INTELLECTUAL DISABILITY PART - II

DR. SUBRATA NASKAR
INTELLECTUAL DISABILITY
PART - II

TOPICS FOR DISCUSSION
• MANAGEMENT OF INTELLECTUAL DISABILITY
• SERVICES AND SUPPORT
• SOME ISSUES

PREVENTION IS BETTER THAN CURE

PRIMARY PREVENTION
• AIM: ELIMINATING FACTORS LEADING TO ID OR REDUCING
ITS INCIDENCE.
• PREVENTABLE MEASURES INCLUDE:
• PUBLIC EDUCATION
• IMPROVED MATERNAL & CHILD CARE.
• PRENATAL SCREENING TEST
• DURING PREGNANCY,GOOD ANTENATAL CARE AND AVOIDANCE OF
TERATOGENS, HORMONES,IODIDES, AND ANTITHYROID DRUGS IS GIVEN.
• DURING LABOR, GOOD OBSTETRICS AND POSTNATAL SUPERVISION IS
ESSENTIAL TO PREVENT BIRTH ASPHYXIA,INJURIES,JAUNDICE AND
SEPSIS.
• GENETIC COUNSELLING: CONSANGUINEOUS MARRIAGES.

I. AMNIOCENTESIS
II. CHORIONIC VILLOUS SAMPELING.
• - AMNIOCENTESIS OR CHORIONIC VILLUS SAMPLING IS OFTEN USED FOR WOMEN AT HIGH RISK OF HAVING A
BABY WITH DOWN SYNDROME, ESPECIALLY THOSE AGED 35 AND OLDER, AND FOR WOMEN WITH FAMILY
HISTORIES OF METABOLIC DISORDERS.
III. ULTRASONOGRAPHY.
IV. MEASURING MATERNAL SERUM ALPHA-FETOPROTEIN IS A HELPFUL SCREENING TEST FOR NEURAL TUBE DEFECTS,
DOWN SYNDROME, AND OTHER ABNORMALITIES.
V. A FEW CONDITIONS, SUCH AS HYDROCEPHALUS AND SEVERE RH INCOMPATIBILITY, MAY BE TREATED DURING
PREGNANCY.
• MOST CONDITIONS, HOWEVER, CANNOT BE TREATED, AND EARLY RECOGNITION CAN SERVE ONLY TO PREPARE THE PARENTS AND ALLOW THEM TO
CONSIDER THE OPTION OF ABORTION.

SECONDARY PREVENTION
• AIM: EARLY DETECTION & INTERVENTION.
• PREVENTABLE MEASURES INCLUDE:
• SCREENING FOR INBORN ERRORS OF METABOLISM : SCREENING OF ALL THE
NEWBORN INFANTS FOR METABOLIC DISORDERS SUCH AS PKU AND
HOMOCYSTINURIA.
• SCREENING FOR ENDOCRINE DISORDER. e.g. HYPOTHYROIDISM
• NEONATAL AND NEUROLOGICAL INFECTIONS SHOULD BE DIAGNOSED AND
TREATED PROMPTLY.
• DIETARY RESTRICTIONS: GALACTOSEMIA, PKU, MAPLE SYRUP URINE DISEASE.

TERTIARY PREVENTION
• AIM: MINIMIZE THE COMPLICATIONS OR SEQULE RESULTING FROM
MENTAL RETARDATION.
• MEASURES INCLUDE:
1. PARENTAL COUNSELING.
2. MANAGEMENT OF EMOTIONAL & BEHAVIOURAL PROBLEMS OF ID
PATIENTS.
3. REHABILITATION
4. SPECIAL EDUCATION FACILITIES FOR CHILDREN.

PROGNOSIS
• BECAUSE ID SOMETIMES COEXISTS WITH SERIOUS PHYSICAL PROBLEMS, THE
LIFE EXPECTANCY OF CHILDREN WITH ID MAY BE SHORTENED, DEPENDING
ON THE SPECIFIC CONDITION.
• IN GENERAL, THE MORE SEVERE THE COGNITIVE DISABILITY AND THE MORE
PHYSICAL PROBLEMS THE CHILD HAS, THE SHORTER THE LIFE EXPECTANCY.
• HOWEVER, IN THE ABSENCE OF PHYSICAL PROBLEMS, A CHILD WITH MILD ID
HAS A RELATIVELY NORMAL LIFE EXPECTANCY, AND HEALTH CARE IS
IMPROVING LONG-TERM HEALTH OUTCOMES FOR PEOPLE WITH ALL TYPES
OF DEVELOPMENTAL DISABILITIES.
• MANY PEOPLE WITH MILD TO MODERATE ID CAN SUPPORT THEMSELVES,
CAN LIVE INDEPENDENTLY, AND CAN BE SUCCESSFUL AT JOBS THAT REQUIRE
BASIC INTELLECTUAL SKILLS.

