the conditions aloneconditions alone

Importance of TrainingImportance of Training

Training repeatedly appeared as Training repeatedly appeared as an important variable for students an important variable for students with depression both with and with depression both with and without IDwithout ID– Multiple significant relationships with Multiple significant relationships with

use and believed effectiveness of use and believed effectiveness of interventionsinterventions

– Predictor of both interest and Predictor of both interest and perceived effectivenessperceived effectiveness

Possible Impact of Possible Impact of TrainingTraining

TRAINING

INTEREST

PERCEIVED EFFECTIVENESS

Service ProvisionService Provision

Interest alone has not been shown to be Interest alone has not been shown to be enough for increased service provisionenough for increased service provision

Perceived effectiveness may be a Perceived effectiveness may be a mediating variable between interest mediating variable between interest and service provision and service provision

With training identified as a key to With training identified as a key to perceived effectiveness, increased perceived effectiveness, increased training may indirectly lead to training may indirectly lead to increased effective service provisionincreased effective service provision

Overall Conclusions: Overall Conclusions: Service ProvisionService Provision

INTEREST SERVICE PROVISION

PERCEIVED EFFECTIVENESS

TRAINING

Recommendations: Recommendations: TrainingTraining

Instruction regarding modifications of commonly Instruction regarding modifications of commonly used interventions for individuals with depression used interventions for individuals with depression (i.e., CBT) for people with cognitive limitations(i.e., CBT) for people with cognitive limitations

Consider training to be multimodal with both Consider training to be multimodal with both direct instruction as well as actual or simulated direct instruction as well as actual or simulated experiencesexperiences– Focusing on a few interventions in an in-depth Focusing on a few interventions in an in-depth

manner may have more impact than overview of manner may have more impact than overview of multiple interventionsmultiple interventions

Rotations in practicum and internship experiences Rotations in practicum and internship experiences based on diagnoses (i.e., mental health needs, based on diagnoses (i.e., mental health needs, MR, and dual diagnoses) rather than on school MR, and dual diagnoses) rather than on school assignment to increase experiencesassignment to increase experiences

Recommendations: Recommendations: The Individual Student The Individual Student

Consider extracurricular activitiesConsider extracurricular activities– Is student involved?Is student involved?– Are there areas of interest that can be Are there areas of interest that can be

addressed via a club or team?addressed via a club or team? Consider intrinsic factorsConsider intrinsic factors

– Does student have opportunities to discuss Does student have opportunities to discuss disability, strengths, needs, and feelings?disability, strengths, needs, and feelings?

– Does student need assistance in Does student need assistance in developing coping skills or specific developing coping skills or specific strategies?strategies?

– Does the student feel comfortable going to Does the student feel comfortable going to a particular adult for needs and concerns?a particular adult for needs and concerns?

Recommendations: Recommendations: InterventionIntervention

Identification and use of supports: Identification and use of supports: employment, school, familyemployment, school, family

One intervention at a time with data One intervention at a time with data collection to determine effectivenesscollection to determine effectiveness

Partnership between family, agencies, Partnership between family, agencies, school, etc.school, etc.

Combined interventions: medication, Combined interventions: medication, skills training, CBT, bereavement skills training, CBT, bereavement therapy, etc.therapy, etc.

Final Final RecommendationsRecommendations

Watch for warning signs and do not Watch for warning signs and do not disregard them given the diagnosis of disregard them given the diagnosis of intellectual disabilityintellectual disability

Incorporate family input and Incorporate family input and involvement at any level of interventioninvolvement at any level of intervention

Consider the individual: self-awareness, Consider the individual: self-awareness, self-perception, involvement and self-perception, involvement and various types of activities, etc.various types of activities, etc.

Consider the system: training, Consider the system: training, awareness, understanding of parents, awareness, understanding of parents, educators, and other health facilitatorseducators, and other health facilitators

ReferencesReferences

Bijou, S. W. (1988). The education and treatment of behavior-disordered mentally retarded children. In Bijou, S. W. (1988). The education and treatment of behavior-disordered mentally retarded children. In J. A. Stark, F. J. Menolascino, M. H. Albarelli, and V. C. Gray (Eds.), J. A. Stark, F. J. Menolascino, M. H. Albarelli, and V. C. Gray (Eds.), Mental retardation and mental Mental retardation and mental health: Classification, diagnosis, treatment, services health: Classification, diagnosis, treatment, services (pp. 294-299). New York: Springer-Verlag. (pp. 294-299). New York: Springer-Verlag.

