Intellectual Disability Psychiatry

A Practical Handbook

Angela Hassiotis, Diana Andrea Barron, Ian Hall

• Publisher: Wiley
• Year: 2013
• ISBN:
  9781118709856
• Edition: 1
• Topic: Medizin
• Subtopic: Psychiatrie & geistige Gesundheit

Intellectual Disability Psychiatry is a comprehensive and accessible guide to the management of mental health problems in people with intellectual disabilities. A clear and user-friendly handbook, it will help busy healthcare professionals develop their understanding of the mental health problems of service users with intellectual disabilities. Most importantly, it will help them make an accurate diagnostic assessment and develop and implement an holistic, person-centred, evidence-based management plan.

Topics covered include the classification of mental disorders in intellectual disability, the clinical assessment of specific disorders, psychological, psychopharmacological and social interventions, and the practical, legal, and social aspects of supporting service users with intellectual disability who have mental health problems.

1

Introduction

Angela Hassiotis¹, Diana Andrea Barron¹ and Ian Hall²

¹Department of Mental Health Services, University College London, UK

²East London NHS Foundation Trust, UK

Clinical involvement with, and awareness of, disability is a core component of the current undergraduate medical curriculum. It is one of eight key themes recommended by the General Medical Council which run through the entire five-year medical programme. Despite this, the majority of clinicians who only meet individuals with intellectual disabilities occasionally, often only have limited experience or training in how to work with this group where communication difficulties and variable symptom presentation create particular challenges in the consulting room.

Intellectual Disability Psychiatry: A Practical Handbook has been written and edited by working clinicians and academics in intellectual disabilities with the aim of creating a concise and practical text that addresses the clinical uncertainties that we face in everyday practice.

Working with people with intellectual disability is intellectually stimulating and professionally rewarding. All contributors have day-to-day clinical contact with people with intellectual disabilities, run diverse and innovative services and train undergraduate medical students and psychiatrists in training.

The complex clinical case work and emerging advances in epidemiological and health services research make this an exciting and interesting field. Recent government policy guidance provides an impetus for service innovation and the results of public enquiries help to prioritize initiatives to combat discrimination that people with intellectual disabilities can be subjected to when accessing health services.

People with intellectual disabilities experience high rates of mental disorders especially if problem behaviours are included in the prevalence rates. They are more likely to have associated physical health problems particularly people with more severe intellectual disabilities. There are many challenges in supporting people with intellectual disabilities overcome mental health problems. The ascertainment of mental disorders in this population is far from straightforward: the existing major classification systems, ICD-10 and DSM-IV-TR, are difficult to apply because the criteria for many mental disorders assume a level of ability and development that is lacking in our population. Furthermore, onset or relapse of a mental disorder may be unrecognized because of assumptions that people with intellectual disabilities behave in a certain way. Conditions that are treatable may therefore remain untreated and consequently the individual’s needs are not met and their quality of life is reduced. Intellectual Disability Psychiatry will enable readers to effectively challenge this diagnostic overshadowing.

Chapters cover the key topics in the psychiatry of intellectual disability and include illustrative cases and examples of good practice. Communication is the topic of our first main chapter, and returned to many times in Intellectual Disability Psychiatry because it is so essential. Good communication skills can make all the difference for a clinician to be able to identify mental health problems in people with intellectual disabilities, and deliver treatment interventions.

In many parts of the world, there are no specific mental health services for people with intellectual disabilities. In other places, people with intellectual disabilities use a combination of specialist and mainstream services. We hope Intellectual Disability Psychiatry, written from a practice perspective, will help enable all psychiatrists to have the confidence and skills to work with people with intellectual disabilities. We have designed it to be an invaluable aid in achieving professional competencies and passing professional exams such as the MRCPsych. It is also highly relevant to other health professionals and social workers working with this client group.

We have deliberately avoided making Intellectual Disability Psychiatry an exhaustive research guide, though references to important papers are included as well as suggestions for further reading.

Psychiatry for people with intellectual disabilities is a very well established specialty in the United Kingdom, and several of our contributors use UK legislation and services to illustrate important principles. However, the content and information presented in Intellectual Disability Psychiatry can be adapted and applied in other settings outside the UK. We have intentionally adopted an international perspective in our community care chapter, and solicited contributions from three continents to help ensure an outward looking, forward thinking focus.