CLINICAL ASSESSMENT OF PATIENTS
• CLINICAL
• PRENATAL
• BIRTH HISTORY
• IMPORTANT PAST MEDICAL/ SURGICAL HISTORY
• FAMILY PEDIGREE
• PHYSICAL EXAMINATION
• MINOR PHYSICAL ANOMALIES
• GROWTH TRAJECTORY
• FACIAL FEATURES
• COMPLETE NEUROLOGICAL EXAMINATION
• DOCUMENTATION OF BEHAVIOURAL PHENOTYPES

CLINICAL ASSESSMENT OF PATIENTS
• EVALUATION
• OPHTHALMOLOGIC
• HEARING
• ORTHOPEDIC
• PSYCHOMETRIC
• DIAGNOSTIC TESTS
• EEG.
• THYROID FUNCTION TEST: T4, TSH.
• KARYOTYPING
• URINE TESTS FOR GALACTOSEMIA, PKU,HOMOCYSTINURIA
• BIOPSY(BONE MARROW,LIVER,RECTUM,BRAIN,SKIN) TO CONFIRM STORAGE DISORDERS.
• X-RAY SKULL, CSF EXAMINATION.
• CT AND MRI SCAN MAY DEFINE HYDROCEPHALUS,ABSENCE OF CORPUS
CALLOSUM,TUBEROUS SCLEROSIS,CORTICAL ATROPHY.

BASIC GUIDELINE FOR
PSYCHOLOGICAL/ PSYCHIATRIC EVALUATION
• GROSS ASSESSMENT OF THE SENSORY & MOTOR DEFICIT IN THE PERSON
SHOULD BE DONE.
• IT SHOULD BE CHECKED WHETHER THE PERSON COMPREHEND THE TEST
INSTRUCTIONS & HAS ADEQUATE SPEECH, LANGUAGE TRAINING FOR
COMMUNICATION.
• USAGE OF ONE STANDARDIZED TEST BATTERY FOR EVALUATION OF
GENERAL ABILITY INDEX AND FEW SUBTESTS FOR INDIVIDUAL ABILITIES IS
RECOMMENDED.
• ONE STANDARDIZED SCALE TO BE USED FOR ADAPTIVE BEHAVIOUR.

BASIC GUIDELINE FOR PSYCHOLOGICAL/ PSYCHIATRIC EVALUATION
• IF APLICATION OF STANDARDIZED TEST IS NOT POSSIBLE, BEHAVIOUR
CHECKLISTS, DEVELOPMENTAL SCHEDULES, SEMISTRUCTURED
INTERVIEWS AND BEHAVIOURAL OBSERVATIONS SHOULD BE USED TO
ASSESS THE GENERAL INTELLECTUAL LEVEL.
• ONE SHOULD START WITH A SIMPLE TEST, PREFERABLY NON-VERBAL
TEST TO PUT THE CHILD AT EASE INITIALLY.
• COLOURFUL, STURDY & USEFUL TOYS SUITABLE FOR DIFFERENT AGE
LEVELS SHOULD BE PRESENT WHILE TEST APPLICATION, AS IT HELPS
IN BUILDING RAPPORT.

• PROBLEMS IN EXPECTATIONS AND SUPPORTS:
• AS INDIVIDUALS WITH INTELLECTUAL DISABILITIES ARE MUCH MORE DEPENDENT
ON EXTERNAL STRUCTURES EMOTIONAL PROBLEMS OFTEN ARISE WHEN
EXPECTATIONS AND SUPPORTS CHANGE OR ARE INAPPROPRIATE
• EMOTIONAL UPSETS
• ILLNESS IN CLIENT OR SIGNIFICANT OTHER
• SEASONAL PATTERN/ANNIVERSARY REACTION
• TRAUMA
• ABUSE OR TRIGGERS TO PAST ABUSES.
• GRIEF CAN BE DELAYED.

• NEW ONSET PSYCHIATRIC DISORDERS AND/OR ONGOING (CHRONIC)
PSYCHIATRIC CONDITIONS SHOULD BE EVALUATED BASED ON PROPER
HISTORY TAKING AND MENTAL STATE EXAMINATION.
• TIME & PATIENCE IS OF ESSENCE
• COGNITIVE FUNCTIONING
• READING
• WRITING AND MATH GRADE LEVELS
• SCHOOL HISTORY
• RESULTS OF PREVIOUS PSYCHOLOGICAL ASSESSMENTS
• INFORMATION ABOUT VERBAL AND NON-VERBAL IQ/FUNCTIONING

• SELF CARE ABILITY :
• CAN BE EVALUATED BY THE ADAPTIVE BEHAVIOUR SCALES.
• GIVE SUPPORT OR TRAINING TO IMPROVE SELF CARE.

