Comprehensive health care services for people with learning disabilities

Nutrition knowledge and influence on diet in the carer-client relationship in residential care settings for people with intellectual disabilities

People with intellectual disabilities generally have poorer health outcomes compared with those who do not, including outcomes related to nutrition-related non-communicable diseases. Carers support people with intellectual disabilities in many aspects including habitual shopping and preparation of food, but their own nutrition knowledge and the influence this may have on dietary intakes of clients is unknown. We explored the nutrition knowledge of carers of people with intellectual disabilities in residential care settings, their dietary habits and their influence on clients' food shopping and preparation and therefore the diet consumed by their clients. Ninety-seven carers belonging to a large independent care sector organisation specialising in the care of people with an intellectual disability completed a validated general nutrition knowledge and behaviour questionnaire. Seventeen carers from the residential care settings were interviewed to contextualise practice. Knowledge about key dietary recommendations scored highly. Carers who had more work experience were found to have higher scores in 'making everyday food choices' (p = 0.034). Daily consumption of fruit and vegetables (at least one portion per day) was observed (for fruit by 46% of the carers and for vegetables by 60% of the carers), whilst most carers reported avoiding consuming full-fat dairy products, sugary foods and fried foods. The concept of a healthy diet; typical dietary habits of clients; role in food acquisition; and training in nutrition emerged as themes from the interviews. Carers discussed various topics including the importance of a balanced diet, cooking fresh foods and control of food portion sizes for clients relative to the care philosophy of a client-centred approach, which encapsulates client autonomy. Gaps in knowledge around specific nutrients, making healthy choices and cooking skills remain. Carers have an influence on clients' dietary choices; they are able to provide healthy meals and share good dietary habits with clients. Further training in nutrition is recommended for impact on clients' health.

Diagnostic progression to bipolar disorder in 17,285 adolescents and young adults with attention deficit hyperactivity disorder: A longitudinal follow-up study

OBJECTIVE

We investigated the diagnostic progression to bipolar disorder (BD) among adolescents and young adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Using the Taiwan National Health Insurance Research Database, we enrolled adolescents and young adults aged 10-29 years with ADHD between January 1, 2001, and December 31, 2010, who were followed up until December 31, 2011, to determine progression to BD. Cox regression analysis was used to examine candidate risk and protective factors.

RESULTS

At the 11-year follow-up, the progression rate from ADHD to BD was 5.12%. Of the participants who progressed, 62.16% (322/518) progressed within the first 3 years. Risk factors for progression were as follows: older age (hazard ratio [HR], 1.058; 95% confidence interval [CI], 1.033-1.084), comorbidity with autistic spectrum disorder (HR, 1.839; 95% CI, 1.415-2.391), disruptive behavior disorder (HR, 1.434; 95% CI, 1.132-1.816), intelligence disability (HR, 1.744; 95% CI, 1.399-2.176), depressive disorder (HR, 1.978; 95% CI, 1.577-2.482), alcohol use disorder (HR, 1.705; 95% CI, 1.057-2.751), cluster A (HR, 2.508; 95% CI, 1.167-5.391) or B (HR, 2.718; 95% CI, 1.974-3.741) personality disorder, and a family history of BD (HR, 2.618; 95% CI, 1.823-3.758) Identified protective factors were male sex (HR, 0.771; 95% CI, 0.630-0.943) and cluster C personality disorder (HR, 0.278; 95% CI, 0.086-0.898).

CONCLUSION

The study demonstrated the specific risk and protective factors for BD progression among adolescents and young adults with ADHD. It is important for clinician and mental health care providers to recognize identified factors to focus on early detection and prompt intervention.

Interface between community intellectual disability and general adult psychiatry services

People with intellectual disability can have a range of common mental health difficulties that sit at the interface of two psychiatry subspecialties: intellectual disability and general adult psychiatry. Clinical presentations, comorbidities and complexities can affect the setting of boundaries between the two disciplines. This article touches on current concepts, drives for inclusion of people with intellectual disability in mainstream psychiatry services and some of the difficulties at the interface. It focuses on potential solutions for managing this interface between the two subspecialties.

