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Summary
SUMMARY
Introduction
The Convention on the Rights of Persons with Disabilities (UN, 2006) establishes in its article 25, that all persons with disabilities have the right to enjoy the highest attainable standard of health. This implies that people with intellectual disabilities have the right to enjoy not only physical and social well-being, but they also have the right to enjoy a state of emotional well-being that facilitates the development of their life project.
Therefore, it is necessary to give visibility to people with intellectual disabilities with mental health problems, so that their right to accessible and quality care is recognized, as in the rest of the population.
For many years, the possibility of people with intellectual disabilities having mental health problems has not been considered.
The concurrence of both situations (intellectual disability and mental disorder), generally not considered, has almost always led to a underdiagnosis (Peña-Salazar, 2017; Reiss et al. 1995) and, therefore, either has not been treated or inadequate treatments have been applied (Novell et al, 2003; Rueda &
Novell, 2021; Verdugo & Navas, 2018)
Objectives
The ultimate purpose of this PhD thesis is to provide greater knowledge about the mental health problems of adults with intellectual disabilities in Extremadura, also analyzing different variables of interest related to these problems and, on the other hand, deepen the study of the difficulties of diagnosis of mental disorders in this population, that lead to diagnostic overshadowing.
Summary
In this way, the research has focused in Phase I on a) studying the presence of mental disorders of people with intellectual disabilities, b) knowing the main behavioral disorders of people with intellectual disabilities, c) analyzing the use of psychotropic drugs in people with intellectual disabilities, d) studying to what extent having support needs in communication and / or interpersonal relationships intervenes in mental health problems of persons with intellectual disabilities, d) knowing the response received by persons with intellectual disabilities from the care services. In Phase II, the research has been aimed at:
a) identifying psychopathology in the population with intellectual disability, d) detecting the suspicion of diagnostic overshadowing and analyzing to what extent the severity of intellectual disability and the number of problems behaviours that occur, make it difficult to diagnose a mental disorder e) analyzing the use of psychotropic drugs in people with intellectual disabilities in whom underdiagnosis is suspected and f) Obtaining information on the medical follow-up received by people with intellectual disabilities in whom underdiagnosis is suspected.
Method
The sample in Phase I consisted of 569 people with intellectual disabilities recognized by the Center for Attention to Disability of Extremadura, aged between 18 and 89 years, attended in day and residential care centers. .
The sampling procedure that was carried out was incidental with respect to the entities since it was determined according to the voluntariness to participate in the study. Once their availability was communicated, the identification of the participants was made from the people with intellectual disabilities of legal age who received support in their care centers.
This identification has been based on the fulfillment of at least one of the following three criteria (inclusion criteria):
Summary
1. Diagnosis of mental disorder (made by professionals from the public/private sector
2. Challenging behaviours as defined by Emerson (2011) "culturally abnormal behavior of such frequency, duration or intensity that they jeopardize the physical safety, well-being or quality of life of the person or others, or that prevent the person displaying them from accessing ordinary community facilities"
(p 7)
3. Consumption of psychotropic drugs as psychiatric treatment, whether or not having been diagnosed with a mental disorder, or the presence of serious disorders behaviours.
In Phase II, a subsample of 104 participants was determined whose inclusion criteria were the same as Phase I. The selection was random, to the extent that it was the professionals who selected the participants of this phase, depending on the relevance of the evaluation of psychopathology in these users.
The collection of information in Phase I was carried out through a Questionnaire developed specifically for the "Study on the prevalence of mental health disorders and / or disorders behaviours in people with intellectual disabilities in Extremadura" (State Observatory of Disability, 2019), and for the Phase II study, psychopathology evaluation scales were applied to a subsample of 108 participants. The scales applied were DASH II (Cronbach's α = 0.879) and Mini PAS-ADD (Cronbach's α = 0.6).
Results.
The results were obtained through a descriptive analysis and an inferential analysis of the data.
As a result of the research we can conclude the importance of verifying the relationship between having a mental disorder and presenting disorders behaviours in people with intellectual disabilities (χ2[1]=6.51; p=0.011, C=0.107).
People with more significant support needs tend to manifest a greater number of
Summary
problems behaviours (t[566]=-5.33; p<0.001, δ=-0.984). Self-harm and stereotypies are behavioral disorders that increase to a greater extent with increasing severity of intellectual disability (p=0.024) (p<0.001).