Dowling, S., Hubert, J., White, S., & Hollins, S. (2006). Bereaved adults with intellectual disabilities: A Dowling, S., Hubert, J., White, S., & Hollins, S. (2006). Bereaved adults with intellectual disabilities: A combined randomized controlled trial and qualitative study of two community-based combined randomized controlled trial and qualitative study of two community-based interventions. interventions. Journal of Intellectual Disability Research, 50Journal of Intellectual Disability Research, 50(4), 277-287.(4), 277-287.

Fletcher, R. J. (1988). A county systems model: Comprehensive services for the dually diagnosed. In J. Fletcher, R. J. (1988). A county systems model: Comprehensive services for the dually diagnosed. In J. A. Stark, F. J. Menolascino, M. H. Albarelli, and V. C. Gray (Eds.), A. Stark, F. J. Menolascino, M. H. Albarelli, and V. C. Gray (Eds.), Mental retardation and mental Mental retardation and mental health: Classification, diagnosis, treatment, services health: Classification, diagnosis, treatment, services (pp. 254-264). New York: Springer-Verlag. (pp. 254-264). New York: Springer-Verlag.

Hurley, A. D., Folstein, M., & Lam, N. (2003). Patients with and without intellectual disability seeking Hurley, A. D., Folstein, M., & Lam, N. (2003). Patients with and without intellectual disability seeking outpatient psychiatric services: Diagnoses and prescribing pattern. outpatient psychiatric services: Diagnoses and prescribing pattern. Journal of Intellectual Journal of Intellectual Disability Research, 47Disability Research, 47(1), 39-50.(1), 39-50.

Lennox, N., & Chaplin, R. (1996). The psychiatric care of people with intellectual disabilities: The Lennox, N., & Chaplin, R. (1996). The psychiatric care of people with intellectual disabilities: The perceptions of consultant psychiatrists in Victoria. perceptions of consultant psychiatrists in Victoria. Australian and New Zealand Journal of Australian and New Zealand Journal of Psychiatry, 30Psychiatry, 30, 774-780., 774-780.

Levitas, A., & Gilson, S. F. (1989). Psychodynamic psychotherapy with mildly and moderately retarded Levitas, A., & Gilson, S. F. (1989). Psychodynamic psychotherapy with mildly and moderately retarded patients. In R. J. Fletcher and F. J. Menolascino (Eds.), patients. In R. J. Fletcher and F. J. Menolascino (Eds.), Mental retardation and mental illness: Mental retardation and mental illness: Assessment, treatment, and service for the dually diagnosedAssessment, treatment, and service for the dually diagnosed (pp. 71-109). Lexington, MA: (pp. 71-109). Lexington, MA: Lexington Books.Lexington Books.

Lunsky, Y. (2004). Suicidality in a clinical and community sample of adults with mental retardation. Lunsky, Y. (2004). Suicidality in a clinical and community sample of adults with mental retardation. Research in Developmental Disabilities, 25Research in Developmental Disabilities, 25, 231-243., 231-243.

Lynch, C. (2004). Psychotherapy for persons with mental retardation. Lynch, C. (2004). Psychotherapy for persons with mental retardation. Mental Retardation, 42Mental Retardation, 42(5), 399-(5), 399-405.405.

McCall, P. J. (2010). McCall, P. J. (2010). School psychologists’ perceptions and experiences regarding students with mental School psychologists’ perceptions and experiences regarding students with mental retardation and depressionretardation and depression. Unpublished doctoral dissertation, Arizona State University, Tempe. . Unpublished doctoral dissertation, Arizona State University, Tempe.

McCall, P. J. (2006). McCall, P. J. (2006). Depression in adolescents with mild mental retardation: Effects of social skills and Depression in adolescents with mild mental retardation: Effects of social skills and placementplacement. Unpublished master’s thesis, Arizona State University, Tempe. . Unpublished master’s thesis, Arizona State University, Tempe.

ReferencesReferences

McCabe, M. P., McGillivray, J. A., & Newton, D. C. (2006). Effectiveness of treatment programmes for McCabe, M. P., McGillivray, J. A., & Newton, D. C. (2006). Effectiveness of treatment programmes for depression among adults with mild/moderate intellectual disability. depression among adults with mild/moderate intellectual disability. Journal of Intellectual Disability Journal of Intellectual Disability Research, 50Research, 50(4), 239-247.(4), 239-247.

