Intellectual

Disability
Care of persons with
Intellectual Disability

Dr. Teris CHEUNG 9 Nov 17

By the end of the lecture,
students will be able to:
1) Define intellectual disability
2) Outline the service
provision for clients with
learning disability in
mental health context
3) Suggest nursing
interventions for clients
with intellectual disability in
the mental health context
4) Discuss the co-morbidity
with mental disorder and
intellectual disabilities
Terminology of Learning Disability
UK Learning disability; specific learning
difficulty (SpLD)
USA Intellectual Disability / Mental
Retardation
Australia Intellectual Disability / Developmental
disabilities
Hong Kong Intellectual Disability

The WHO has proposed a new name for learning disabilities:-

Intellectual Developmental Disorder (IDD) in 2014
Diagnostic Criteria for Intellectual Disability in DSM-5 (APA, 2013)

1. Deficits in Intellectual functioning

1.1. Reasoning; Problem solving; Planning; Abstract thinking;
Judgement; Academic Learning; Experiential learning
2. Deficits or impairments in adaptive functioning
2.2 Communication, social skills, personal independence, school or
work functioning
3. These deficits are evident during childhood / adolescence

*Intellectual Disability – formerly known as Mental Retardation

 Definition of Mental Retardation by ICD-10

• Mild MR: IQ 50 – 69, mental age 9 to under 12 yrs

(85%)
• Moderate MR: IQ 35 – 49, mental age 6 to under 9
yrs (10%)
• Severe MR: IQ 20 – 34, mental age 3 to under 6 yrs
(3-4%)
• Profound MR: IQ < 20, mental age below 3 yrs
(1 – 2%)
 Mental incapacity

Mood
Disorders

Stereotypic
movement
disorder MI ADHD

Mental Mental
handicap disorder
Dementia
 Types of learning disabilities
1) Reading disorder (ICD-10 & DSM-IV)
- Developmental Dyslexia
- most common learning disabilities
2) Writing disorder (ICD-10 & DSM-IV)
- Dysphasia / Aphasia
3) Math disability (ICD-10 & DSM-IV)
- Dyscalculia
Definition of Intellectual Disability
• Both ICD – 10 & DSM-IV/V is applicable to
clients with Mild ID BUT
• Clinically, it is more difficult to accurately
diagnose clients with moderate to severe
(profound) ID because some psychotic
symptoms can ONLY be defined in broader
terms
Diagnostic Criteria for Psychiatric Disorders for use with
adults with Learning Disability / Mental Retardation

• DC – LD is the most
common diagnostic
manual in Psychiatry
for diagnosing clients
with moderate, severe
(profound) ID
 Co-morbidity of mental disorder and
learning disability (Dual Diagnosis)
• Numerous empirical research have indicated that
individuals with learning disability (mental retardation)
are at significantly HIGHER RISK of developing
psychiatric & behavioural disorders (Kwok, 2001)
• Learning disability is also closely linked with ‘aggression’ and
sudden ‘violent outbursts’ in hospital / community settings –
primary reasons for the breakdown of the community
placements
• Dual diagnosis of a major mental disorder and learning
disability is NOT UNCOMMON in mental health context
(e.g. Autism, ADHD, schizophrenia, depression)
 Source: O Brien et al. (2000). Adult learning disability psychiatry services: local
’

implementation of national guidelines. Hong Kong Journal of Psychiatry 10(4), 22-24.

Relative prevalence of psychiatric
disorder in Learning Disability
Prevalence of Intellectual Disability (HK)
• 1.0 to 1.3% of the general population
• 67, 000 to 87, 000 individuals being diagnosed
with ID
(Source: Current Opinion in Psychiatry, 2009, 22, 462 – 468)
 Autism
• Onset of autism is normally between 30 – 36
months at infancy or toddlerhood
• Characteristic features:
~ poor social interactional skills, lack of
reciprocity & affect
~ cannot articulate appropriate to their actual age
~ poor linguistic understanding
~ repeat endless questions and demand standard
answers
 Etiology of Intellectual Difficulty
• Heredity (5%) – genetic influences have strong influences
in LD (e.g. Down’s Syndrome)
• Problems during pregnancy or birth (10%) – LD
can result form anomalies in the developing brain, illness, or
injury. Fetal exposure to alcohol / drugs, low birth weight,
oxygen deprivation at birth, premature birth, or prolonged
labor, viral infections, trauma)
• General medical conditions in infancy /
childhood (5%) – e.g. head injuries, malnutrition, toxic
exposure to some poisonous substances (e.g. pesticides),
infections
Etiology of Intellectual Difficulty (cont’d)
• Environmental influences & other mental
disorders (15-20%) (e.g. under-nurturing,
Autism)
• Unclear etiology (30-40%) both scientifically
& clinically
 Risk factors for psychiatric problems
• Individuals with ID are at HIGHER RISK of
developing mental health problems due to:
§ brain damage resulting from ID ->
predispose individual to mental disorder
§ Some syndromes are associated with
behavioural abnormalities and psychopathology
(e.g. Down’s Syndrome is associated with
Alzheimer’s Disease; Lesch-Nyhan Syndrome is
associated with self-injurious behaviours)
 Risk factors for psychiatric problems
§ Low self-image & chronic frustration by repeated
failures and multiple disabilities
§ Limited repertoire of coping strategies & self-
defense mechanisms
§ Stigmatization, rejection, and social isolation in
hospitals and in the community
§ Inappropriate / excessive demands / over-
protection by carers
§ Poor access to community resources -> restricted
& small social circles and lifestyles
 Diagnostic methods of ID
• IQ (Intelligence Quotient) tests carried out by psychologists
in schools, primary care settings, community settings, or
hospitals