Specialist psychiatric beds for people with learning disability

Aims and Method

To examine the use of specialist psychiatric beds for people with learning disability, created following the closure of a long-stay institution. Admission and discharge data were examined, including history of previous institutional admission, diagnosis at discharge and number of subsequent readmissions.

Results

Out of 348 admission episodes, 59 were accounted for by 40 patients who were previously resident in the long-stay institution. Most admissions were for new patients from the community. Over time, admissions to the specialist unit decreased when occupancy reached and persisted at 100%, coinciding with a significant rise in admissions of adults with learning disability to general adult psychiatric wards.

Clinical Implications

Resettlement after closure of long-stay learning disability institutions has not been accompanied by a high readmission rate for former residents, but neither has there been a decreasing need for psychiatric beds for those with learning disability and severe psychiatric disturbance. Most of these admissions are for people with learning disability who are relatively new to the service. There has been a persistent problem with full occupancy of these beds, which reflects delayed discharges indicating a lack of community resources and an increasing demand for admission.

Mainstream health professionals' stigmatising attitudes towards people with intellectual disabilities: a systematic review

BACKGROUND

Equal access to mainstream healthcare services for people with intellectual disabilities (ID) still requires attention. Although recent studies suggest that health professionals hold positive attitudes towards people with ID, stigmatising attitudes may influence their efforts to serve people with ID in community healthcare practice. To stimulate inclusion in mainstream healthcare services, this systematic review focussed on barriers in attitudes of mainstream health professionals towards people with ID.

METHOD

Five electronic databases were systematically searched and references in full text articles were checked for studies published in the English language between January 1994 and January 2016. A social-psychological triad of cognitive, affective and behavioural dimensions of stigmatising attitudes is used to structure and discuss the results.

RESULTS

The literature search generated 2190 records with 30 studies that passed our exclusion criteria. Studies were mostly cross-sectional and of moderate quality. With respect to stigma, a lack of familiarity with and knowledge about people with ID was found. ID was considered as a stable condition not under personal control. Moreover, mainstream health professionals had either low or high expectations of the capabilities of people with ID. Professionals reported stress, lack of confidence, fear and anxiety, a tendency to treat people with ID differently and a lack of supporting autonomy.

CONCLUSIONS

Stigmatising attitudes towards people with ID appeared to be present among mainstream health professionals. This might affect the ongoing challenges regarding inclusion in mainstream healthcare services. To facilitate inclusion in mainstream healthcare services, it is recommended to include contact and collaboration with experts-by-experience in education programs of health professionals. Future research should progress beyond descriptive accounts of stigma towards exploring relationships between cognitive, affective and behavioural dimensions as pointers for intervention. Finally, inclusion would benefit from an understanding of 'equal' treatment that means reasonable adjustments instead of undifferentiated treatment.

'What vision?': experiences of Team members in a community service for adults with intellectual disabilities

BACKGROUND

In the UK, the closure of 'long-stay' hospitals was accompanied by the development of community teams (CTs) to support people with intellectual disabilities (IDs) to live in community settings. The self-reported experiences of staff working in such teams have been neglected.

METHODS

Focusing on a single county-wide service, comprising five multi-disciplinary and inter-agency CTs, we measured perceptions among the health care and care management Team members of (1) their personal well-being; (2) the functioning of their team; and (3) the organisation's commitment to quality, and culture.

RESULTS

Almost three-quarters of the questionnaires were returned (73/101; 72%). The scores of health care practitioners and care managers were very similar: (1) the MBI scores of more than half the respondents were 'of concern'; (2) similarly, almost four in ten respondents' scores on the Vision scale of the TCI were 'of concern'; (3) the perceived commitment to quality (QIIS-II Part 2) was uncertain; and (4) the organisational culture (QIIS-II, Part 1) was viewed as primarily hierarchical.

DISCUSSION

The perceived absence of a vision for the service, combined with a dominant culture viewed by its members as strongly focussed on bureaucracy and process, potentially compromises the ability of these CTs to respond proactively to the needs of people with IDs. Given the changes in legislation, policy and practice that have taken place since CTs were established, it would be timely to revisit their role and purpose.

A register study of life events in young adults born to mothers with mild intellectual disability

BACKGROUND

Young adults, born to population-representative mothers with intellectual disability (ID), were targeted for psychosocial/life event follow-up.

