12. Working with People with Intellectual Disabilities

Question 1

Why do clinical psychologists see people with intellectual disabilities?

Answer 1

See them for the additional physical and life challenges faced as a result of their intellectual disability. More prone to psychological and behavioral problems due to their limited intellectual capacity.

Question 2

What are the 3 domains of adaptive functioning?

Answer 2

1) conceptual domain
- language, reading, writing, memory, math, reasoning
2) social domain
- empathy, social judgment, interpersonal communication skills, ability to make and retain friendships
3) practical domain
- personal care, independent living skills, money management, time management

Question 3

What are the 3 types of additional challenges people with intellectual disabilities face?

Answer 3

1) intellectual disability linked disorders
2) psychological problems
3) stigma and prejudice

Question 4

What kind of intellectual disability linked disorders may clients face?

Answer 4

physical problems - sensory deficits, mobility, and respiratory problems.
behavioral problems - overeating (prader-willi syndrome)

Question 5

What are some common psychological problems people with intellectual disabilities face?

Answer 5

Anxiety and depression

due to tough demands of living in modern society

Question 6

In what ways does stigma and prejudice contribute to psychological pressures experienced by those with intellectual disabilities?

Answer 6

People with intellectual disabilities naturally have fewer psychological resources to manage negative attitudes and are even less able to fight for their rights. This brings additional psychological pressures to an already vulnerable group

Question 7

Therapist should consider the problems faced by the individual with intellectual disabilities within a ____ framework.

Answer 7

Ecological

work at the individual level, support structures level, community level

Question 8

What other the different biological congenital contributions? (6) GAPPES

Answer 8

• Genetic
• Acquired
• Prenatal
• Postnatal
• Environmental (eg. pollution)
• Social (eg. malnutrition)

Question 9

Biological factors can impact body ____ and __ __.

Answer 9

function; structure

Question 10

How can environmental factors influence individuals with intellectual disabilities?

Answer 10

• others’ reactions can influence their self-esteem and sense of inclusion
• others’ lowered expectations on them can hinder them from reaching their full potential

Question 11

How can personal factors play a role in individuals who face intellectual disabilities?

Answer 11

• personality of individual
• resilience and coping styles
• gender and age

Question 12

What are the benefits of using a bio-psychosocial model in understanding the problems faced by individuals with intellectual disabilities?

Answer 12

Takes focus away from individual’s disability to consider contextual factors that are interrelated. These disabilities can be conceptualized in terms of a social construct (ie. something that only exists in this time and place as a consequence of how we structure our society such as demand for high levels of literacy)

Question 13

What are the different types of referrals related to intellectual disability?

Answer 13

• Assessment of learning disability
• Challenging behaviors
• Mental health issues: anxiety, depression, anger
• Victims/Perpetrators of abuse and harm
• Bereavement/loss
• Sexually inappropriate behavior
• Family issues (caregiver burnout, carer’s consultation and training)
• Baseline assessments (eg, dementia, down syndrome)
• Capacity assessments

Question 14

When do challenging behaviors require intervention?

Answer 14

When they are of such intensity, frequency, or duration as to threaten the QOL and/or the physical safety of the individual or others, and likely to lead to responses that are restrictive, aversive, or result in exclusion

Question 15

What strategies do families usually use to tackle challenging behaviors?

Answer 15

Use aversive or restrictive methods (eg. tying them or holding them down, keep them at home). Modification of behavior to fit in with institutional environments.

Question 16

What alternative strategy should family use instead?

Answer 16

positive behavioral support! :) more respectful, integrated approach.

Question 17

What are the characteristics of positive behavior support? (PBS)

Answer 17

1) Based on Applied Behavioral Analysis (ABA) principles, but set within a clear framework of rules. Strong values-based and delivered in person-centred ways. Most ethical form of support.
2) Non-linear. Recognise that multiple Antecedents and Consequences may act on a behavior simultaneously.
3) Most recommended approach with challenging behavior

Question 18

What are the 5 components of PBS?

Answer 18

1) Functional analysis to understand the purpose of the behavior for the individual
2) Ecological strategies - ensure that environment meets the individual’s needs
3) Positive programming - teach the person skills to control the environment
4) Focused support strategies - manage context and reduce need for reactive strategies (eg. avoid noisy places)
5) Reactive strategies - gain control of the situation once behavior has occurred, reduce escalation

Question 19

The effectiveness of PBS is dependent on what?

Answer 19

Dependent on the caregivers who are delivering it on a day-to-day basis.

Question 20

For individuals with intellectual disabilities, will psychoeducation work?

Answer 20

Sometimes, but usually no because it’s hard to communicate with them. Some won’t even acknowledge your presence. Hence behavioral and systemic intervention seems to be the way to go.

Question 21

What is the aim of systemic interventions?

Answer 21

To look for positive cycles in the family. Give family the necessary skills to care for the client.

Question 22

What does it mean to find out the meaning of the client’s behavior?

Answer 22

Finding out what the client is trying to communicate through his challenging behaviors. (eg. attention? sensory seeking?)

Question 23

What are some systemic reflections you should consider as a therapist?

Answer 23

1) where is the problem located? individual or relationships
2) meaning of behaviors?
3) mum’s expectations of you?
4) gender roles in the family?
5) will traditional client-in-clinic model work?

Question 24

According to Matthew’s slides, what are the 3 components of Positive Behavioral Support?

Answer 24

1) Applied Behavioral Analysis
2) Social Valorization
3) Person Centered

Question 25

What is Applied Behavioral Analysis (ABA)?

