Intellectual disability

Diagnosis

Intellectual disability refers to a disorder with onset during a patient’s developmental period that affects their intellect and adaptive functioning (i.e. functioning independently). It is graded by the DSM-5 as mild, moderate, severe, and profound.

Mild

• Conceptual domain: support needed in academic skills to match peers; adults have impairment in abstract thinking, executive function, memory, functional use of academic skills (as with reading and money management); problems are approached concretely
• Social domain: Immature compared to peers, may miss social cues, tend to be more concrete, there may be difficulties regulating emotion/behavior; at risk for being manipulated by others
• Practical domain: May function age appropriately in personal care, need some support with complex daily living tasks (grocery shopping, transportation, home and child-care organizing, money management; may be employed in jobs that do not require conceptualization; require help with medical and legal decisions

Moderate

• Conceptual domain: academic skills are that of an elementary school level; requires assistance with conceptual tasks required in daily life, others may take over this responsibility fully
• Social domain: markedly different from peers, spoken language is much less complex. May not perceive social cues accurately. Capacity for relationships in family and friends, sometimes romantic. Significant communicative support is needed for work settings.
• Practical domain: after extended teaching can care for personal needs (eating, dressing, elimination, hygiene), and basic chores, though reminders may be needed. Independent employment in jobs with limited conceptual / communication skills with significant support from coworkers. Recreational skills can be developed.

Severe

• Conceptual domain: limited conceptual skills, little understanding of written language or concepts involving numbers, time, money; requires extensive supports for problem solving
• Social domain: speech is limited to certain words or phrases; understand simple speech and gestures; relationships w/ familiar people are a source of pleasure and help
• Practical domain: requires support for all ADLs, requires supervision at all times, cannot make responsible decisions regarding their well-being or safety

Profound

• Conceptual domain: conceptual skills are limited to physical rather than symbolic content; limited use of basic objects, matching and sorting skills may be acquired
• Social domain: nonverbal, nonsymbolic communication; limited understanding of speech or gestures; enjoys relationships w/ well known people (i.e. parents)
• Practical domain: dependent on others for all aspects of daily physical care, health, and safety (though can participate in some activities)

Treatment

Behavioral treatment

• Applied behavioral analysis
  • Identify target behaviors (aggressive or assaultive behaviors, inappropriate sexual statements or behaviors, self-injurious behavior, crying episodes)
  • Measure the behavior (frequency, rate, duration, intensity, response latency)
  • Analyze the behavior (ABCs)
    • Antecedent: stimulus / situation to which the individual responds (a request, a refusal, someone coming/going, physical discomfort)
    • Behavior: target behavior exhibited
    • Consequence: stimulus or stimuli that the individual receives, or that he is stopped being subjected to, as a result of the behavior (gets attention, calms down, gets removed from situation)
  • Develop an intervention intervening on ABCs
    • Token economy, provides a visual cue as a tangible marker of progress (chaining)
    • Planned conflict management – a designated time to channel questions, grievances, and reinforce skills w/ specific staff
    • Forced choice - Give two choices, either of which have positive outcomes, praise for choosing an activity, offers illusion that the individual is making their own choice
  • Program generalization of the behavior
  • Empirically evaluate results – observe decrease in undesirable behaviors and increase in desirable behaviors

Syndromes

Down syndrome

Fragile X syndrome

Rett syndrome

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). (American Psychiatric Association).