PSYCHOLOGICAL ASSESSMENT
• TESTS COMMONLY USED:
1. DEVELOPMENTAL SCHEDULES
a) BAYLEY INFANT SCALE
b) GASSELL’S DEVELOPMENTAL SCHEDULE
c) NIMH DEVELOPMENTAL ASSESSMENT SCHEDULE
2. VERBAL TESTS
a) BINET KAMAT TEST
b) BINET KULSHRESTA TEST
c) BINET SHUKLA TEST
d) MALIN’S INTELLIGENCE SCALE FOR INDIAN CHILDREN

3. NONVERBAL TESTS
a) DEVELOPMENTAL SCREENING TEST
b) RAVEN’S PROGRESSIVE MATRICES – COLOURED
4. PERFORMANCE TESTS
a) SEGUIN FORM BOARD TEST
b) GASSELL’S DRAWING TEST
c) DRAW-A-MAN TEST
d) M.I.S.I.C
e) ALEXANDER’S PASSALONG TEST
f) KOCH’S BLOCK DESIGN TEST

5. ADAPTIVE BEHAVIOURAL SCALE
a) VINELAND SOCIAL MATURITY SCALE
b) VINELAND ADAPTIVE BEHAVIOUR SCALE
c) AAMR – ADAPTIVE BEHAVIOUR SCALE
6. TEST FOR SPECIFIC ABILITIES
a) ATTENTION-CONCENTRATION
b) TEST OF PERCEPTION
I. DIGIT SPAN
II. PACED AUDITORY SERIAL ADDITION TEST (PASAT)
III. CONTINUOUS PERFORMANCE TEST.
IV. DIGIT VIGILANCE TEST
I. BENDER-GESTALT TEST (BENDER VISUAL MOTOR
GESTALT TEST)
II. VISUAL OBJECT AND SPACE PERCEPTION BATTERY.
III. BEHAVIOURAL INATTENTION TEST.

INTELLIGENCE TEST AGE RANGE (YRS-
MOS)
DOMAINS TESTED
WECHSLER PRESCHOOL AND PRIMARY SCALE OF INTELLIGENCE-
REVISED (WECHSLER, 1989)
3 TO 7-3 VERBAL IQ, PERFORMANCE IQ, FULL-SCALE IQ
WECHSLER INTELLIGENCE TEST FOR CHILDREN-III (WECHSLER,
1991)
6 TO 17-11 VERBAL IQ, PERFORMANCE IQ, FULL-SCALE IQ
WECHSLER ADULT INTELLIGENCE SCALE-REVISED (WECHSLER,
1981)
16 TO 74 VERBAL IQ, PERFORMANCE IQ, FULL-SCALE IQ
STANFORD-BINET INTELLIGENCE SCALE: FOURTH EDITION
(THORNDIKE, HAGEN, AND SATTLER, 1986)
2 TO ADULT VERBAL, QUANTITATIVE, ABSTRACT/VISUAL, SHORT-TERM MEMORY,
COMPOSITE SCORE
KAUFMAN ASSESSMENT BATTERY FOR CHILDREN (KAUFMAN
AND KAUFMAN, 1984)
2-6 TO 12-6 SEQUENTIAL AND SIMULTANEOUS PROCESSING, MENTAL PROCESSING
COMPOSITE
KAUFMAN ADOLESCENT AND ADULT INTELLIGENCE TEST
(KAUFMAN AND KAUFMAN, 1993)
11 TO 85 CRYSTALLIZED AND FLUID SCALES, COMPOSITE IQ
DIFFERENTIAL ABILITY SCALE (ELLIOTT, 1990) 2-6 TO 17-11 VERBAL, NONVERBAL REASONING, SPATIAL ABILITIES, GENERAL
CONCEPTUAL ABILITY
DAS-NAGLIERI COGNITIVE ASSESSMENT SYSTEM (NAGLIERI AND
DAS, 1997)
5 TO 17-11 PLANNING, ATTENTION, SIMULTANEOUS AND SUCCESSIVE PROCESSING,
FULL-SCALE SCORE
COLORED PROGRESSIVE MATRICES (RAVENS AND SUMMERS,
1986)
5 TO 11 FIGURAL REASONING
COLUMBIA MENTAL MATURITY SCALE (BURMEGERSTER, BLUM,
AND LORGE, 1972)
3-6 TO 9-11 REASONING ABILITY, FORMING AND USING CONCEPTS
TEST OF NONVERBAL INTELLIGENCE-2 (BROWN, SHERBENOU,
AND JOHNSEN, 1990)
5-0 TO 85-11 REASONING ABILITY, SIMILARITIES, DIFFERENCES, RELATIONSHIPS
LEITER-R (ROID AND MILLER, 1999) 2-0 TO 20-11 NONVERBAL, FLUID INTELLIGENCE; VISUALIZATION AND REASONING;
INTELLIGENCE TESTS

WHO TO INVOLVE ?
• MULTIDISCIPLINARY TEAM CONSISTING OF :
• THE PRIMARY CARE DOCTOR
• SOCIAL WORKERS
• SPEECH THERAPISTS
• OCCUPATIONAL THERAPISTS
• PHYSICAL THERAPISTS
• NEUROLOGISTS
• DEVELOPMENTAL PAEDIATRICIANS
• PSYCHOLOGISTS
• NUTRITIONISTS.
• TOGETHER WITH THE FAMILY, THESE PEOPLE DEVELOP A COMPREHENSIVE,
INDIVIDUALIZED PROGRAM FOR THE CHILD, WHICH IS BEGUN AS SOON AS THE
DIAGNOSIS OF ID IS SUSPECTED.
• THE PARENTS AND SIBLINGS OF THE CHILD ALSO NEED EMOTIONAL SUPPORT
AND SOMETIMES COUNSELING.
• THE WHOLE FAMILY SHOULD BE AN INTEGRAL PART OF THE PROGRAM.