Answer 25

• Comprehensive functional assessment. understanding the meaning and function of the behavior.
• Recognizes that there are different contributors (Antecedent, Consequences). Relationship between ABC may not be on a linear track, can have feedback loops.
• A behavioral intervention

Question 26

What is social valorization?

Answer 26

• The guiding value system that guides ABA towards inclusion, choice, independence, respect. ABA can shape behaviors through means that can be quite constraining and aversive.
• views challenging behaviors as mismatch between needs and context. Allow system to better support their disability.
  (eg. visual aids)

Question 27

What does a person centred approach mean in positive behavior support?

Answer 27

• only positive reinforcement, no punishment
• quality of life is primary, challenging behaviors are manifestations and responses to poor QOL. improve QOL = reduce challenging behaviors

Question 28

What is the key concept involved in social valorization?

Answer 28

challenging environments and unmet needs. locating the problem of challenging behaviors in the context, not the person.

Question 29

What are some antecedent triggering environments and consequent reinforcing events that can make the environment challenging?

Answer 29

A - intrusive and limiting environment

C - punitive and distancing environment

Question 30

What is the use of looking at challenging environments and unmet needs?

Answer 30

Opens up more options for treatment/intervention

Question 31

How do you target antecedent triggering events, challenging behaviors, and consequent reinforcing events separately?

Answer 31

A - skills training for carers (proactive strategies)
B - skills training for clients (improve their functioning, help them be less dependent on caregivers, teach them more adaptive alternative behaviors rather than extreme behaviors)
C - skills training for carers (reactive strategies) teach them to react in a more helpful way.

Question 32

What kind of skills training can we do for clients?

Answer 32

Positive programming of behaviors

1) independent living skills
- daily functioning, cooking, public transport, making choices
2) communication skills
- communicating his needs and wants
3) social skills
- interpersonal interaction
4) emotional regulation skills
- understanding and managing strong emotions, learning to wait and be patient

Question 33

What are the 2 kinds of skills training that we provide for caregivers?

Answer 33

1) Proactive strategies (for prevention)

2) Reactive strategies (helpful response to challenging behaviors)

Question 34

Describe proactive strategies

Answer 34

Antecedent control - remove situations that trigger challenging behaviors

• show client more attention (Social support)
• give them more opportunity and choices
• reward him only when he does desired behavior
• sticking to routine and structure (autism)
• enrich the environment
• look into medical problems
• set guidelines and make sure they understand the rationale behind them

Question 35

Describe reactive strategies

Answer 35

• de-escalation: calm and clear voice
• extinction: ignore bad behavior and don’t give in
• natural consequences: get child to clean up if they create a mess
• identifying and removing the trigger immediately. redirect them to new activity. (distraction)
• punishment based approaches not recommended. be as non-intrusive and non-restrictive as possible.
• promote new adaptive behaviors through differential reinforcement
• physical restraint only used in emergencies.

Question 36

As a critical practitioner, you should:

Answer 36

1) take into account cultural, social, language, interpersonal contexts of the case. make sure your recommendations are compatible with the social system
2) design effective environments rather than fix the person
3) respond to the person rather than react to the behavior. The behavior is just a manifestation of poor QOL.

Question 37

How do you find out your client’s needs if they don’t speak or react to you?

Answer 37

done through observation

Question 38

What are some benefits of getting a diagnosis?

Answer 38

• can use the guidelines for treatment

- applying for special school admission

Question 39

In the assessment stage, what sources of information do you need?

Answer 39

1) observation of client in different settings
2) multiple perspectives from family members and closed ones
3) family history and family transitions
4) challenging behaviors using behavior problem inventory - find out frequency and severity of behavior

Question 40

At what stage can the behavior problem inventory be used?

Answer 40

assessment and evaluation to track progress and see if interventions are working

Question 41

What are the 3 aspects of problem behavior measured in the behavior problem inventory?

Answer 41

1) self-injurious behavior (SIB)
2) aggressive or destructive behaviors directed towards others or property
3) stereotyped behaviors that look unusual, strange, or inappropriate

Question 42

Which tool do we use to assess functions of behaviors through ABA?

Answer 42

ABC charts

• help us identify antecedent and consequent factors (what happened before and after the challenging behvior)
• after recording over a period of time, can see patterns emerging

Question 43

What are some guidelines for recording antecedents?

Answer 43

• what happened just before the behavior occurred?
• when, where, what exactly were they doing?
• anyone else around, or anyone just left?
• had a request been made of the person?
• environment noisy, hot, cold, crowded?
• what do you think the person was wanting? specific object or activity?
• person’s mood

Question 44

What are some guidelines for recording behaviors?

Answer 44

• be specific

- don’t give judgmental descriptions

Question 45

What are some guidelines for recording consequences?

Answer 45

• exactly how did you respond to the behavior (step by step description)
• how did the client respond to your reaction
• anyone else around who responded or showed a reaction?
• did their behavior result in them gaining anything they did not have before the behavior was exhibited?

Question 46

What are the 4 principles of formulation for causes behind challenging behavior?

Answer 46

1) social attention - doing it to get attention
2) tangibles - effective way of getting things he want/need
3) escape - simple way out of undesired situations or activities
4) sensory - internally rewarding or can be an emotion regulation strategy when bored or scared

Question 47

How do we assess and evaluate clients with intellectual disability if they can’t fill up scales?

Answer 47

have easy read documents with pictures (Eg. smiley faces) for them to fill up.

Question 48

What is the difficult choice surrounding a vulnerable person such as those with intellectual disabilities?

Answer 48

Their right to be protected vs their right to act in the way they choose.

Question 49

In what cases do we use talking therapies like CBT, cognitive therapy, and psychodynamic approaches?

Answer 49

More effective for individuals with mild intellectual disabilities as they can better engage with the therapy.