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EDF, 12.07.2011 Persons with intellectual disabilities and mental health problems Filip Morisse & Leen De Neve Psychiatric 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. 2. 3. 4. Autismspectrumdisorders Attachment problems Mood and anxiety disorders 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 practices Care-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 carefacility (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… …