TREATMENT PROPER
• ENHANCING SELF IMAGE
• MANAGEMENT OF ASSOCIATED PSYCHIATRIC COMORBIDITIES.
• PARENT COUNSELLING
• MANAGEMENT IN CASE OF PSYCHOSOCIAL DEPRIVATION
• REHABILITATION

ENHANCING SELF IMAGE
• ACCEPTANCE OF ID CHILD IN THE FAMILY AND SOCIETY DESPITE
BEING HANDICAP IS THE FIRST MOST IMPORTANT STEP.
• AVAILABILITY OF PROPER FACILITIES FOR LEARNING & DEVELOPING
SOCIAL, ACADEMIC, VOCATIONAL & MOTOR SKILLS AND LATER
SUITABLE JOBS.
• THESE THINGS PROVIDE A SENSE OF SELF-DIGNITY, IDENTITY & SENSE
OF RESPONSIBILITY IN THE PERSON, HELPING HIM/HER TO ADJUST IN
LIFE AND ADAPT MORE EFFECTIVELY.

MANAGEMENT OF ACCOMPANYING
PSYCHIATRIC COMORBIDITIES
• APPROPRIATE PHARMACOTHERAPY.
• APPROPRIATE PSYCHOTHERAPY
• SKILL TRAININGS
• ERADICATION OF EXPRESSED EMOTIONS.

PHARMACOTHERAPY
• DRUGS SHOULD ONLY BE USED FOR SPECIFIC INDICATIONS LIKE
PSYCHOSIS, DEPRESSION, ANXIERTY, ADHD….
• ID PATIENTS ARE MORE SENSITIVE TO SIDE EFFECTS AND PRONE TO
DRUG TOXICITY.
• ID PATIENTS ARE RESPONSIVE TO LOWER DOSES OF PSYCHOTROPHIC
DRUGS.
• GOLDEN RULE: “ START LOW, GO SLOW”

POINTERS ON INDIVIDUAL CLASSES OF DRUGS IN ID PATIENTS
ANTIPSYCHOTICS
• INDIVIDUALS WITH INTELLECTUAL DISABILITY APPEAR TO BE AT GREATER RISK OF
DEVELOPING TARDIVE DYSKINESIA THAN THE GENERAL POPULATION, WITH RECORDED
RATES RANGING FROM 18 TO GREATER THAN 30 PERCENT FOLLOWING CHRONIC RECEIPT
OF FIRST-GENERATION ANTIPSYCHOTICS.
• ON THE OTHER HAND, SPONTANEOUS ABNORMAL INVOLUNTARY MOVEMENTS ARE
COMMON IN THIS POPULATION, AND THIS MAY REPRESENT A CONFOUND IN
INTERPRETING RATES OF NEUROLEPTIC-INDUCED TARDIVE DYSKINESIA.
• THERE IS NO CONVINCING EVIDENCE THAT THE MECHANISM OF ACTION OF
ANTIPSYCHOTICS IN SIB OR AGGRESSION IS MERELY TO SUPPRESS BEHAVIOR GENERALLY
THROUGH A NONSPECIFIC SEDATING EFFECT. SUCH AN OUTCOME IS CLEARLY
UNDESIRABLE IN AN INDIVIDUAL WITH PRE-EXISTING COGNITIVE IMPAIRMENT

ANXIOLYTICS
• ALTHOUGH BENZODIAZEPINES ARE COMMONLY PRESCRIBED IN TREATMENT
FOR ANXIETY IN THE GENERAL POPULATION, THERE ARE UNIQUE CONCERNS
WHEN THEY ARE USED IN THE CONTEXT OF DEVELOPMENTAL DISORDERS,
PARTICULARLY REGARDING THE POSSIBILITY OF INCREASED CONFUSION,
COGNITIVE IMPAIRMENT, UNSTEADINESS, AND PARADOXICAL EXCITEMENT.
• NEVERTHELESS, THEY ARE USED.
• BUSPIRONE IS ANOTHER SEROTONERGIC AGENT THAT HAS BEEN REPORTED TO
BE OF BENEFIT IN SOME PERSONS WITH DEVELOPMENTAL DISORDERS WITH
DIAGNOSED ANXIETY DISORDERS MANIFESTED BY AGGRESSIVE AND SELF-
INJURIOUS BEHAVIORS. TYPICAL DOSES AT WHICH PATIENTS RESPONDED WERE
ON THE ORDER OF 15 TO 45 MG PER DAY.