METHODS

The whole group originally comprised 42 individuals but 3 had died and 1 had moved abroad. The remaining 38 were approached and 10 consented to participate in an interview study. However, of the remaining 28, it was not possible to establish contact with 21 who were instead searched for in various official registers.

RESULTS

Most (n = 18) individuals in the study group had been in contact with different authorities and clinics. Of the 21 individuals, 10 had contact with social services since childhood and 4 of these had been taken into care (foster family) and 6 had had contact families during childhood. One individual had been taken into a treatment centre and one grew up mainly with the father. Altogether 12 (57%) of 21 individuals did not grow up full-time with their biological mother. Twelve (57%) had major neurodevelopmental/neuropsychiatric conditions, including five with ID and seven with attention-deficit hyperactivity disorder (ADHD). Four individuals were registered within the Prison and Probation Service due to various types of crimes.

CONCLUSION

Individuals born to mothers with ID in our study group were at high risk of adverse experiences and negative outcomes, such as increased childhood mortality, a relatively large proportion of children taken into care, high rates of ID and ADHD in the children and of criminality in young adulthood. Taken together with the results obtained in an in-depth interview study of those in the originally targeted sample with whom it was possible to obtain contact, the present findings suggest that it will be important to provide early support and longitudinal developmental follow-up in groups of children growing up with a mother with ID. Children in this situation appear to be at a number of risks, probably related both to hereditary factors and to social disadvantage.

Females with Down syndrome: lost opportunities in primary care

PURPOSE

Nurse practitioners (NPs) need to be aware of the health disparities that exist between adult females with and without Down syndrome (DS). It is essential that necessary primary and preventive healthcare services are available to women with DS to maintain adequate health and quality of life, and reduce the occurrence of misdiagnosed or underdiagnosed treatable diseases.

DATA SOURCES

Review of published literature, DS society reports, and U.S. government reports.

CONCLUSIONS

A lack of agreed guidelines for the screening of adult females with DS contributes to unmet health needs in primary care for this population. Adequate promotion of health in all persons with disabilities, including the specific needs of women with DS, will help prevent the development of preventable secondary disabilities. Research shows that health promotion, screenings, and preventive care are overlooked or ignored in the female population with DS. Barriers to this care were consistent with misconceived attitudes and beliefs about adults with DS and a lack of training for primary care providers in caring for persons with disabilities.

IMPLICATIONS FOR PRACTICE

Although much research is needed, there are some resources for NPs who provide care for this vulnerable population. Screening for preventable conditions, such as obesity, sexually transmitted infections, and sexual exploitation, can improve the quality of life for adult women with DS.

Prevalence of obesity and metabolic syndrome in a long-stay psychiatric unit

Objective:The aim of this study was to determine the prevalence of metabolic syndrome and obesity as defined by Body Mass Index (BMI) in a long-stay psychiatric unit where all care is provided by the psychiatric team.

Method:All residents in this long-stay unit were screened. Their BMI was calculated. Waist circumference and blood investigations were done. Ward records were used to determine those who had been previously diagnosed with hypertension and diabetes. The ATP 111 criteria were used to determine the prevalence of metabolic syndrome.

Results:We found a prevalence of 33% for BMI obesity and a prevalence of 66% for metabolic syndrome. These are higher than those of the general Irish middle aged population and the accepted estimate of a general psychiatric population. It is also higher than that of a previous published study on an Irish long-stay psychiatric ward population.

Conclusion:There is high prevalence of BMI obesity and metabolic syndrome in long-stay psychiatric residents. This has the potential to impact significantly on physical morbidity and mortality. People with severe and enduring mental illness should have access to primary care and other health services on the same basis as any other citizen.

Intellectual disability in children with attention deficit hyperactivity disorder

OBJECTIVE

To determine whether children with attention deficit hyperactivity disorder (ADHD) and mild intellectual disability (ID) are a clinically distinct ADHD subgroup.

