Maria Quintero-Conk, Ph.D., FAAIDD › wp-content › uploads › 2019 › 06 › ...When a person...
Transcript of Maria Quintero-Conk, Ph.D., FAAIDD › wp-content › uploads › 2019 › 06 › ...When a person...
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Maria Quintero-Conk, Ph.D., FAAIDD
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By the end of the session, participants will be able to:
◦ Identify appropriate treatment strategies for
people with ID and Autism who are experiencing substance abuse or are at risk for suicide.
◦ Analyze risk and protective variables related to
substance abuse and suicide in target population.
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In the 1950s, an important social experiment began that would culminate in deep cultural change for people with mental disabilities.
Realizing that many people in
institutional care could live in communities, states began discharging people with mental illness and with intellectual disabilities (IDs) into communities.
“Normalization” included
unanticipated risks
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Adults with ID are generally less likely to use substances than adults without ID.
As a group, a substantial number of people with ID live with families or other caregivers who provide some degree of monitoring; therefore, the opportunities to engage freely in all adult choices can be limited by the presence of a caregiver.
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Caregiver presence does not prohibit all opportunities.
Some people with ID do use alcohol and illicit
drugs Those who do so are more likely to develop an
abuse problem. ◦ In a 2010 study, Slayter reviewed Medicaid healthcare
billing claims and concluded that 2.6% of all people with ID had a diagnosable substance abuse disorder.
◦ Other estimates using different methodologies vary widely, ranging as high as 26% (Strain, Buccino, Brooner, Schmidt, & Bigelow, 1993).
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When a person with ID also has a mental illness the estimates of co-occurring substance abuse range from 7% to 20% (Sinclair, 2004).
The research in this area is sparse, but the numbers are alarming, especially compared with substance abuse in a non-ID population of adults with mental illness, where the rate estimated to be 7.6% (Substance Abuse and Mental Health Services Administration, 2008).
The myth that people with ID do not drink alcohol or do drugs has been dispelled.
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As a group, they tend to begin drinking alcohol a couple of years later than their peers without ID
They are less likely to be Caucasian They are less likely to seek help for their problem …and when they do, the resources that are helpful for
the general public fall short of meeting their needs. They are at greater risk of complications from drinking
because they tend to be prescribed medications for other conditions, such as seizures, and co-occurring mental illness that might negatively interact with alcohol and drugs.
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Research in this area is lagging.
Modified Alcoholics Anonymous (AA)
◦ Concept of powerlessness over substances is usually too abstract for people with ID
◦ Modified content instead emphasizes being capable and empowered to make changes in one’s life (Phillips, 2004).
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Reading skills ◦ People with ID have limited reading ability. ◦ The books, pamphlets, and signs used in AA are written
at an eighth- to ninth-grade level (Sinclair, 2004), well beyond what most people with ID can read and comprehend, if they can read at all.
Cognitive skills ◦ AA depends heavily on spiritual concepts. ◦ While having ID does not imply that a person is
incapable of having spiritual beliefs, the application of these concepts to recovery is a higher-order function that is often beyond the cognitive ability of the person with ID.
◦ Analogies and metaphors, used liberally in recovery literature and discussions, can be beyond the comprehension of the person with ID.
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Social and communication skills ◦ An ID diagnosis includes deficits in adaptive behavior,
which includes the person’s ability to engage in social exchanges.
◦ Limited communication skills are barriers to someone sharing his or her story and engaging in small talk, which is often the glue of relationships in their early stages.
Meeting structure and flow ◦ AA meetings follow a common process: opening welcome,
book study, step study, discussion, and sharing. ◦ The welcome may involve stating the rules of the group,
including anonymity, followed by a reading from the Big Book, a study of one of the 12 steps, and then open sharing.
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Simplify the materials ◦ Readings from the Big Book can be simplified into
more concrete language using shorter sentences and including visual supports.
◦ A chart on an easel provides the ability to draw an idea or, with preparation, pictures from magazines and short videos can be introduced to illustrate concepts.
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Repetition and checking for comprehension ◦ After introducing a concept, it is helpful to check for
comprehension. ◦ This exchange is in direct contrast with the AA flow of
strict voluntary initiations of interactions, but the attention of a person with ID is greatly improved by varying stimuli and promoting exchange in which the person repeats or paraphrases what they have heard.
◦ The facilitator should remain sensitive to a participant’s
desire to remain silent and such choice should be respected, with follow-up after the group to confirm that the lack of active participation is not masking lack of understanding.
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Use of a teaching approach ◦ In AA, learning occurs incidentally as members
share and internalize the experiences of others.
◦ This process can be too complex for most people with ID, who can benefit from a didactic portion of a meeting in which the facilitator specifically teaches key points of a concept from the Big Book and/or one of the 12 steps using language, materials, and role playing exercises that are at the participants’ level of comprehension.