ANTIDEPRESSANTS
• INDIVIDUALS WITH INTELLECTUAL DISABILITY MAY REQUIRE LOWER LEVELS OF
ANTIDEPRESSANT DRUGS THAN THEIR NORMALLY DEVELOPING PEERS.
• TRICYCLIC ANTIDEPRESSANTS IN PARTICULAR (E.G., CLOMIPRAMINE) MUST BE USED
WITH THE KNOWLEDGE THAT THE RISK OF LOWERING SEIZURE THRESHOLD IS REAL.
• CARDIAC ANOMALIES ARE COMMON IN SOME INTELLECTUAL DISABILITY
SYNDROMES, AND THE ANTICHOLINERGIC SIDE EFFECTS OF SOME MEDICATIONS
MAY BE PARTICULARLY SIGNIFICANT
• TRIALS OF SEROTONIN REUPTAKE INHIBITORS ARE INCREASINGLY COMMON
AMONG PATIENTS WITH SIB.
• FAVORABLE EXPERIENCES HAVE BEEN REPORTED FOR FLUOXETINE, PAROXETINE, SERTRALINE,
TRAZODONE, AND CLOMIPRAMINE IN THIS REGARD.
• HOWEVER, OF THESE AGENTS, ONLY CLOMIPRAMINE HAS BEEN SHOWN TO BE USEFUL IN
WELL-CONTROLLED STUDIES.
• DUE TO ITS EFFECT OF LOWERING SEIZURE THRESHOLD, CLOMIPRAMINE IS GENERALLY NOT A
FIRST-LINE TREATMENT FOR COMPULSIVE SIB IN INDIVIDUALS FREQUENTLY COMORBID FOR
EPILEPSY.

ANTICONVULSANTS
• ID WITH EPILEPSY
• SOME ANTICONVULSANT DRUGS MAY IMPROVE CYCLICAL MOOD
DISORDERS AND IMPULSIVE AGGRESSION
• CARBAMAZEPINE IS THE MOST WIDELY PRESCRIBED
ANTICONVULSANT FOR PERSONS WITH INTELLECTUAL DISABILITY
• GABAPENTIN AND LAMOTRIGINE
• IMPROVING CHALLENGING BEHAVIOUR
• HOLD PROMISE FOR PERSONS WITH INTELLECTUAL DISABILITY AND
TREATMENT-RESISTANT EPILEPSY

PSYCHOSTIMULANTS
• DESPITE REPORTS OF PARADOXICAL RESPONSES TO STIMULANT
MEDICATIONS IN PERSONS WITH INTELLECTUAL DISABILITY, WITH
HIGHER-THAN-EXPECTED RATES OF EMERGENT MOTOR TICS AND
EMOTIONAL LABILITY, A GROWING BODY OF LITERATURE SUPPORTS
THE USE OF STIMULANT DRUGS FOR THE TREATMENT OF ADHD IN
THE CONTEXT OF INTELLECTUAL DISABILITY.

OPIOID ANTAGONISTS
• NALTREXONE IS THE OPIOID ANTAGONIST MOST WIDELY USED FOR
SIB, BUT THE LITERATURE IS MIXED
• NALTREXONE APPEARS TO BE WELL TOLERATED IN PERSONS WITH
DEVELOPMENTAL DISORDERS, WITH SEDATION AS THE SIDE EFFECT
MOST LIKELY TO BE OBSERVED

NOOTROPICS
• THE “HOLY GRAIL” OF PSYCHOPHARMACOLOGY IN INTELLECTUAL
DISABILITY WOULD BE DRUGS THAT POSITIVELY AFFECT COGNITION,
OR NOOTROPIC DRUGS.
• PIRACETAM IS A PUTATIVE NOOTROPIC AGENT, BUT INTEREST IN THIS
AGENT HAS LARGELY BEEN FUELED BY ANECDOTAL INTERNET AND
MEDIA REPORTS OF ITS POSITIVE EFFECTS ON LEARNING, MEMORY,
ATTENTION, AND GENERAL WELL-BEING.

LITHIUM
• ANTIAGGRESSIVE EFFECT
• THERE IS EVIDENCE TO SUGGEST THAT IN THE SETTING OF CYCLICAL
MOOD DISTURBANCE, LITHIUM MAY ALSO BE HELPFUL

NEW RESEARCHES
• AMANTADINE IS ANOTHER DRUG WHOSE AFFINITY AT THE NMDA
RECEPTOR HAS ONLY RECENTLY BECOME APPRECIATED.
• THE USE OF AMANTADINE IN CHILDREN WITH VARIOUS
DEVELOPMENTAL DISABILITIES AND DISRUPTIVE BEHAVIOURS IS
QUITE PROMISING
• MELATONIN DESERVES BROADER CONSIDERATION FOR THE
TREATMENT OF CHILDREN WITH INTELLECTUAL DISABILITY AND
DISTURBED CIRCADIAN RHYTHM OF SLEEP.
• DEXTROMETHORPHAN, AN ANTITUSSIVE AGENT WAS REPORTED TO
HAVE MARKEDLY ATTENUATED SIB.