STUDY DESIGN

This was a cross-sectional study comparing clinical characteristics (ADHD subtypes, total number of symptoms, and rates of common comorbidities) between children with ADHD and mild ID and those with ADHD and IQ test scores >70, and also between children with ADHD and ID and a general population sample of children with ID alone. The sample comprised a clinical sample of children with ADHD with ID (n = 97) and without ID (n = 874) and a general population sample of children with ID and without ADHD (n = 58).

RESULTS

After correcting for multiple statistical tests, no differences were found between the 2 ADHD groups on any measure except the presence of conduct disorder (CD) symptoms and diagnoses. Children with ADHD and ID had higher rates of both (OR, 2.38; 95% CI, 1.71-3.32 and OR, 2.69; 95% CI, 1.69-4.28, respectively). Furthermore, children with ADHD and ID had significantly higher rates of oppositional defiant disorder (OR, 5.54; 95% CI, 2.86-10.75) and CD (OR, 13.66; 95% CI, 3.25-57.42) symptoms and a higher incidence of oppositional defiant disorder diagnoses (OR, 30.99; 95% CI, 6.38-150.39) compared with children with ID without ADHD.

CONCLUSION

Children with ADHD and mild ID appear to be clinically typical of children with ADHD except for more conduct problems. This finding has implications for clinicians treating these children in terms of acknowledging the presence and impact of ADHD symptoms above and beyond ID and dealing with a comorbid CD.

Health professionals' attitudes and emotions towards working with adults with intellectual disability (ID) and mental ill health

OBJECTIVES

Mainstream mental health services are providing more care for individuals with an intellectual disability (ID); this has implications for staff and service users. Attitudes of staff towards people with ID in mental health services may be negative and negative staff attitudes may have a detrimental impact on service provision.

DESIGN

A cross-sectional design was used.

METHODS

A questionnaire designed to investigate the attitudes and emotions of staff towards delivering mental health care to adults with ID was completed by 84 staff from mainstream and specialist ID services.

RESULTS

Staff in both services experienced more positive emotions when working with clients whom they are currently employed to work with. When the frequency of contact with adults with ID, the number of individuals worked with and the amount of formal ID training received were considered, there was no significant difference between the attitudes of staff in both services. Positive correlations were found between attitude scores and positive emotional experiences in both services.

CONCLUSIONS

The research suggests that numerous factors, including the role of emotional experience and a number of environmental aspects, need to be considered in the context of providing mental health services to adults with ID to ensure the highest quality. Research limitations and clinical implications of the study are also considered.

Cancer prevention and health promotion for people with intellectual disabilities: an exploratory study of staff knowledge

BACKGROUND

As people with intellectual disabilities (ID) are living longer, their chances of developing cancer also increases. However, recognising the early signs and symptoms of cancer in a population with cognitive impairment and communication difficulties poses difficulties for both family carers and professional care staff. Engagement in health promotion and cancer prevention activities is also a challenge; yet, people with ID have an equal right to these important public services as other members of the population.

AIMS

The aim of this study was to examine how care staff engaged in cancer prevention and health promotion activities on behalf of people with ID.

METHODS

This was an exploratory descriptive study using a postal survey design employing a questionnaire. Fifteen residential facilities for adults with ID were targeted within one geographic region of the UK. In total, 40 residential staff completed a questionnaire about their knowledge of the risk and protective factors of stomach, breast, cervical and testicular cancer. Staff then completed questionnaires regarding 90 adults with ID, recording details about body mass index (BMI), lifestyle choices (i.e. smoking, dietary intake), Helicobacter pylori testing, family history of cancer and staff's health promotion and cancer prevention activities with these individuals.

FINDINGS

The women with ID were reported to have significantly higher BMIs than the men with ID and only two people with ID had been tested for the H. pylori infection: potential risk factors for developing breast and stomach cancer, respectively. The majority of the staff reported that they did not receive training in cancer prevention. Likewise, the majority of the staff reported that they were unaware of the family histories of the people with ID in their care. Reports varied with how staff engaged with people with ID regarding stomach, breast, cervical and testicular cancer health promotion activities and cancer screening opportunities.

DISCUSSION

Findings of this study show that health promotion and cancer prevention activities for people with ID may be less than optimal. The importance of staff training in order to raise knowledge and awareness is highlighted. Educating both staff and people with ID about the early signs and symptoms of cancer and the importance of a healthy lifestyle as a protective factor may help lead to more informed healthier lifestyle choices and lower cancer risk and morbidity.