• Well known IQ tests include:

~ Wechsler Adult Intelligence Scale ( > 16 y.o.)
~ Wechsler Intelligence Scale for children (age 6-16)
~ Standford-Binet Intelligence Scale (age 2 -23)
~ Woodcock-Johnson Tests of Cognitive Abilities
~ Kaufman Assessment Battery for Children
~ Raven’s Progressive Matrices
 Diagnostic methods of ID
• Behavioural Analysis
- assess, identify & analyze client’s problematic
behaviour in three main aspects:
- predisposing ( ) factors (biological)
~ assess client’s developmental milestones and
identify any developmental delay; any problems
at infancy stage and pregnancy period
- precipitating factors ( ) (psychological)
- perpetuating factors (social / organizational)
 Diagnostic methods of ID
- identify any RISK behaviours & challenging
behaviour which may endanger self (i.e. self-
inflicting / self-harm behaviour) or to others
e.g. sulking, refusal to communicate
mood swings, odd mannerisms, socially
unacceptable behaviour, over-excitement,
restlessness, altered sleep patterns, poor dietary intake
Scope of service for clients with Intellectual Disability in HK

§ In-patient service
§ Out-patient clinic (referrals from GPs, SWD, courts,
& probation officers)
§ Outreach service (e.g. visit clients’ homes, hostels,
day activity centres, sheltered workshops etc)
§ Respite service (clients live away from carers
temporarily to provide a break / relief to carers)
 HOSPITAL-BASED SERVICE PROVISION

Long stay Short stay Respite

beds beds beds

Specialty units for Learning Disabilities: PULD in KCH, PULD, PSID, MH Unit in TMH,

PULD - Psychiatric Unit for Learning Disability

 is considered as a specialty
in psychiatry which requires
specialized service provision
for those affected

Allied health professionals: Consultant psychiatrists, psychiatrists, clinical

psychologists, mental health nurses, social workers, occupational therapists, and
physiotherapists and sometimes, speech therapists
 PSYCHIATRIC SERVICES OF
INTELLECTUAL DISABILITY
(PSID)

Castle Peak Hospital

Historical Development of PSID, CPH

• 1972 – Grand opening in Siu Lam Hospital with 200 beds

• 1993 - SLH reopened with new extension block housing 300 beds
• 1994 - Establishment of MHU at TMH with 200 beds
(total: 500 beds)
1994 - Development of SLH outreach service
2003 - Clinical merging of SLH + MHU at TMH into
‘ Mental Handicap Infirmary Service’
2012 - Relocation of SLH + MHU at TMH to Block B, CPH
(500 beds)
In-patient services at PSID, SLH

- 3 male + 1 female rehabilitation wards

- Day services:
- *IDACE sessions
- OT sessions
- Admission criteria to Severe Mental Handicap Infirmary at SLH
- Centralized applications via HAHO from age 16
- Clients with physical disablement, bedridden, feeding
problems, challenging behaviour, poorly controlled epilepsy, &
those requiring constant nursing care

*IDACE: Intellectual Disability Activity Centre of Excellence

Out-patient services, & Support & Outreach Service

• Out-patient services
- 4 doctor sessions / week
- each doctor assessing ~ 25 – 30 patients / session

- Support & Outreach Service (SOTID)

- SOTID to clients in the community to prevent admission or
re-admissions or long stay in PSID wards
- Offer intensive rehabilitation & support for long stay clients
with ID for discharge back to the community
- Arrange hostels appropriate to clients’ needs
- Managing challenging behaviour for in-patient / out-reach
patients & out-patients
Intellectual Disability

50% of clients
with
ASD Intellectual
Disability has
Challenging
Behaviour

CB MI
ASD: Autism Spectrum Disorders
MI: Mental Illness
CB: Challenging Behaviour
 Prevalence of Challenging Behaviour in
Intellectual Disability