People with communication support needs and people with interpersonal relationship support are more likely to have a greater number of behavioral disturbances (χ2[1]=23.1; p<0.001, C=0.198; (χ2[1]=88.58; p<0.001, C=0.367).
On the other hand, it has been observed that the use of psychotropic drugs increases with age (rs=0.136; p=0.001), with the percentage of intellectual disability (rS=0.215, p<0.001), with the number of serious disorders behaviours (rs=0.357; p<0.001) or, with the number of mental disorders diagnosed (rS=0.212, p <0.001).
In general, there is a very high prescription in the case of antipsychotics, in that not only is it the psychotropic drug that is prescribed in greater proportion when there is a diagnosed mental disorder (χ2[1]=10.2; p=0.001, C=0.134), but also, in 56.2% of cases it is consumed even without a diagnosis of mental disorder. On the other hand, 63.6% of people with intellectual disabilities who present severe disorders behaviours have prescribed antipsychotics (χ2[1]=39.6;
p<0.001, C=0.256), also noting that 36.6% of people with intellectual disabilities even without presenting serious problems behaviours, also have them prescribed.
People with intellectual disabilities who receive supports in residential services are prescribed antipsychotics to a greater extent than people who attend to other care services (χ2[1]=22.2; p<0.001, C=0.194).
On the other hand, our data show that there is a significant relationship between pharmacological intervention and primary and secondary prevention strategies carried out from care services (χ2[1]=79.0; p<0.001, C=0.353;
(χ2[1]=45.8; p<0.001, C=0.276).
On a different note, we found that a high percentage of mental disorders have not been previously diagnosed in people with intellectual disabilities, having
Summary
detected an average of 1.18 more disorders per individual in the evaluation carried out. To determine if this trend is generalizable, the t-test was applied for paired samples with significant results (t[107]=6.339; p<0.001, δ= 610). In 50.9% of the participants in Phase II, at least one mental disorder that had not been previously diagnosed has been identified, observing that as the percentage of intellectual disability of a person increases, the probability of not being diagnosed with the mental disorder he suffers increases (underdiagnosis): a logistic regression model reveals significant differences (p<0.001) with an odds ratio between 1.005 and 1.016 to 95% confidence.
We observed a greater tendency to underdiagnosis in subjects with severe-severe intellectual disability, to whom the DASH-II test was applied.
Specifically, while people with mild-moderate disability had an average of 0.278 underdiagnosed disorders, in the severe-severe disability group, the average of underdiagnosed disorders was 2.972. This difference was contrasted by t-test for independent samples with significant results (t[106]=9.09; p<0.001, δ=1.856).
The Mann-Whitney test provided the same conclusion.
People with intellectual disabilities who had not been detected at least one mental disorder they suffer from (underdiagnosis) have a greater number of disorders behaviours (t[105]=-2.85; p=0.005, δ=-0.552), and have a higher prescription of psychotropic drugs (t[103]=-2.58; p=0.005, δ=-0.504).
Furthermore, only 15.4% with suspected underdiagnosis do not have mental health follow-up, compared to 57% of cases with suspected underdiagnosis who do have medical follow-up, which makes us consider that having a medical follow-up does not guarantee the adjusted diagnosis of mental health problems in the population with intellectual disability.
Conclusions
From the results obtained, it is concluded that people with intellectual disabilities have a high prevalence of mental health problems. Specifically, people
Summary
with severe- profound intellectual disability regularly express atypical psychiatric symptoms, with disorders behaviours being the main reason for psychiatric consultation, especially aggressive behavior. These are relevant aspects to consider in the evaluation since these problems behaviours can mask mental disorders. In addition, they are people who tend to have more difficulties in communication.
All the above leads us to raise the need to focus the response on a more functional understanding of behavioral disorders, as well as to progress in the search for strategies for these people to achieve optimal levels of communication.
Pharmacological intervention should be part of a multidisciplinary, person- centered plan of care. However, especially when the focus is on behavioral disorders, it is a priority to implement new intervention strategies from the psychosocial field. These techniques should promote, in a proactive and less restrictive way, a response to problems behaviours from a functional approach, with the use of methodologies such as active support or positive behavioral support, as well as the reduction of restrictions..
In response to the fundamental right of people with intellectual disabilities to enjoy the highest attainable standard of health, we must avoid the consequences of not detecting or mistreating mental disorders, as it can lead to an increase in the severity of symptoms and the chronicity of the disease. All this can cause unnecessary suffering, as well as a deterioration of functionality and capacity for social interaction that will negatively impact the quality of life of the person.