Intellectual Disabilities Flashcards
What are the 3 diagnostic criteria for an intellectual disability?
- Significant impairment of intellectual functioning
- – IQ of >2 S.D.s below the mean on a standardised measure
- – I.e. <69 on the WAIS-IV for adults
- Significant impairment of social adaptive functioning
- – “The collection of conceptual, social and practical skills that have been learned and are performed by people in their everyday lives”
- – Performance ought to be assessed against cultural and peer group expectations
- – Recommend use of a standard measure
- – Deficits should not be solely result of illness, physical/sensory disability, mental health problems
- Age of onset before 18 years of age
- – Difficulties should start during developmental period
What are the criticisms of the diagnostic criteria for an intellectual disability?
- The constructs of IQ and social & adaptive functioning are contested ones; decisions about what skills are relevant involve imposition of cultural assumptions
- There are problems with the reliability and validity of the tests of IQ and social adaptive functioning
- The criteria say nothing about aetiology; access to education etc.
- Diagnosis is reliant upon an arbitrary cut-off point that isn’t necessarily sensitive to whether a person needs support or not
What are some of the problems with IQ assessment validity and reliability?
- Intelligence’ is a contested construct
- Ethnic and class bias
- ‘Flynn effect’ – environmental causes?
- Poor WAIS-WISC inter-correlation
- – WAIS = adults
- – WISC = young persons
- Floor effects impact on ability of tests to detect lower IQ scores
- – The further we go from the mean, the less accurate the tests are
What are some of the problems with assessing social and adaptive functioning?
- Methodological issues
— Reliant on self-report or carer’s perspectives
• Respondents may be motivated to rate a person’s abilities higher or lower
— Poor reliability when all sources of error are factored in
— Measures normed in USA
• Cultural differences!
— Equal weighting given to items irrespective of impact on person’s life - Theoretical/epistemological issues
— Little consensus as to what skills should be assessed
— Concepts risk exclusively locating vulnerability and difficulties within individuals
• Medical model of disability
— Influenced by and reinforce socio-cultural norms
• Dominant societal ideas about how people should behave day to day
What are some of the possible aetiological factors for intellectual disability?
- Genetics:
— Genetic profiles for particular syndromes
• Down’s syndrome, Prader-Willi
• Genetic aetiology uncommon for ‘significant’ IDs
• More common for severe - Pre- and post-natal bacterial and viral infection
- Peri- and post-natal oxygen starvation, brain injury, seizure activity
- Trauma and abuse
- Poverty
- Malnourishment
- Lack of access to prenatal care
- Lack of access to birth care
- Lack of access to education
- Parental substance dependency
- Domestic violence (witnessed as a child)
- Parental rejection/abandonment
- Lack of stimulation; neglect
- Neglect/chronic stress
— Gerhardt, 2004
— Read et al 2014
— Brain development inhibited in many ways, including:
• Underdevelopment of prefrontal and orbitofrontal cortices
• Smaller hippocampi, decreased short-term and long-term memory, deficits in new learning
• Prolonged cortisol release through stress results in cell death and stops neural growth
What are some factors associated with increased distress amongst people with intellectual disabilities?
- Embodied/biological factors
- – Sensory differences/impairments
- – Difficulties with cognitive processes (executive functioning, theory of mind, problem solving)
- – Behavioural phenotypes
- – Limited expressive communication skills
- Environmental/systemic factors
- – Limited opportunities for communication
- – Disempowered; enmeshed with systems
- – Social isolation
- – Mismatch between environments and developmental needs (e.g. discourses of ‘age appropriateness’ or ‘independence’)
- Social material factors
- – Significantly more likely to be victim of all kinds of abuse (sexual, emotional, physical, financial)
- – Hate crime: 88% experienced bullying/harassment in past year, 32% victimised daily/weekly - Mencap, 2007
- – Poverty, unemployment, cuts to support
- – Low levels of meaningful activity → boredom
- – Social exclusion and marginalisation
- – Society structured such that resources distributed in relation to someone’s ability to contribute to the economy
What are some indirect interventions for intellectual disabilities?
- Applied behaviour analysis
— Easily operationalised, outcomes observable → good evidence base
— Ethical stance has been criticised (Emerson and McGill, 1989) - Positive behaviour support
— Evidence supporting:
• Reduction of behaviours that challenge others
• Improved skills and knowledge of staff
— Challenging behaviour – “behaviour can be described as challenging when it is of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion”
• RCP/BPS, 2007
— Recommended by NICE
— Tends to ignore the importance of relationships, both as:
• “Triggers”
• In terms of staff and service users having different relationships
— PBS plans/training don’t change the culture of services
— Focus on skill development: privileges independence over “being with” and acceptance of the individual
What role does Bowlby’s attachment theory play in intellectual disabilities?