PSYCHOTHERAPY
• SPECIFIC PSYCHOTHERAPEUTIC APPROACHES THAT HAVE BEEN SHOWN TO BE EFFECTIVE
INCLUDE BEHAVIOURAL (IN PARTICULAR, APPLIED BEHAVIOUR ANALYSIS MODELS),
COGNITIVE-BEHAVIOURAL, PSYCHODYNAMIC, PSYCHOEDUCATIONAL, AND SKILLS
TRAINING (E.G., COPING SKILLS, SOCIAL SKILLS) APPROACHES.
• BEHAVIOURAL THERAPIES ARE DEMONSTRABLY EFFECTIVE IN MANAGING MANY
MALADAPTIVE BEHAVIOURS, PARTICULARLY AGGRESSION AND SELF-INJURY, IN PERSONS
WITH INTELLECTUAL DISABILITY.
• PSYCHOANALYTIC APPROACHES, FOCUSING ON DEVELOPMENTAL THEORIES, TO IMPROVE
EMOTIONAL EXPRESSION, ENHANCE SELF-ESTEEM, INCREASE PERSONAL INDEPENDENCE,
AND BROADEN SOCIAL INTERACTIONS.
• GROUP THERAPY CAN BE AN IMPORTANT PART OF A TREATMENT PROGRAM FOR PERSONS
WITH INTELLECTUAL DISABILITY, PARTICULARLY IN THE AREA OF SOCIAL SKILLS BUILDING.

BEHAVIOUR THERAPY
• IMPAIRMENT IN ADAPTIVE BEHAVIOUR MAY BE EITHER A DEFICIT
BEHAVIOUR OR AN EXCESS BEHAVIOUR.
• 5 MAJOR STEPS IN IMPLEMENTATION OF BEHAVIOUR MODIFICATION
PROGRAMME:
I. IDENTIFICATION OF PROBLEM BEHAVIOUR.
II. DEFINING THE TARGET BEHAVIOUR.
III. BEHAVIOUR RECORDING – BASELINE & AFTER TREATMENT.
• QUESTIONS ABOUT BEHAVIORAL FUNCTION (QABF)
IV. FUNCTIONAL ANALYSIS.
V. TREATMENT PROCEDURES & EVALUATION.

SKILL TRAINING
• URBAN AREA:
• SPECIAL SCHOOLS
• VOCATIONAL TRAINING CENTRES
• CHILD GUIDANCE CLINIC IN GENERAL HOSPITAL.
• RURAL AREA:
• VILLAGE LEVEL WORKER EQUIPPED WITH SKILLS IN HOME TRAINING OF ID
PEOPLE.

SKILL TRAINING
STEPS:
1. EACH TRAINING ACTIVITY SHOULD BE DIVIDED INTO SMALL STEPS
AND DEMONSTRATED PROPERLY.
2. REPEATED TRAINING IN EACH ACTIVITY.
3. TRAIN REGULARLY AND SYSTEMATICALLY.
4. PARENTAL COUNSELING : PATIENCE

PARENT COUNSELING
• IT IS AN IMPORTANT STEP IN MANAGEMENT OF ID PATIENTS.
• SINCERITY, REASSURANCE, EFFECTIVE COMMUNICATION &
ENHANCING EMOTIONAL STABILITY ARE THE IMPORTANT MEASURES.
• THE STAGES OF COUNSELING ARE:
1. IMPARTING INFORMATION REGARDING THE CONDITION OF THE ID CHILD.
2. HELPING THE PARENT TO DEVELOP RIGHT ATTITUDE TOWARDS THEIR
DISABLED CHILD.
3. CREATING AWARENESS IN THE PARENT REGARDING THEIR ROLE IN
TRAINING THEIR ID CHILD.

ETIOLOGY-BASED EDUCATIONAL APPROACHES
• CHILD'S AETIOLOGY OF INTELLECTUAL DISABILITY INFLUENCE HIS/HER
BEHAVIOUR.
• INDIVIDUALS WITH EACH SYNDROME DIFFER FROM OTHERS IN
MALADAPTIVE BEHAVIOUR AND PSYCHOPATHOLOGY, AS WELL AS IN
RELATIVE STRENGTHS (OR WEAKNESSES) IN LANGUAGE, VERSUS OTHER
ABILITIES.
• SUCH AETIOLOGY-RELATED PROFILES MAY EVENTUALLY LEAD TO
AETIOLOGY-RELATED INTERVENTIONS.
• ETIOLOGY-RELATED INTERVENTIONS HAVE ADOPTED THE APPROACH OF
“PLAYING TO STRENGTHS” AS OPPOSED TO AMELIORATING WEAKNESSES.

ETIOLOGY-BASED EDUCATIONAL APPROACHES
• MOST CHILDREN WITH DOWN SYNDROME SHOW PARTICULAR
DIFFICULTIES IN LINGUISTIC GRAMMAR, EXPRESSIVE LANGUAGE, AND
ARTICULATION, BUT THEIR ABILITIES IN VISUAL SHORT-TERM
MEMORY APPEAR TO BE RELATIVELY STRONG.
• THUS, WHEN ASKED TO RECALL A SERIES OF HAND MOVEMENTS,
THESE CHILDREN PERFORM BETTER THAN WHEN RECALLING A SERIES
OF SPOKEN NUMBERS OR WORDS.
• USING THIS VISUAL-OVER-AUDITORY PROFILE, VARIOUS
RESEARCHERS HAVE BECOME INTERESTED IN TEACHING CHILDREN
WITH DOWN SYNDROME TO READ.

