Working Psychologically with People with Intellectual Disabilities

Question 1

What is ID?

Answer 1

The term ‘Intellectual disability’ (ID) is now more commonly used in research, government papers and BPS.
However many services in the UK still use the term ‘Learning disability’ (LD)

Question 2

How does the Department of Health (2001) define an ID?

Answer 2

Department of Health (2001) defined an ID as having three key aspects:

1. Significantly reduced ability to understand new or complex information, and to learn new skills (IQ <70). However, just looking at IQ is not sufficient
2. A reduced ability to cope independently e.g. impaired social functioning
3. A condition that started before adulthood (aged 18) and has a lasting effect – a condition that someone has been born with that affects their ability to learn new skills and cope.

Question 3

How do we measure IQ?

Answer 3

¥ The Wechsler Adult Intelligence Scale – has a full-scale IQ (IQ number). Determined by a number of different tests. Can be split into verbal IQ (VIQ) (e.g. verbal comprehension, vocabulary) and performance IQ (PIQ) (assessed by our ability to perceptually manipulate information, e.g. making up shapes and processing speed).
¥ Average IQ is an IQ of 100. Less than 70 indicates an ID.
¬ IQ is a multi faceted concept, so caution is required about how we apply it.

Question 4

When should we use IQ tests?

Answer 4

1) They are designed for individual administration not groups – one-to-one assessment.
2) They are constructed on the basis of the normal distribution of ‘general intelligence’ and standardised using a representative sample of adults in the UK.
3) Reliable and valid.
4) Based on multidimensional, hierarchical model of intelligence NOT just based on a single score but made up of a range of composite score.s
⎫ Wechsler Adult Intelligence Scale IV (WAIS IV) is the only one that does all of this.
⎫ Also “WISK” for children

Question 5

Why should ID’s be categorised further?

Answer 5

People who have an intellectual disability have a wide range of experiences and impact of the intellectual disability can be further categorized as:
♣ Mild
♣ Moderate
♣ Severe
♣ Profound, e.g. dealing with someone non-verbal – this would change the type of assessment you would use for this person.
Because of the impact, it can’t be reduced to just being measured by IQ. Also use clinical assessments, home assessments, and school assessments.

Question 6

What is the importance of physical and psychological health care for people with ID?

Answer 6

¥ People with an ID are more likely to develop physical and psychological health difficulties.
¥ Yet people with an ID are less likely to access services.
e.g. Less than 55% of eligible adults with an intellectual disability received a health check in 2010/11. Even though they have increased need, they’re less likely to access this.

Question 7

Why are mental health services important for people with an ID?

Answer 7

People with an intellectual disability are more at risk of:
1. Vulnerability to abuse
2. Higher social deprivation
3. Poor communication skills so less able to communicate when feeling anxious/low in mood, so less likely to get the help that they’re needing -
All of which are risk factors for poor metal health.

Question 8

What is the historical overview of ID’s?

Answer 8

¬ Hospitalisation was dominant model – people with an ID and mental health difficulties would be hospitalized.
¬ The picture above is of Bedlam Hospital approx. 1739 (now The Bethlem Hospital)
¬ 1953 nearly half of NHS beds were for mental illness and/or people with an ID.
¬ Concerns about the level of spending were likely to be a factor in shifting government thinking towards Community Care policies
¬ 1961 Enoch Powell, Minister of Health, says mental health hospitals to close in 15 years.
¬ 1980/90s shift to care in the community model - which leads to range of client-focused mental health therapies, which hadn’t been developed/researched before.

Question 9

What does the BPS suggest?

Answer 9

The British Psychological Society (2011) suggests “to promote valued, inclusive lives for people with learning disabilities. Much of our work is with those with complex needs and this value base guides our clinical interventions”. We should be thinking how we can enable those with an ID to access help.

Question 10

What are key clinical areas identified by the BPS?

Answer 10

¥ Assessment of capacity, e.g. intellectual capacity for understanding certain aspects of their lives
¥ Behaviours that challenge services
¥ People with mental health difficulties, e.g. differences in ability to recognise (such as depression, anxiety)
¥ People with Autistic Spectrum conditions
¥ People with dementia or who are at risk of developing dementia
¥ Offenders and those at risk of offending
¥ People with profound and multiple intellectual disability
¥ People with physical health needs.
¥ Supporting parents who have an intellectual disability – supporting service around that young person.

Question 11

What are community learning disability teams?

Answer 11

¥	Community Learning Disability Nurses
¥	Speech and Language Therapists
¥	Clinical Psychologists
¥	Occupational Therapists
¥	Physiotherapists
¥	Psychiatrists
¥	Social workers/care managers

Question 12

Who to work with?

Answer 12

¥	Individual clients
¥	Groups
¥	Families 
¥	Staff teams
¥	Services, e.g. liaison with social workers and schools
¥	Multidisciplinary working

Question 13

What are individual emotional/psychological difficulties for those with an ID?

Answer 13

e.g.
¥	Anxiety
¥	Depression
¥	Anger
¥	Bereavement
¥	Behavioural problems

Question 14

What is assessment for those with an ID?

Answer 14

¥ Cognitive assessment – IQ assessment and home reports
¥ Dementia assessment
¥ Autistic Spectrum Disorders
¥ Service needs
¥ Capacity to consent
¥ Risk assessment – is the person at risk in the places they live or the services they are using?

