Mitchel Fleming reviews two recent articles examining treatment approaches for people with intellectual disabilities who have mental health problems or challenging behaviour. Mitchel Fleming, Senior Clinical Psychologist, Daughters of Charity Services, Dublin

Psychological approaches

Suzanne Collins, a consultant psychologist from Cambridge, reviews the range of psychological approaches used to treat people with intellectual disabilities who present with emotional and behavioural difficulties. These difficulties include anxiety, phobias, depression, sexual abuse, emotional control skills, loss and bereavement, feeling worthless, relationships and attachment difficulties, powerlessness and secondary handicaps.

All psychological treatments are based on an initial thorough assessment of the causes, functions and meaning of the problems with which the individual presents. From this assessment a formulation is made which explains how the person arrived at his or her presenting problems. Reference is typically made to a psychological theory or model which helps make sense of why the person is behaving as s/he is and which will guide the intervention which follows. The psychological models most frequently used to inform therapeutic interventions for people with intellectual disabilities are based on learning, developmental, insight and systemic theories.

The main therapies based on learning theories are cognitive and behavioural therapies, including interventions such as relaxation training, self-control strategies and emotional control skills, exposure procedures and problem solving. A detailed functional analysis usually precedes intervention and processes such as modelling, role play and reinforcement are used to facilitate the learning of new behaviours and attitudes. Positive programming is a fairly new approach based on learning theory. It emphasises the building of greater skills and competencies in order to control challenging behaviour and improve social integration.

Developmental theories, which often overlap with learning theories, are based on an understanding of how people develop cognitions, attachments and social relationships. Interventions using this model include aspects of the TEACCH system in the field of autism, opportunities for people to relearn ways of interacting with others, and providing people with a secure base to form relationships.

Insight theories, which use approaches such as psychoanalysis, are seldom directly used to treat people with intellectual disabilities, although ideas which stem from these models, such as the importance of boundaries, transference and the use of the relationship during the therapeutic process, have been incorporated into other interventions. A systemic approach looks at any structure in terms of its interrelating parts, including complementary beliefs and interconnected relationships. This approach has been most extensively used in work with children and their families.

The success of different approaches is difficult to evaluate. Findings show that there are often problems with the generalisation and continuance of outcomes following treatment. The most crucial element in effective treatment appears to be the preliminary functional analysis which ensures that the correct intervention is subsequently chosen. Dr Collins concludes her review of psychological interventions with a brief case study which illustrates a treatment approach for a person with very complex needs.

Use of medication

David Clarke, of the University of Birmingham, reviews the use medication to treat two broad types of mental health problems among people with intellectual disability: psychiatric disorders such as depression, schizophrenia and obsessive-compulsive disorder, and challenging behaviours such as self-injury, impulsive aggression or inappropriate sexual behaviour. Most medication used to treat psychiatric and behavioural problems (psychotropic drugs) act by stimulating or blocking receptors at nerve cell junctions.

The effectiveness of medication in the treatment of psychiatric disorders is well established for the non-intellectually disabled population. There is good evidence to show that antidepressants are effective in treating moderate and severe depression and that antipsychotic drugs are useful in treating psychosis (schizophrenia, delusional disorders, hallucinatory states). Most psychotropic drugs do not relieve symptoms immediately; both antidepressants and antipsychotic drugs take about two weeks to work. There have been few treatment trials on the effectiveness of psychotropic drugs conducted specifically for people with intellectual disabilities and mental health problems. In clinical practice, medication seems to be broadly as effective for people with intellectual disabilities, according to Dr Clarke. The effectiveness of medication in the treatment of challenging behaviour is less well established, although evidence for effectiveness is accumulating for some types of problem behaviours. Cyproterone acetate has been shown to be effective in reducing sexual drive in men, and there is increasing evidence that serotonergic compounds and opiate antagonists are effective in treating certain types of self-injury. Also, there is some evidence that antipsychotic drugs and carbamazepine can be effective in the treatment of some types of aggressive behaviour. Medication is often used in combination with other management strategies to treat challenging behaviour.

Most people who take psychotropic medication do not have problems with side effects. It is important, however, that family members and people who work with individuals who have difficulty communicating have a knowledge of side effects so that they can report problems before they become severe. Some of the common adverse effects of psychotropic medication are: agitation, sexual dysfunction, rashes (Prozac), tremor, stiffness, abnormal movements, sedation, sunburn, constipation, low blood pressure when standing up (Largactil), thirst, passing much urine, coarse tremor or unsteadiness (Priadel and Camcolit), loss of white blood cells, excessive salivation, weight gain and seizures (Clozaril). Dr Clarke advises that when using medication it is important to try and achieve the best benefit : risk ratio, taking into account the person’s health problems and disabilities.


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