MANAGEMENT IN CASE OF PSYCHOSOCIAL DEPRIVATION
• A VARIETY OF VERBAL, SENSORY STIMULATION SHOULD BE
PROVIDED.
• INTRODUCTION OF NEW, PLEASURABLE & USEFUL SKILLS TO
INCREASE CHILD’S KNOWLEDGE.
• FREQUENT PLAY THERAPY SESSIONS.
• EXTRA & SPECIAL COACHING IN SMALL GROUP TO COVER UP FOR
SOCIAL & CULTURAL DEPRIVATION.

REHABILITATION
• DEPENDING UPON THEIR LEARNING POTENTIAL & ASSESTS,
PREVOCATIONAL & VOCATIONAL TRAINING NEEDS TO BE PROVIDED.
• VOCATIONAL SERVICES INCLUDE:
• COUNSELING OF THE TRAINERS & THEIR FAMILIES.
• SUPPORTED EMPLOYMENT INCLUDING JOB PLACEMENT.
• FOR MULTIPLE PHYSICAL DISABILITY: PHYSICAL REHABILITATION.
• PHYSIOTHERAPY
• ORTHOPEDIC SERVICES.
• SENSORY DISABILITY: SPECIAL TRAINING

SOCIAL INTERVENTION
• ONE OF THE MOST PREVALENT PROBLEMS AMONG PERSONS WHO
ARE INTELLECTUALLY DISABLED IS A SENSE OF SOCIAL ISOLATION AND
SOCIAL SKILLS DEFICITS.
• THUS, IMPROVING THE QUANTITY AND QUALITY OF SOCIAL
COMPETENCE IS A CRITICAL PART OF THEIR CARE.
• SPECIAL OLYMPICS INTERNATIONAL IS THE LARGEST RECREATIONAL
SPORTS PROGRAM GEARED FOR THIS POPULATION.
• IN ADDITION TO PROVIDING A FORUM TO DEVELOP PHYSICAL
FITNESS, SPECIAL OLYMPICS ALSO ENHANCES SOCIAL INTERACTIONS,
FRIENDSHIPS, AND (IT IS HOPED) GENERAL SELF-ESTEEM.

ORGANIZATIONS IN ASSAM
PROVIDING THE ABOVE MENTIONED SERVICES

FOR LIST OF GOVERNMENT SANCTIONED ORGANIZATIONS WORKING FOR
SPECIAL NEED CHILDREN AND ADULTS IN INDIA
• http://www.udaan.org/parivaar/india.html
• THE NATIONAL TRUST WORKS FOR THE WELFARE OF PERSONS WITH
ANY OF THE FOLLOWING FOUR DISABILITIES
• AUTISM
• CEREBRAL PALSY
• MENTAL RETARDATION
• MULTIPLE DISABILITIES

‘Samarth’ SCHEME
• ITS A CENTRE BASED SCHEME (CBS) WHICH WAS INTRODUCED IN JULY 2005
FOR RESIDENTIAL SERVICES - BOTH SHORT TERM (RESPITE CARE) AND LONG
TERM (PROLONGED CARE).
• ACTIVITIES IN A SAMARTH CENTRE INCLUDE EARLY INTERVENTION, SPECIAL
EDUCATION OR INTEGRATED SCHOOL, OPEN SCHOOL, PRE-VOCATIONAL AND
VOCATION TRAINING, EMPLOYMENT ORIENTED TRAINING, RECREATION
SPORTS ETC.
• THE FACILITIES IN THE HOME SHALL BE AVAILABLE TO BOTH- MEN AND
WOMEN- ON 50-50% BASIS AND SHALL COVER ALL THE FOUR DISABILITIES
UNDER THE NATIONAL TRUST

‘Niramaya’
• THIS IS A HEALTH INSURANCE SCHEME TO PROVIDE AFFORDABLE HEALTH
INSURANCE TO PERSONS WITH AUTISM, CEREBRAL PALSY, INTELLECTUAL
DISABILITY AND MULTIPLE DISABILITIES.
• THE SCHEME IS IMPLEMENTED IN ALL THE DISTRICTS OF THE COUNTRY
(EXCEPT J & K). THE HEALTH INSURANCE COVER UNDER THE SCHEME IS
PROVIDED UPTO RS.1.0 LAKH.

DISABILITY IN ID
• ACCORDING TO GOVERNMENT OF INDIA GAZETTE:
• MILD ID: 50%
• MODERATE ID: 75%
• SEVERE ID: 90%
• PROFOUND ID : 100%
• ACCORDING TO NIMH, SECUNDERABAD RECOMMENDATION:
% OF DISABILITY = 110 – IQ SCORE

DISABILITY CERTIFICATE ISSUE
• ELIGIBILITY CRITERIA
1. A PERSON HAVING DISABILITY OF 40% AND ABOVE SHALL BE ELIGIBLE AND
MAY BE CONSIDERED FOR ISSUANCE OF DISABILITY IDENTITY
CARD/CERTIFICATE.
2. THE PERSON SHOULD BE A BONAFIDE CITIZEN OF INDIA.

WHO CAN ISSUE A DISABILITY CERTIFICATE
• PSYCHIATRIST
• PAEDIATRICIAN
• CLINICAL PSYCHOLOGIST.