• Male > Female

• * the more severity of the ID, the more
challenging behaviour exhibits in clients*
• e.g. self-mutilation, self-stimulation,
aggression
Structure / design of specialized units for LD

• Time-out room
• Domestic training room
• Mini-school
• Multi-sensory room
• Model home
• Long stay beds (>/ 3 months)
• Short stay beds (< 3 months)
• Respite beds (in hostels)
 Multidisciplinary team approach
• LD is a specialized, vulnerable population in mental
health context
• Requires collaboration from MDT to monitor progress,
facilitate recovery and rehabilitation
- Occupational therapists
~ occupational / vocational skills assessment & training
~ general adaptation skills training
~ assertive skills training
 Multidisciplinary team approach
• Clinical Psychologists
~ administer IQ tests,
~ prescribe behavioural modification
programmes
~ CBT (Cognitive-Behavioural Therapy) (less
common in clients with moderate to severe
LD)
 Multidisciplinary team approach
• Medical Social Workers (MSW)
~ identify suitable residential placements (e.g.
half-way houses; respite beds) and training
venues (e.g. sheltered workshops)
~ assess family circumstances (home visits) &
financial situations – provide financial subsidy
if indicated (e.g. disability allowance)
~ sort out finance & bills (e.g. auto bank transfer),
assign POA for client to look after client’s
finance
 Multidisciplinary team approach
• Physiotherapist
- muscle training, body posture and
positioning, limb movements
- progressive muscle relaxation
Chiropody / Podiatry
- finger nails and toe nails cutting / trimming,
assessing, and diagnosing potentially
infectious diseases of limbs
 Nursing interventions
I) History-taking
§ Assess client’s demographic data (developmental history,
family history, history of mental illness, history of previous
psychiatric admissions, history of violence / aggression (e.g.
physical assault, verbal assault)
§ Conduct interview with client’s family members to gather
more information
§ Assess clients physical and mental health problems (existing
behavioural / challenging behaviour)
§ Gather ‘subjective’ & ‘objective’ data
 Nursing interventions
II) Assessment
§ Assess clients physical and mental health problems (existing
behavioural / challenging behaviour)
§ Identify and prioritze client’s problematic behaviour
§ Conduct RISK ASSESSMENT – to ascertain the extent of
potential RISK TO SELF AND TO OTHERS (ie. HIGH
RISK, MODERATE RISK or LOW RISK)
§ Gordon Functional Health Pattern (11 categories) as
assessment framework before focus assessment
 Nursing interventions
Personal attributes
§ Be calm, non-judgmental, non-critical but assertive
Activity – Exercise
§ Assist client to maintain self-care, personal hygiene
and grooming
§ Encourage client to maintain adequate daily exercise
regime (e.g. morning exercise)
§ Explore client’s hobbies & interests (e.g. drawing,
painting, listening to music, dancing) and encourage
client to participate in group activities to reduce
social withdrawal
 Nursing interventions
Sleep-rest
§ Maintain a safe, therapeutic, non-threatening
physical environment to reduce environmental
stimulation
§ Reduce environmental stimuli to the minimal
extent esp. over the night time to promote
sleep
 Nursing interventions
Nutrition-Metabolic
§ Observe eating & drinking pattern. Inspect client’s skin
integrity, skin colour and complexion. Check client’s
teeth and nails regularly. Monitor BW
§ Monitor eating, drinking and elimination pattern.
Report for abnormality
Elimination
§ Observe client’s excretory pattern (urination, bowel
movements)
§ Alert to s/s of constipation, abdominal cramps, signs of
distress
 Nursing interventions
Coping/Stress tolerance
§ Alert to client’s verbal and non-verbal cues of escalating
behaviour to prevent aggressive / violent episodes
§ Protect other clients from potential bodily harm or injury in
case client is losing control in behaviour or causing disruptions
in ward routine (e.g. TIME OUT ROOM)
§ Reduce environmental stimuli to the minimal extent esp. over
the night time to promote sleep
§ Provide a structured environment & routine to reduce stress
§ Design behaviour modification programmes with client
consensus
 Nursing interventions
Self-perception / self concept
§ Explore client’s self-concept pattern and perception of own body
image, functional abilities.
§ Engage client in tasks that may help increase self-esteem and
improve body image (empowerment) (e.g. leading a dance in a
dancing group)
Role-relationship
§ Identify client’s existing role & responsibilities in the family
§ Explore familial relations (? harmonious/ conflictual)
 Nursing interventions
Sexuality-reproductive
§ Identify socially unacceptable sexual pattern
(e.g. masturbation in public)
§ Sex education (e.g. use of contraception; risk
of pregnancy for female clients)
§ Reinforce socially acceptable behaviour
§ Parenting skills
 Nursing management of challenging
behaviour in LD
• Assessment
• ABC approach
