EDF, 12.07.2011

Persons with intellectual disabilitiesand mental health problems

Filip Morisse & Leen De NevePsychiatric Centre Dr. Guislain and Caritas

1. Examples

Aggression: yelling, screaming, scratching, hitting, biting, destroying, self-injurious behaviour,… (fight)

Nagging, physical complaining Running away, fugue, restlessness,… (flight) Regression-depression: withdrawal, no more

energy, staying in bed, loss of skills

Problems in eating, sleeping,… Criminal behaviour: offending, sexual assault,

robbery, stealing…

1. Examples

Obsessive-compulsive behaviour

Symptoms of psychiatric disorders: delusions and hallucinations,…

Extreme mood swings

Atypical behaviour problems: skin picking, smearing, ruminating,…

2. Prevalence

30 à 50 % (10% in normal population) More with level of ID Atypical symptoms Most occurring disorders:

1. Autismspectrumdisorders

2. Attachment problems

3. Mood and anxiety disorders

4. Psychotic disorders

3. Definition population: terms

Behaviour problems, behavioural disorders, problem behaviour, emotional problems

Conduct disorder (CD), oppositional-defiant disorder (ODD)

Difficult to understand behaviour Psychic/psychiatric problems/ disorders Mental health problems / needs Co-occurring disorders

3. Definition population

Intellectual disability (ID) and

Challenging behaviour (Emerson, 2001) Dual diagnosis (NADD, 2011) Clinical description in practice (Outreach

St-M, 2011)

3. Definition population

“Challenging behaviour: culturally abnormal behaviour(s) of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities“ (Emerson, 2001)

3. Definition population

“Dual Diagnosis is a term applied to the co-existence of the symptoms of both intellectual disabilities and mental health problems. Mental health problems are severe disturbances in behaviour, mood, thought processes and/or interpersonal relationships… the presence of behavioural and emotional problems can greatly reduce the quality of life of persons with intellectual disabilities” (NADD, 2011)

3. Definition:clinical description in practice

Personal characteristics: Multiplication of vulnerabilities Tendency to present socially desirable and

adapted Behaviour problems as coping way to

survive Difficult detection and diagnostics

3. Definition:clinical description in practice

Characteristics of the environment: Tendency to overestimate and to over-ask Structures and systems of support often

inadequate Inappropriate support because of

indiscriminate and biased interpretation of emancipation/integration paradigm

3. Definition:clinical description in practice

Characteristics of the environment: Caregivers/family sometimes difficult in

regulating balance distance-closeness Expects solid constructs solutions Tendency to control, segregation,

institutionalisation Human rights under pressure

4. Needs of support

Basic Emotional Needs

✓ cognitive abilities

✓ social skills

… It’s all about fine tuning: address people at

appropriate emotional level Sensitive responsiveness Variable => flexible support

4. Needs of support

Respect & Unconditional Acceptance Closeness:

- sensitive responsiveness

- give an answer to signals of pleasure and

displeasure

- basic needs

- adjust tension/anxiety (inner rest)

- care for safety

4. Needs of support

Closeness

Availability

Relapse base

4. Needs of support

Regulate stimuli

- individual differences => observation

- well dosed

- reduction

- balance between rest and action

! be careful: narrowing environment

4. Needs of support

Structure: time and space To bound where it is necessary

- boundaries = safety

- balance between necessary boundaries and indispensible opportunities/chances to get grip on

one’s own life (QOL)

4. Needs of support

An environment that is:

- stimulating and inviting

- safe and with possibilities to “refuel”

- flexible and variable

5. Systems of support in Belgium

History:

- before 1967: care for adults with ID at home or in psychiatric hospitals

- from 1967: specific services for adults with ID: pedagogic places

(however: a lot of adults with ID & additional behaviour problems stay in the

psychiatric hospitals)

5. Systems of support

1990: admissionstop for people with ID

in psychiatric hospitals

2011: still remaining population of

persons with ID in psychiatric centres

(+/- 800)

5. Systems of support

Facilities for people with ID (VAPH)- ‘Care’ (right to adequate support, living)

- Diverse range (nursing home, home for working people, daytime activities centre, living alone with support, living at home with support, etc…)

- Mostly supply-driven, with professional staff, taking over care…

- Low inclusion / still segregated

- Low community based

5. Systems of support

Psychiatric centre

- ‘Cure’ (right to mental health / treatment)

- Still strong residential, medical system

- Units with “remaining”-population (PVT): discrimination !

- Specific Units for treatment of people with ID

6. Bad / good practicesCare-facilities are Supply-driven (package of support) and segregated

Care-facilities are Demand-driven (needs) and more inclusive

Different and separated Models/framework & biased interpretation:- psychiatric: medical, controlling- special education: emancipation / empowering

Integration of the strenghts of each model

Non-flexible way of being in a care-facility (once you’re there, you’re staying there) and redirect people to each other

Flexible use of care-facilities + working together for these people: creating a Circuit of Care: a seamless transition between care/cure facilities = partners

Cure OR Care Cure AND Care

6. Bad / good practices

Restraint (in different ways) – behaviouristic approach – high use of medication

Search for less invasive, less violent ways of approach, with a multidisciplinary team, on a basis of unconditional acceptance

Diagnosis as a label, in a medical/psychiatric perspective

Diagnosis as a dynamic hypothesis, in a multidisciplinary perspective

Priority to the professional staff, in taking care (they’re taking over the care)

Priority to the natural environment, community in taking care (professionals support where needed)

6. Bad / good practices

Hospitalisation, taking away from one’s own environment

Professionals go to the environment = outreach (ambulant modules); support in the natural environment

Forbid relationships, sexuality, etc… because it is difficult

Search for possibilities, support relationships, talk about it etc…

…