Monfils, M. J. (1989). Group psychotherapy. In R. J. Fletcher and F. J. Menolascino (Eds.), Monfils, M. J. (1989). Group psychotherapy. In R. J. Fletcher and F. J. Menolascino (Eds.), Mental Mental retardation and mental illness: Assessment, treatment, and service for the dually diagnosedretardation and mental illness: Assessment, treatment, and service for the dually diagnosed (pp. (pp. 111-125). Lexington, MA: Lexington Books.111-125). Lexington, MA: Lexington Books.

Pluymert, K. (2002). Best practices in developing exemplary mental health programs in schools. In A. Pluymert, K. (2002). Best practices in developing exemplary mental health programs in schools. In A. Thomas and J. Grimes (Eds.) Best Practices in School Psychology IV (Vol. 2, pp. 963-975). Thomas and J. Grimes (Eds.) Best Practices in School Psychology IV (Vol. 2, pp. 963-975). Washington, DC: National Association of School Psychologists.Washington, DC: National Association of School Psychologists.

Reiss, S., & Benson, B. A. (1984). Awareness of negative social conditions among mentally retarded, Reiss, S., & Benson, B. A. (1984). Awareness of negative social conditions among mentally retarded, emotionally disturbed outpatients. emotionally disturbed outpatients. American Journal of Psychiatry, 141American Journal of Psychiatry, 141(1), 88-90.(1), 88-90.

Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review. Rones, M., & Hoagwood, K. (2000). School-based mental health services: A research review. Clinical Child Clinical Child and Family Psychology Review, 3and Family Psychology Review, 3(4), 223-241.(4), 223-241.

Ruedrich, S., Noyers-Hurley, A. D., & Sovner, R. (2001). Treatment of mood disorders in mentally Ruedrich, S., Noyers-Hurley, A. D., & Sovner, R. (2001). Treatment of mood disorders in mentally retarded persons. In A. Dosen and K. Day (Eds.), retarded persons. In A. Dosen and K. Day (Eds.), Treating mental illness and behavior disorders in Treating mental illness and behavior disorders in children and adults with mental retardation children and adults with mental retardation (pp. 201-226). Washington, DC: American Psychiatric (pp. 201-226). Washington, DC: American Psychiatric Press.Press.

Stavrakaki, C., & Lunsky, Y. (2007). Depression, anxiety and adjustment disorders in people with Stavrakaki, C., & Lunsky, Y. (2007). Depression, anxiety and adjustment disorders in people with intellectual disabilities. In N. Bouras and G. Holt (Eds.), intellectual disabilities. In N. Bouras and G. Holt (Eds.), Psychiatric and behavioural disorders in Psychiatric and behavioural disorders in intellectual and developmental disabilitiesintellectual and developmental disabilities (pp. 113-130). London: Cambridge University Press. (pp. 113-130). London: Cambridge University Press.

Stoddart, K. P., Burke, L., & Temple, V. (2002). Outcome evaluation of bereavement groups for adults Stoddart, K. P., Burke, L., & Temple, V. (2002). Outcome evaluation of bereavement groups for adults with intellectual disability. with intellectual disability. Journal of Applied Research in Intellectual Disabilities, 15, Journal of Applied Research in Intellectual Disabilities, 15, 28-35.28-35.

Thurneck, D. A., Warner, P. J., & Cobb, H. C. (2007). Children and adolescents with disabilities and health Thurneck, D. A., Warner, P. J., & Cobb, H. C. (2007). Children and adolescents with disabilities and health care needs: Implications for intervention. In H. T. Prout and D. T. Brown (Eds.), care needs: Implications for intervention. In H. T. Prout and D. T. Brown (Eds.), Counseling and Counseling and psychotherapy with children and adolescents: Theory and practice for school and clinical settings psychotherapy with children and adolescents: Theory and practice for school and clinical settings (4th ed., (4th ed., pp. 419-453). Hoboken, NJ: John Wiley & Sons.pp. 419-453). Hoboken, NJ: John Wiley & Sons.

Whitaker, S., & Read, S. (2006). The prevalence of psychiatric disorders among people with intellectual Whitaker, S., & Read, S. (2006). The prevalence of psychiatric disorders among people with intellectual disabilities: An analysis of the literature. disabilities: An analysis of the literature. Journal of Applied Research in Intellectual Disabilities, 19Journal of Applied Research in Intellectual Disabilities, 19, , 330-345.330-345.