SOME CONTROVERSIAL ISSUES
• STERILIZATION OF ID PATIENTS
• ETHICAL ISSUE WHICH A PHYSICIAN OFTEN FACES.
• FEMALE PATIENTS IN ADOLESCENCE OR EARLY ADULTHOOD MAY NEED THIS
BECAUSE GIRLS MAY BE SUBJECTED TO SEXUAL ABUSE RESULTING IN
UNWANTED PREGNANCY.
• DUE TO INVOLVEMENT OF LEGAL ASPECTS, INDIVIDUALIZED ADVICE MAY BE
GIVEN DEPENDING UPON SEVERITY OF ID, SOCIAL SUPPORT & ATTITUDE OF
CARE TAKER.

MARRIAGE & INTELLECTUAL DISABILITY
• A LACK OF CAPACITY TO UNDERSTAND THE OBLIGATIONS OF
MARRIAGE & TO GIVE VALID CONSENT.
• MILD ID CASES WHO HAVE ATTAINED A SATISFACTORY DEGREE OF
ACHIEVEMENT IN LIFE & SELF DEPENDENCE, NOT SUFFERING FROM
GENETIC DEFECT, A CONSIDERATION FOR MARRIAGE CAN BE GIVEN.

CAPITAL SENTENCE AND PERSONS WITH INTELLECTUAL DISABILITY
• WORLDWIDE, THE GENERAL OPINION IS THAT THE PERSONS WHO ARE
INSANE AND INTELLECTUALLY DISABLED SHALL NOT BE EXECUTED.
• THE SAME LAW IS FOLLOWED IN INDIA
• BUT, OF LATE, THIS NORM HAD A DENT TO SOME EXTENT WHILE DEALING
WITH PERSONS WITH ID AND SIMILARLY WITH THOSE WHO COULD NOT TAKE
INDEPENDENT DECISIONS OWING TO MENTAL ILLNESS.
*Raveesh BN, Anil KMN, Narendra KMS (2013) Law & Psychiatry in India: An Overview. J Forensic Sci Criminol
1(2): 203. doi: 10.15744/2348-9804.1.203

LEGAL ISSUES IN NEED TO BE ADDRESSED FOR
PEOPLE WITH ID
• MENTALLY RETARDED PERSONS ARE NOT MENTALLY ILL PERSONS
• RIGHT TO EDUCATION
• LAWS FOR PREVENTION OF EXPLOITATION AND ABUSE
• LEGAL SERVICES FOR OWING AND INHERITING PROPERTIES AND TO HAVE FINANCIAL RIGHTS
• APPOINTMENT OF GUARDIANS UNDER THE NATIONAL TRUST ACT, 1999
• CREATING AWARENESS CAMPAIGNS AMONGST THE OTHER SCHOOL CHILDREN
• AWARENESS CAMPS FOR EDUCATING THE FAMILY MEMBERS
• AWARENESS PROGRAMMES FOR THE GENERAL PUBLIC
• SENSITIZATION PROGRAMME FOR JUDICIAL OFFICERS AND LAWYERS
*NATIONAL LEGAL SERVICES AUTHORITY (LEGAL SERVICES TO THE MENTALLY ILL PERSONS AND PERSONS WITH MENTAL
DISABILITIES) SCHEME, 2010 [Adopted in the Meeting of the Central Authority of NALSA held on 8.12.2010 at Supreme Court
of India]

ROLE OF PSYCHIATRIST
• ROLE AS DIAGNOSTICIAN, THERAPIST & RESEARCHER.
• INTERMEDIARY AND COORDINATOR BETWEEN STAFF AND PHYSICIANS IN
OTHER SPECIALTIES
• ROLE AS CONSULTANT AT VARIOUS SPECIAL SCHOOLS OR VARIOUS INSTITUTE
FOR ID.
• REHABILITATION SERVICES RECOMMENDATION

MISTAKES THAT WE COMMIT IN DEALING WITH
PEOPLE WITH ID
• SEDATION IS NOT THE SOLUTION TO PROBLEM BEHAVIOUR.
• OVERLOOKING ASSOCIATED PSYCHIATRIC COMORBIDITIES AND SPECIFYING
THE HIDDEN SYMPTOMS UNDER THE UMBRELLA OF DISABILITY SYMPTOMS.
• WE PROVIDE THE INFORMATION ABOUT DISABILITY, WE PROVIDE THE
TREATMENT BUT WE DO NOT SHOW THE WAY TO REHABILITATION.

INTELLECTUAL DISABILITY PART - II

BIBLIOGRAPHY
• COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, VOL 2, KAPLAN AND SADOCK.
• SYNOPSIS OF PSYCHIATRY, 10TH EDITION - BENJAMIN J SADOCK & VIRGINIA A
SADOCK
• OXFORD TEXTBOOK OF PSYCHIATRY
• MENTAL RETARDATION – A MANUAL FOR PSYCHOLOGISTS – NIMH, MINISTRY OF
SOCIAL JUSTICE, GOVET OF INDIA
• http://www.pbhealth.gov.in/pdf/DISABILITY%20GUIDELINES_With%20TOC_Versio
n%204.pdf
• INTERNET SOURCES.

INTELLECTUAL DISABILITY PART - II

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