New Approaches in Mental Health for People with Intellectual Disability

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1 Lisbon Conference MHID 2010 New Approaches in Mental Health for People with Intellectual Disability Prof.dr. Anton Dosen Radboud University,, Nijmegen, Netherlands

2 International and national organizations for MHID WPA Section on Psychiatry in Intellectual Disability NADD; National association for the Dually Diagnosed Royal College of Psychiatrists EADHID; European Association for Mental Heath in Intellectual Disability IASSID; ; MHID Interest Group Natioal associations MHID: German, Dutch- Flamish, Spanish, Italian, Norvegian, Croatian..

3 Shortage of the current definition of ID DSM criteria: - significantly subaverage intellectual functioning, - impairments in adaptive functioning, - onset before age 18 years Not included: - emotional development, - personality development

4 Mental health problems/mental disorders in persons with ID % of the idividuals with ID suffer on mental disorders % of individuals with ID use psychotropic medication. In % of individuals who use psychotropic medication there is no identifiable psychiatric diagnosis.

5 Striking features among persons with ID Significantly higher occurrence of psychopathology Different symptoms for the same diagnoses Different mechanisms of onset (pathogenesis)

6 Diagnostics and classification of psychiatric disorders in persons with ID DSM and ICD systems are not suitable for entire population with ID Adapted systems have been developed with modified diagnostic criteria: - DC-LD LD, Royal College of Psychiatrists; Practice Guidelines, EAMHMR,, DM ID, NADD,, 2007.

7 Problem behaviour Difficulties with definition Difficulties with diferentiation betwen normality and abnormality at different developmental levels What is challenging behaviour? Problems of identification of onset mechanisms Difficulties with differentiation: symptoms of psychiatric disorder behaviour problems

8 Two basic steps in development of scientific thinking (Wells( 1972, Kegan 1982) 1. Entity oriented perception of the phenomenon with taxonomy and classification. 2. Process oriented perception of the phenomenon with emphasis on development (explanation; understanding).

9 Diagnostic process Phenomenon (problem/disorder description) Explanation (discovery of multilevel mechanisms of onset by assessment) Understanding (interpretation of symptoms and finding the meaning: normal, abnormal, pathological etc.) Diagnostic formulation (categorical, descriptive, integrated etc.) Treatment (integrated)

10 What are we talking about? Mental health? Mental illness and behaviour disorders (mental health problems)?

11 Psychiatry is always talking about mental health, but nobody ever does anything about it (G. Vaillant, Am.J.Psychiatry,, 2003, 160)

12 Understanding of the concept of mental health in persons with ID is necessary in order to explain and understand the phenomenon of mental illness and behaviour disorders

13 State of mental health in persons with ID For a proper understanding of the state of mental health in a particular individual with ID it is necessary to determine: - biological and functional aspects, - basic psycho-social social needs, - motivations, - emotional experiences, - risk factors, - resilience - interaction with the environment, - adaptation of the environment to the person s s needs

14 Alternative approaches in psychiatric diagnostics in persons with ID Dimensional approach (characterization of the diagnosis along the continuum of severity) Functional approach (psychological disfunctioning is the basic problem causing primary and secondary symptoms); (H. van Praag 2004) Developmental approach (knowledge of developmental levels of different bio-psycho psycho-socialsocial aspects is important for explanation of onset mechanism of the disorder and for interpretation of the related symptoms; ; Dosen 2005). Genetic approach (meaning of behavioural and psychopathological phenotypes in onset of disorders; Dykens et al 2000) Integrative approach

15 Developmental approach; Four dimensions in assessment, diagnostics and treatment Biological dimension Psychological dimension Social dimension Developmental dimension

16 Understanding of psychopathology in persons with ID from the developmental perspective Psychiatric disorders have been seen as maladaptive reactions to harmful intrinsic and extrinsic stimuli. The level and quality of personality development play an important role in vulnerability of the person and in the presentation form of the disorder.

17 Assessment of psychiatric disorders from the developmental perspective (explanation) is focused on: Determination of the level of personality (emotional) development. Discovering of the person s s basic emotional needs and motivations. Discovering how the environment deals with the person s s basic emotional needs?

18 Assessment approach in problem behaviour A multidisciplinary assessment is directed to: 1. The person (biological problems, functional problems, personality development, psychiatric problems) 3. The interaction/behavior (behaviour analysis) 2. The environment (social, cultural, emotional)

19 Understanding (meaning) of the problem and the diagnosis Understanding of the sort and severity of the problem; e.g.: - normal (difficult) behaviour of a person at particular personality developmental level in the given (environmental) circumstances problem behaviour psychiatric disorder Interpretation of symptoms Making integrative diagnosis

20 INTEGRATIVE APPROACH The goal of Integrative approach is to explain the processes which have led to the psychopathology and to understand the presentation and the meaning of the disorder within given circumstances.

21 Integrative diagnosis 1. Psychiatric diagnosis (DSM dg., Developmental psychiatric dg. Functional dg.) 2. Onset mechanism 3. Other bio-psycho psycho-socio-developmental aspects: somatic and physiological features, personality characteristics, interaction aspects, environmental circumstances 4. Treatment strategy

22 INTEGRATIVE APPROACH IN TREATMENT - Holistisc treatmnet of the person - Integrative treatment of the disorder Integrative diagnosis Care-need The persoon disorder Holistic treatment Integrative treatment

23 Integrative treatment approach Two components in the treatment 1. Holistic treatment of the involved persoon: - The person and his/her surroundings are in the focus of treatment and related support. 2. Integrative treatment of the conditions connected with the onset and maintaining of the disorder; - Finding of appropriate strategy Selection of appropriate methods

24 Strategy integrative treatment of psychotic disorder 1. Biological dimension (e.g. medication) 2. Developmental dimension (e.g. meeting at developmental level) 3. Psychological dimension (e.g. psychotherapy) 4. Social dimension (e.g. systemic therapy)

25 Strategy integrative treatment of severe problem behaviour 1. Developmental dimension meeting person s s basic emotional needs 2. Social dimension adaptation of the surroundings and interactions at the person s s needs 3. Psychological dimension training, psychotherapy 4. Biological dimension medication if necessary

26 Effect of treatment All mental processes are biological Kandel 2006) General effect of psychotropic medication (as well as psychotherapy) is reducing distress or arousal (improving capacity to regulate affect) (Bradley, 2000) Different forms of psychotherapy lead to different structural changes in the brain (changes of gene expression), just as other forms of learning do (Kandel 2005) Psychotropic medication as well as psychotherapy causes comparable morphological and functional changes in the brain.

27 Future directions Determination of state of mental health and development of instruments for measuring of state of mental health. Promotion of mental health and development of prevention of behavioural and psychiatric disorders. Promotion of integrative approach in diagnostics and treatment. Establishing of appropriate mental health care for this population.

28 Further information Bouras N. & Holt G. (2007): Psychiatric and behavioural disorders in intellectual and developmental disabilities; Cambridge, Cambridge University Press. Dosen A. (2005 a,b): Applying the developmental perspective in the psychiatric assessment and diagnosis of persons with intellectual disability, part I and II; J. Intellectual Disability Research, 49, 1, Dosen A., Gardner W. et al (2007): Practice guidelines and principles; MHID publication, CCE, Gouda.