- Interactions between infant and attachment figure(s) are necessary for emotional development
— E.g. Tronick’s still face experiment - Infants share an instinct to seek proximity to an attachment figure when under stress
- Responses of attachment figure impact on how child comes to respond to stress as an adult
- Responses to the infant vary with factors related to carer; infant; environment
- In non-ID populations a ‘securely attached’ infant is likely to become an ‘autonomous’ adult
— 60% of the time - Impact of insecure attachment:
— Potential for learning inhibited by insecure attachment
— Attention focused on hyperactivation/deactivation
— In children, evidence of:
• Less persistence in problem solving aged 2yrs (Meins, 1997)
• Poorer theory of mind at age 4-6 (Meins et al 1998)
• Difficulties in interactions with peers and associated low self-esteem (Groh et al 2014)
• Infant more likely to find it harder to ‘self-soothe’ as grows older
— In adults, evidence of:
• Increased risk of paranoia and diagnosis of schizophrenia (Sitko et al 2014)
• Low mood and increased likelihood of being diagnosed with other ‘mental health problems’ (Fossati et al 2003) - Some studies suggest attachment security rates are similar between ID and non-ID populations (Larson et al 2011)
- Possible reasons for increased attachment difficulties:
— PwID more likely to have been separated from attachment figures in hospital due to complications at birth
— Infants with ID may respond slower to their attachment figures’ interactions resulting in difficulties with attunement (how ‘in-synch’ infant & attachment figure are) → decreasing levels of interaction
— PwID more likely to have been abused or neglected as children
— PwID more likely to grow up in poverty → impacts negatively on attachment figure’s abilities to be emotionally& physically available
— Parents often experience stress in relation to parenting a child with ID associated with feelings of ‘loss’ for the fantasised ‘perfect child’ - Insecure attachment and people with ID (PWID)
— Avoidant → dismissing:
— Higher rates of substance misuse, masturbation
— Interact with others as if an object
• E.g. talking at, rather than with
— Anxious-ambivalent → preoccupied
• Obsessive/monotropic relationships formed with certain staff members: follow the person around, jealous of threat to attention from others, attention-needing
• Difficulty exploring/engaging in activities that they might be capable of
— Disorganised → unresolved
• Struggle to self-soothe
What attachment-based interventions are there for intellectual disabilities?
Damen, Kef, Worm, Janssen, Schuengel. 2011
- The start of the Contact programme coincided with improved quality of interaction between professional caregivers and clients with visual and intellectual disabilities in group homes
— When clients signaled, professional caregivers more often provided evidence for their attention by showing an explicit confirmation of this signal
— When clients took initiatives for interaction, they were often met with a response
— The overall quality of the interaction became more characterized by affective mutuality
- The expectation was that by positively influencing the responsiveness of the professional caregivers, clients would also become more responsive to the initiatives of the professional caregivers
— No evidence of this was found
— A longer follow-up period would be advisable
- Generalization beyond the clients in the study should be carried out with caution, due to the low statistical power of the test and small sample size
Sterkenburg et al 2008
- Integrative therapy for attachment and behaviour
— For children with a severe ID and severe, therapy-resistant challenging behaviour, showing little or hardly any attachment behaviour towards their caregivers
- 3 phases:
— 1 = a therapeutic attachment relationship is built by following the stages in the development of an attachment relationship (between client and therapist)
— 2 = reward value is used to leverage behaviour modification of remaining challenging behaviours
— 3 = support the daily caregivers in building secure attachment relationships with the client as well, so that the therapist can reduce the investment in the relationship
Schuengel, Kef, Damen and Worm – 2012 = Video interaction guidance
- Has been shown to enhance positive parenting skills, reduce parents’ stress and help the child’s development
— Kennedy, Landor and Todd, 2011
- Professional caregivers participated in an intervention to improve interaction with children and adults with serious intellectual and visual disabilities
- Completed a video-feedback interaction program
- 51 caregivers
— Only 18% male
- Caregivers received 4 coaching sessions following the baseline recordings
- Training and supervision of the interaction coaches was provided by one of the developers of Contact
- Generally, interaction quality improved from baseline to intervention period
— Indicated by confirmation of signals, responsiveness to signals and affective mutuality
Cooper et al, 2005 - The Circle of Security
- Aims to increase parents’ awareness of their child’s attachment needs and to develop healthier attachment relationships between parents and children
- Marvin, Cooper, Hoffman and Powell – 2002
— A 20 week, group based, parent education and psychotherapy intervention designed to shift patterns of attachment-caregiving interactions in high risk caregiver-child dyads to a more appropriate developmental pathway
— The dyad is videotaped during an interaction
— This is shown to the group, whereby the group members evaluate the interaction
— Look at an area of competency and an area in which they are struggling
Hughes, 2011 = Dyadic Developmental Psychotherapy
- Involves therapy sessions with a child and their caregiver using PACE (playful, acceptance, curious and empathic)
- The therapist attunes to the child’s emotional state and experiences when they are talking about distressing experiences of mistreatment and abuse
- A good therapeutic relationship is important here
Hudson, Matthews, Gavidia-Payne, Cameron, Mildon, Radler and Nankervis – 2003 = Signposts
- A flexible intervention system for families of children who have intellectual disability and challenging behaviour
- Designed so that it can be delivered in several different ways, i.e. group support (led by therapist), telephone support and self-directed modes (+ waiting list control)
- 115 mother-child dyads included in study
- The design is only semi-randomised – due to families not wanting to travel to the venue of the group meetings and schools requesting group format to be delivered at their school
- Only 65 (57%) families completed the post-test measures
— High drop out rate!
- After use of Signposts materials in parent training programmes, the subjects reported that they were less stressed, felt more efficacious about managing their children’s behaviour, less hassled about meeting their own needs and that their children’s behaviour had improved
- There were minimal differences among the 3 modes of delivery on the measures used
— But those who used the self-directed mode were less likely to complete the materials
Sterkenburg, Janssen and Schuengel – 2007
- A combination of an attachment based therapy and behaviour modification was investigated for children with persistent challenging behaviour
- Participants = 6 clients with visual and severe intellectual disabilities, severe challenging behaviour and with a background of pathogenic care
- Challenging behaviour was recorded continuously in the residential home and during therapy sessions
- In phase 1, the experimental therapist attempted to build an attachment relationship in sessions alternating with sessions in which a control therapist provided positive attention only
- In phase 2, both therapists applied the same behaviour modification protocol
- Across clients, challenging behaviour in the residential home decreased during the attachment therapy phase
- The behaviour modification sessions conducted by the experimental therapist resulted in significantly more adaptive target behaviour than the sessions with the control therapist