How might clinical work be different with people with an intellectual disability?

Question 15

What is the core principle of CBT?

Answer 15

¥ May do more work on behavioural level with those with ID

¥ Able to engage in CBT as long as adaptions are made

Question 16

What is the focus on behavioural work?

Answer 16

¥ “Challenging behaviour – or behaviour that challenges”.
¥ Some people with an intellectual disability display behaviour which may put themselves or others at risk, or which may prevent the use of ordinary community facilities or a normal home life.
¥ This behaviour may be in the form of aggression, self injury, stereotyped behaviour or disruptive and destructive behaviours.
¥ Often times, however, that behaviour can be serving a purpose for that individual – Hewett, 1998 – “challenging behaviour in people with learning disabilities can be seen as an appropriate response to the forces affecting them in their lives”.
¥ For all of us, behaviour serves a purpose. For people who may be non-verbal or have problems with communication, behaviour problems are a form of communication, and serve a purpose.

Question 17

How does positive behaviour support to manage behaviour that challenges?

Answer 17

Dunlap et al. 2009
AIM: Understand the meaning of behaviour for an individual and the context in which the behaviours occur – can see why the person is doing that, and help them find another way to communicate.
Key elements:
1. Undertake functional analysis to understand what purpose behavior serves.
2. Inclusion of stakeholder perspective/involvement – including parents, relevant school teachers etc. (support system around that person)
3. Use of ecological strategies to ensure environment meets the person’s needs – e.g. a quieter place
4. Support strategies to manage environment and reduce need for reactive behavior.
5. Enhance Quality of life (QOL) outcomes for person and other stakeholders.

Question 18

What is functional analysis?

Answer 18

¥ Functional analysis is one tool used as part of a wider assessment which examines behaviour that is challenging at three stages.
1. A(antecedent) - what happens just before (trigger)?
2. B(behaviour) - what does the person do?
3. C(consequence) - what does the person get as a result of the behaviour?
May do this in person (very time intensive), have someone videoed and then analyse the video, to unpick behaviours and what purpose this seems to be serving to understand patterns of behaviour.

Question 19

What are ABC charts?

Answer 19

Get to record an ABC chart (antecedent, behaviour and consequence) for different behavioural occurrences. May do this multiple times. If someone is non-verbal, maybe give them signs around meal times to avoid this self-harm behaviour. Being taken out of the classroom – may be helpful as it is quieter etc.

Question 20

What function does challenging behaviour serve for people?

Answer 20

¥ Social attention
¥ Tangibles e.g. getting yogurt off someone
¥ Escape
¥ Sensory

Question 21

What is behavioural intervention?

Answer 21

¥ Address antecedents (triggers) – can we remove triggers, and is this useful to prevent challenging behaviours?
¥ Address consequences (reinforcers) – e.g. being taking out of class
¥ Address function – what is that person trying to tell us? If there is a clear communicative intent, we need to help that person communicate in another way
¥ The therapist is directive and work is done through others (carers, family)

Question 22

What is CBT?

Answer 22

¥ Based on the premise that our thoughts and beliefs primarily influence our emotions and behaviours
¥ External events are processed by cognitions to create personal meaning for an individual – it’s the interpretation we give things that gives them their strength
¥ Almost all behaviour is a product of an interaction between external events, cognitions, and emotions

Question 23

How can we adapt CBT for a person with an ID?

Answer 23

¥ CBT is effective for people with an intellectual disability as long as adaptations are made to ensure the client can engage with the model.
¥ Examination of the evidence base for CBT for people with an intellectual disability suggests post research participants had a mild to moderate learning disability (Barrera 2017)

Question 24

What are potential requirements and modifications for CBT?

Answer 24

Potential requirements for CBT:
¥ Emotional recognition
¥ Naming and reporting emotions
¥ Linking situation to mood
¥ Identifying and reporting thoughts
¥ Memory – enough ability to remember information
¥ Oriented in time/space
¥ Sequencing
¥ Understanding cause and effect
¥ Rating moods and beliefs
¥ Recording- writing, reading
¥ evaluating
Modifications to CBT:
¥ Consider alterations to though records/diaries e.g. Dictaphones or images
¥ Structure during sessions is important
¥ Allow more time (more sessions) and consider more behavioral work
¥ For home work use more visual aids/supportive strategies
¥ Consider engaging the system family/carers around the individual in therapy/homework if you have permission from your client

Question 25

IAPT practitioners’ experiences of providing therapy to people with intellectual disabilities (reading) - Shankland and Dagnan

Answer 25

Online survey of IAPT practitioners about their experience, confidence and attitudes to working with people with ID’s. Identified need to adapt theory, but believe it should be offered in mainstream services. Said they need extra training. Problems people with an ID have accessing help include lower communication skills and lower cognitive skills.

Question 26

What is the WHO’s bio-psychosocial model of ID’s?

Answer 26

At the top of the model, consider the biological contributions to the aetiology of ID’s, e.g. Down’s, maternal drug abuse etc. May have had consequences on neurological system. At the bottom of the model consider the environmental and personal factors (expectations, adjustments, personality of the person, their resilience and coping styles, etc.). Model moves focus onto functioning, which is dependent on the interrelating set of factors, suggests a wider range of possibilities in terms of intervention.