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Research highlights that antipsychotic medications are prescribed more in people with Intellectual Disability (ID) without a diagnosis of severe mental illness. Despite non-pharmacological interventions recommended as alternatives, their application can be challenging due to heterogeneity of the patient group. The purpose of this paper is to discuss application of quality improvement (QI) methodology in adapting interventions, aiming to reduce challenging behaviour of people with ID, thereby reducing use of antipsychotic medication.

Two interventions were introduced as “tests of change”; an “Attention-Deficit Hyperactivity Disorder (ADHD) clinic” and “Positive Behaviour Support (PBS) clinic”. Process (Clinical Global Impression (CGI) and Modified Overt Aggression Scale (MOAS)) and outcome measures (total antipsychotic use) were used to assess the interventions, with each being reviewed as per QI methodology guidelines.

There was an improvement in CGI scores for both interventions. MOAS scores reduced for those attending the ADHD clinic, resulting in reductions of antipsychotic medication. MOAS scores did not reduce for the PBS clinic, so there was no reduction in medication for this group.

Based on the introduction of pilot clinics, this paper provides a commentary on how QI interventions can be used to evaluate and adapt evidence-based interventions, in managing the needs of patients with ID. It further highlights the importance of the diagnosis of ADHD in patients with ID and challenging behaviour. Although PBS is recommended to manage challenging behaviour, this paper demonstrates the importance of continuous evaluation of behavioural interventions. There is currently no existing literature investigating use of QI methodology to reduce challenging behaviour in ID populations, emphasising scope for future research and service evaluation.

The purpose of this paper is to illustrate the possible basis of challenging behaviour (CB) can lie in a treatable neurodevelopmental disorder.

Two case studies were used to illustrate the clinical characteristics of attention deficit hyperactivity disorder (ADHD) presenting as CB in people with intellectual disability (ID).

The findings of this paper show that the appropriate use of drug therapy for ADHD effectively reduced the behavioural challenges.

Limited by two cases. Application of the findings of this paper is limited given it is a case study. This paper highlights an important clinical implications which need to be studied in a larger scale to make clinical recommendations.

Findings from the two case studies may be used when making decisions in clinical practice.

The paper explores the possibility of ADHD presenting as CB in people with ID.

The Dementia Questionnaire for People with Learning Disabilities (DLD) is one of the main screening and monitoring tools for dementia in people with Down’s syndrome (DS). As part of a quality improvement project to improve the care for people with DS and dementia in an intellectual disability service, the authors studied the screening and monitoring process by retrospectively investigating the use of DLD and exploring clinicians’ experience of using it.

DLDs completed in the service was retrospectively assessed. Changes in DLD scores were matched against people who received a clinical diagnosis of dementia. Data were analysed to estimate sensitivity, specificity and predictive values of DLD. A questionnaire was used to assess clinicians’ experience.

Data for 20 service users was collected. DLD cognitive scores showed 80% sensitivity and 60% specificity for the diagnosis of dementia, with a positive predictive value of 40% and negative predictive value of 90%. Staff found DLD to be easy to perform but time consuming. This led to the preparation of a decision tool for appropriateness of performing a DLD.

The results show that a negative DLD helps to exclude dementia where there is concern over cognitive decline, but a positive result is not specific enough to suggest the possibility of dementia. This shows that DLD may have limitations if used as a screening tool alone but could be used for the monitoring of the disease trajectory of those with a confirmed diagnosis as well as to establish a baseline DLD when a person is screened for dementia first.

This paper aims to examine effective diagnostic and treatment pathways for attention deficit hyperactivity disorder (ADHD) in prison settings given the high prevalence of ADHD and comorbidities in the prison population.

Two studies were carried out in two separate prisons in London. Firstly, data were collected to understand the prevalence of ADHD and the comorbidities. The second study used quality improvement (QI) methodology to assess the impact of a diagnostic and treatment pathway for prisoners with ADHD.

Of the prisoners, 22.5% met the diagnostic criteria for ADHD. Nearly half of them were screened positive for autistic traits, with a higher prevalence of mental disorders among prisoners with ADHD compared to those without. The QI project led to a significant increase in the number of prisoners identified as requiring ADHD assessment but a modest increase in the number of prisoners diagnosed or treated for ADHD.

Despite various challenges, an ADHD diagnostic and treatment pathway was set up in a prison using adapted QI methodology. Further research is needed to explore the feasibility of routine screening for ADHD in prison and examine at a national level the effectiveness of current ADHD prison pathways.

Intellectual disability (ID) is prevalent in 1 per cent of the population. Premenstrual syndrome (PMS) affects up to 5 per cent of the general population of adult women. Identification of PMS is challenging in women with ID due to differences in communication. Management of PMS in the ID population requires careful consideration of baseline function, co-existing mental and physical health problems, drug interactions as well as complex ethical considerations. The paper aims to discuss this issue.