2

Effective Communication

Diana Andrea Barron¹ and Emma Winn²

¹Department of Mental Health Sciences, University of London, UK

²Camden Learning Disabilities Service, London, UK

2.1 Introduction

This chapter aims to give some good practice points to facilitate communication with people with intellectual disability. In reality very few practitioners will have any training specific to the communication needs of this group of people. Our Health, Our Care, Our Say: A New Direction For Community Services [1] drew attention to the lack of skills and training; stating that there is a need to build up skills, especially in basic communication, in social care settings where only 25% of employees have a qualification. Healthcare for All [2] recommends that training for all health care professionals at undergraduate and postgraduate level must include intellectual disabilities on the curriculum.

People communicate in a variety of different ways and all have a right to communicate. A simple definition of communication is dependent upon three things:

1. a message to communicate

2. people who need to communicate with each other

3. a shared way of communicating.

This simple definition applies to everyone regardless of their age and ability to communicate.

Understanding and improving communication can greatly enhance clinical care and the experience of people with intellectual disabilities and those working with them. Moreover recent changes in UK legislation formalize a duty upon practitioners to strive to communicate effectively with individuals in order to maximize their understanding and ability to make decisions. For this reason we hope that this chapter will be used by the reader to help inform their understanding of many other parts of this textbook.

We discuss the different components of communication and the way that these impact upon the assessment and management of mental health disorders in people with intellectual disabilities. The basis of communication difficulties and their prevalence are outlined.

We also consider the general issues of communication in a clinical setting and the role of communication with others including carers, other disciplines and agencies that are frequently involved in the network working with a person with intellectual disabilities. The chapter is written from the joint perspective of psychiatry of intellectual disabilities and speech and language therapy and includes good practice points and case vignettes that can be used by readers to improve their own communication practices.

2.2 Background

There is a high incidence of communication difficulties in people with intellectual disabilities in comparison to the rest of the population. Research has indicated that anything between 50 and 90% of people with intellectual disabilities have such difficulties [3]. Therefore health professionals need to modify their communication to accommodate the communication needs of the person with intellectual disabilities. This will include spoken language, non-verbal communication such as facial expression, body language and gestures and any written forms of communication.

An approach that encompasses all the above and values all forms of communication equally is Total Communication. This is the communication approach that we have based the chapter on. The environment plays a key role in promoting effective communication. Considerations should also be made to ensure that communication is culturally appropriate with increased use of interpreters versus reliance on family members.

There is a higher incidence of sensory impairments with people with intellectual disabilities than in the general population. The literature shows that up to 60% of people with intellectual disabilities are likely to have a sensory impairment of some kind. 50% of people with intellectual disabilities were found to have a hearing impairment and between 30 and 70% have visual impairment [4, 5]. This figure can rise to 80% with certain ‘at risk’ groups, such as people with Down’s syndrome.

There is also a higher incidence of physical disability amongst people with intellectual disabilities [2] and this can impact on communication skills. Such people are more likely to be dependent on others, therefore the ability and opportunity to communicate their needs and wishes and to have these acted upon is essential. The communication modes such as speech and signing may be more difficult for people with intellectual and physical disabilities to use easily.

From the speech and language therapist’s perspective the communication skills of people with intellectual disabilities are described as:

1. Pre-verbal: This means that people do not have the cognitive abilities to understand words. They have profound and multiple learning disabilities. They can be helped to understand through routines, tone of voice, repetition, the context of the situation, objects and their own experience.

2. Non-verbal: This means that people have abilities to understand words but do not have the ability to express themselves using words and will use an alternative means, for example signing, pictures.

3. Verbal: People will have a variety of skills in understanding language and expressing themselves, predominantly using speech.

2.3 Professional obligations

Communication with patients, family members, carers and other professionals is an inherent part of everyday practice. There is a general assumption that both doctor and patient are able to understand what is being said and to contribute and respond in a way that is also understood. In clinical practice this assumption often does not hold true particularly in the context people with intellectual disabilities. In these situations doctors have a duty to communicate in a way that is appropriate for the individual.

This duty stems from the doctor’s duty to preserve the autonomy of the patient, their right to self-determination and is a cornerstone of medical ethics. Increasingly this ethical principle has become incorporated into the law and has led to legal obligations set out in statute. See Box 2.1 for key statutes and policy applicable in England.

Box 2.1 Key statutes and policy in Eng...