• Antecedents (triggering factors)
• Behaviour
• Consequences
• e.g. noise levels, physical illness / injuries or
other possible physical discomfort
 Nursing management of challenging
behaviour in LD
• Antecedents
- environmental: noise levels (TV, radio noise,
human voices), ? Stimulus (special events
occurring, ? celebrations / ? irritants)
- physical: any forms of physical illnesses /
injury / discomfort (e.g. pyrexia, headache,
constipation, any signs of pain or distress)
 Nursing management of challenging
behaviour in LD
• Antecedents (cont’d)
• Emotional
- any mood swings? Any traumatic / stressful
events happened in client’s family (e.g.
bereavement, critical illnesses etc)
 Nursing management of challenging
behaviour in LD
• Behaviour
- any form of physical or verbal aggression /
agitation / violence either to self, and or to
others
- e.g. hitting, fisting, kicking, throwing
objects, pushing, yelling or screaming,
punching, biting, damaging behaviour ~
smashing objects, tearing things into parts
 Nursing management of challenging
behaviour in LD
• Consequences
- assess the consequences of client’s
behavioural problems
~ ? any injury (to self or to others)
~ actual bodily harm inflicted to self / others
~ any physical / psychological threat / abuse
to others
 Nursing management of challenging
behaviour in LD
• Motivation
- assess client’s motivation for challenging behaviour:
~ attention-seeking
~ expression of affection / emotions
~ stress coping response
~ ? Any secondary gains (e.g. more attention given to
client whenever client is hitting somebody on the
ward by being on ‘constant observation’)
 Pharmacological interventions
• Psychotropic medications are used to stabilize client’s
mood and reduce undesirable behaviour
• Mood stabilizers (e.g. lithium, lamotrigine,
clonazepam, fluoxetine, valproaic acid)
• Anxiolytics (e.g. diazepam)
• SSRIs (e.g. quetiapine, olanzepine)
• Antipsychotics (e.g. risperidol, olanzapine,
quetiapine)
• Opiate blockers (e.g. naltrexone) may be prescribed
to reduce self-inflicted behaviour (e.g. banging own
head against wall, punching self)
 Pharmacological interventions
• When clients with LD are given medications to
reduce undesirable behaviour, nurses should
always remember that:
• Drugs should NOT be used excessively
• Drugs are NOT prescribed as a punishment
• Drugs should NOT be administered for the sake of
staff convenience to control client behaviour
• Drugs should NOT be administered in an amount that
disrupt client’s ADL
 Nursing implications on clients with LD
• Nurses are taking a pivotal role in working with LD
clients
• Specialist training and nursing management with
challenging / problematic behaviour should be provided
to nurses -> increase competence and manage
problematic behaviour effectively without jeopardizing
client’s best interest
• Adequate sheltered residential placements and
community day centres to provide community support
to LD clients
• Adequate community support services should be
available to carers (e.g. respite care, financial advice) to
provide temporarily stress relief
 Nursing implications on clients with LD
• ‘NORMALIZATION’ is the current and future theme
• Clients should be able to integrate (live and work) in the
community with support they need
• Society at large should be more ‘receptive’ to this vulnerable
population (through government campaign, mass media
coverage, scientific research etc)
• The Government, Department of Health, HA, NGOs, Social
Welfare Department, CP, OT, Physiotherapy, community health
centres should collaborate in achieving the common goal – help
LD clients reintegrate back into community instead of having
long stay care in hospital setting
 References
• Fernadez-Prieto et al. (2016). Pitch perception deficits in nonverbal learning disability.
Research in Developmental Disabilities, 59, 378-386.
• Kwok, W.M. (2001). Development of a specialized psychiatric service for people with
learning disabilities and mental health problems: report of a project from Kwai Chung
Hospital, Hong Kong. British Journal of Learning Disabilities, 29, 22-25.
• Lovell, A., & Bailey, J. (2017). Nurses’ perceptions of personal attributes required when
working with people with a learning disability and an offending background: a
qualitative study. Journal of Psychiatric and Mental Health Nursing, 24 (1), 4-14.
• Millichap, J. G. (2015). Focal MRI and learning disability with reduced automaticity.
Paediatric Neurology Briefs, 29(9), 69. http://doi.org/10.15844/pedneurbriefs-29-9-4
• O’Brien, G., Radley, J., & Joyce, J. (2000). Adult learning disability psychiatry services:
local implementation of national guidelines. Hong Kong Journal of Psychiatry, 10(4),
22-24.
• Scanlon, D. (2013). Specific learning disability and its newest definition. Journal of
Learning Disabilities, 46(1), 26-33.
• Shifrer, D., Callahan, R.M., & Muller, C. (2013). Equity or Marginalization. American
Educational Research Journal, 50(4), 656-682.