Prospero-registered systematic review (CRD42019119398) of papers exploring the diagnosis and management of patients with PMS and ID (n=414). In total, 35 relevant titles were identified and 27 full text papers were assessed for eligibility, resulting in 10 studies for final qualitative analysis.

Ten original research papers were included. There are no standardised symptom criteria for diagnosis of PMS in women with ID. Studies relied on observer-reported data. All papers demonstrated higher rates of PMS in women with ID compared with the general adult population. Management was not standardised and varied between centres. Mainstays of treatment included non-steroidal anti-inflammatories, combined oral contraceptive pills and intramuscular progesterone. Newer evidence suggests levonorgestrel intrauterine systems may be appropriate. There was no quantitative method of establishing success of management.

A modified symptom diary should be used for diagnosis in this population. Differentiation between cyclical behavioural change due to pain vs mood disturbance remains challenging. Conservative, psychological and medical management should be the mainstay of treatment, with surgery considered in exceptional cases.

This paper demonstrates the current limited evidence for the management of PMS in women with a diagnosis of ID and offers an overview of the current options for managing these patients’ symptoms.

Services for people with intellectual disabilities in the UK have evolved over the years from hospital-based care to more community provision. There are multiple reasons for these changes, however, often it was due to changes in social policy or following a scandal in provision. The paper aims to discuss these issues.

Providing services to meet the health and social care needs of people with intellectual disabilities is well-established in the four countries of the UK with support from legislation. There are often specialist mental health and social care teams. Dedicated professionals work with people with intellectual disabilities who experience mental health problems with a focus on support in the community. A range of services for children and adults and for offenders exist across the UK that often vary in composition and structure.

The challenges in providing mental health services for children and adults with intellectual disabilities in the future include recruitment and training of the workforce with the remit of enhancing community support and reduced in-patient care.

This paper helps the reader to understand how ID mental health services are organised in the UK.

This paper gives a summary of the ID mental health services in the UK. Even though there are various papers looking at different aspects of mental health services for people with ID in the UK, this paper brings all that information together to help reader get a better understanding of the mental health services for people with ID.

The literature on the use of Community Treatment Orders (CTOs) is primarily focused on people without intellectual disabilities. This paper aims to explore how CTOs are used in people with intellectual disability in the UK.

An audit was conducted among Consultant Psychiatrists in intellectual disability psychiatry in Nottinghamshire Healthcare NHS Trust. Each consultant was asked to provide information on demographic data of their patients on CTOs, reasons for being on a CTO, conditions specified, patients' capacity to consent and their understanding of their CTOs. Conditions of CTOs were analysed using thematic analysis.

There were 17 CTOs done for patients with intellectual disability from November 2008 to May 2011. Mean age was 38 with a range of 20‐59. All patients had a mild or moderate intellectual disability. Only a small percentage of patients had a diagnosis of schizophrenia. More than 50 per cent had a diagnosis of pervasive developmental disorder (PDD). All patients had behavioural problems as a reason for being on a CTO. About one third of patients did not have any understanding of their CTOs. Themes of conditions were focused on providing a structured life to prevent relapse of the mental disorder.

This paper highlights that CTOs are used differently in the intellectual disability population. CTOs are adapted to use for patients with behavioural challenges and PDD in an intellectual disability population. This contrasts with its common use to manage non‐compliance with medication in patients with schizophrenia in the general adult population. This paper also suggests the main themes of conditions which clinicians can use when deciding on CTO conditions.

Carers play a vital role in looking after people with intellectual disabilities (ID). Caring role can be stressful and challenging in nature. Carers use various coping strategies to deal with stressors. The purpose of this paper is to explore coping strategies of carers looking after people with ID and dementia.

Qualitative methodology was used to explore coping strategies. Focus groups and face-to-face interviews were carried out. These interviews were transcribed and analysed using thematic analysis.

Nine interviews with carers (six paid carers and three family carers) and two focus groups with nursing staff looking after people with ID were carried out. Three key themes of “Narrative”, “Strategy toolbox” and “Compartmentalisation” emerged from analysis. Narrative and strategy took box were further subthemed. Carers had narratives about them and the person they look after. These “narratives” helped them to deal with day to day stressors. They also carried a “strategy toolbox”, which they used when they were in stressful situations. Compartmentalisation helped them to separate their personal life from work life as a carer.

Understanding carers’ coping strategies is important when planning services to help carers who play an important role in our society. Professionals can support carers to understand and improve their existing coping skills and help them to thrive in their role as carers.