Inclusion in primary care for people with intellectual disabilities: gaining the perspective of service user and supporting social care staff

The aim of this study was to gain service user and social care staff perspectives on the barriers facing people with intellectual disabilities when accessing primary healthcare. A qualitative mixed methods semi-structured approach involved the use of focus groups and individual interviews within the service users' homes. A purposive sampling strategy identified people using primary healthcare in the last 6 months (N = 6) with support from social care staff (N = 19). Three emergent themes were common to service users and carer staff: ;accessing the surgery', ;communication issues' and ;waiting around'. Other themes were unique to each group. Social care staff identified the ;attitudes and behaviour of primary healthcare staff' as sometimes problematic, and the importance of ;knowing the service user'. Service users identified ;feelings about going to the doctor', ;health education' and ;making changes'. Gaining these views is an important first step in improving access to primary healthcare.

Out-of-area placements in Scotland and people with learning disabilities: a preliminary population study

People with learning disabilities have a different pattern of disease from the general population and high health needs that are frequently unidentified and unmet. Many require responses from general and specialist health services. A picture is emerging of some people with learning disabilities, often with complex care needs, moving from their home area on what is being termed, out-of-area placements, to receive specialist care. However, within the learning disability population, limited research has been undertaken and the impact on health services is unknown. Data were collected from health and social care providers to identify people with learning disabilities moving in and out of services across Scotland. Further data about the consequences and impact of out-of-area placements were gathered in one geographical area using focus group methodology. The results suggest that people with learning disabilities are moving in, out and across Scotland, often as a result of breakdown of local care arrangements or because of lack of specialist resources. Planning, service development and effective communication need to be in place to address the needs of this increasing and ageing population.

Zur Versorgung von Menschen mit Intelligenzminderung und psychischen Störungen in den Kliniken für Kinder- und Jugendpsychiatrie/Psychotherapie in Deutschland - Ergebnisse einer Fragebogenuntersuchung

Zusammenfassung: Fragestellung: Versorgungssituation geistig behinderter Kindern und Jugendlichen mit psychischen Auffälligkeiten durch die Kliniken der Kinder- und Jugendpsychiatrie in Deutschland im Jahre 2003. Methodik: Postalische Befragung aller Kinder- und Jugendpsychiatrischen Kliniken (N = 136); 68 überwiegend geschlossene Fragen mit Antwortvorgaben; Rücklauf: 54,4%. Ergebnisse: Der durchschnittliche Anteil geistig behinderter Patienten liegt ambulant wie stationär bei 6%. N = 6 (8%) verfügen über ein spezialisiertes ambulantes und stationäres Angebot, N = 4 (5%) haben entweder nur eine entsprechende Station oder eine Spezialambulanz. Die Versorgung erfolgt überwiegend nur im Rahmen der kinder- und jugendpsychiatrischen Grundversorgung. Diagnostik und Therapie erfolgen nach den üblichen Standards des Fachgebietes. Die übermäßige Verwendung von Psychopharmaka ist nicht nachweisbar. Auf einer Schulnotenskala wird die ambulante wie stationäre Versorgung mit etwas schlechter als 4, die psychotherapeutische Versorgung als mangelhaft (Note: 5) bewertet. 83% der Klinikchefs fordern spezialisierte Schwerpunktkliniken in jedem Bundesland. Schlussfolgerungen: Die insgesamt defizitäre Versorgungssituation wurde bestätigt. Mit den wenigen Schwerpunktkliniken und -ambulanzen ist selbst eine annehmbar überregionale Versorgungsstruktur nicht zu leisten. Die versorgungspolitische Forderung der Klinikleitungen ist insofern eindeutig, diesen Mangel durch spezialisierte Kliniken und Ambulanzen aufzuheben. Die Qualität der Diagnostik und Behandlung genügt offensichtlich den fachlichen und ethischen Standards der Kinder- und Jugendpsychiatrie. Umgekehrt sind die oftmals sehr schwierigen diagnostischen und therapeutischen Probleme grundsätzlich mit den Methoden unseres Fachgebiets lösbar.