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More work is needed in this area to develop empirically based interventions for a growing
social problem.
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Most suicides are related to psychiatric disease, with depression,
substance use disorders and psychosis being the most relevant
risk factors
Bachman (2018)
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Approximately one third of
persons with IDD have a co-existing
psychiatric disorder.
AUTISM Nearly 50% of adults with Autism will experience depression
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Adults with autism are about four times more likely to experience depression than other people
Average rate of suicidal ideation 66% ◦ Average prevalence for suicide attempts is 35% ◦ Mortality rate 0.31% (compared to 0.04%
matched controls)
Among children identified with ASD who had IQ scores available, nearly a third (31%) also had intellectual disability. ◦ Stated differently, about 2/3 had IQ in the
average range
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Among adults aged ≥18 years in the United States during 2013:
An estimated 9.3 million adults (3.9% of the adult U.S. population) reported having suicidal thoughts in the past year. ◦ Adults aged 18 to 25 = 7.4% ◦ Adults aged 26 to 49 = 4.0% ◦ Adults aged 50 or older = 2.7%
An estimated 2.7 million people (1.1% ) made a plan about how they would attempt suicide in the past year.
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Among students in grades 9-12 in the U.S. during 2013:
17.0% of students seriously considered attempting suicide in the previous 12 months
13.6% of students made a plan about how they would
attempt suicide in the previous 12 months 8.0% of students attempted suicide one or more
times in the previous 12 months 2.7% of students made a suicide attempt that resulted
in an injury, poisoning, or an overdose that required medical attention
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Data from the National Vital Statistics System, Mortality
From 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population.
Suicide rates increased from 1999 through 2014
for both males and females and for all ages 10–74.
The percent increase in suicide rates for females
was greatest for those aged 10–14, and for males, those aged 45–64.
https://www.cdc.gov/nchs/products/databriefs/db241.htm
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Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
History of mental disorders, particularly clinical depression
Feelings of hopelessness
Isolation, a feeling of being cut off from other people
History of alcohol and substance abuse
Impulsive or aggressive tendencies
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Loss (relational, social, work, or financial)
Physical illness
Local epidemics of suicide
Easy access to lethal methods
Barriers to accessing mental health treatment
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts
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Protective factors buffer individuals from suicidal thoughts and behavior.
Effective clinical care for mental, physical, and substance
abuse disorders Easy access to a variety of clinical interventions and
support for help seeking Family and community support (connectedness) Support from ongoing medical and mental health care
relationships Skills in problem solving, conflict resolution, and
nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and
support instincts for self-preservation
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For years, ID has been thought to be a “buffer” against suicide
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Not studied sufficiently
People with ID have fewer protective factors
In ID, higher risk of suicide is correlated with lower IQ
Higher suicide risk, lower mortality
◦ In Autism, higher IQ is correlated with higher rate of Depression
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42% have MI
◦ Slightly above 35-37% in current literature, but within ranges often cited
8% are suicidal, with history of hospitalization and attempts/threats
12
63
0
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Suicide MI
150 cases seen for intake at the Local IDD Authority (LIDDA) at Tri-County Behavioral Healthcare between 6/11/15 to 1/26/16
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Mr. B ◦ 35yo male with Down syndrome with moderate ID (IQ
46). He has lost his appetite for favorite foods. He used to look forward to going to day hab but has been increasingly combative in the mornings over the last six months when caregivers wake him. At day hab he puts his head down and slaps at people who try to wake him or engage him in activities. He also becomes aggressive when staff instruct him to bathe. Mr. B has always had limited speech (two and three word combinations) but he has gradually stopped talking except in rare circumstances. Last week, he alarmed staff by swallowing several pieces of paper.
◦ Recent events: One staff person retired after 11 years in the
program. Two roommate changes within a year and a half
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◦ Choice of means; generally linked to opportunity
Hanging
Poisoning
Jumping from heights
Running into traffic
Drowning
Stabbing/slashing
Attempts with more atypical means ◦ Eating coins ◦ Biting an electrical cord ◦ Refusing to eat
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Boris ◦ 10yo male with ASD. IQ 98, adaptive behavior
moderately impaired with greater deficits in social skills and communication. In class, he wound a belt around his neck and quickly tightened it. The teacher was able to release it and he was hospitalized for 5 days. After discharge, he returned to school without further incident, but kept talking to his parents and writing long essays about wanting to die. One month later, he slipped out of the house at night and was picked up by police who found him weaving in and out of cars on a busy road. He calmly said that he wanted to die. His doctor recommended inpatient treatment, but the family could not find a hospital to admit him because he presented calmly. He returned home and continues to say that he wishes he were dead.
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Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
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Local epidemics of suicide Isolation, a feeling of being cut off from other
people Barriers to accessing mental health treatment Loss (relational, social, work, or financial) Physical illness Easy access to lethal methods Unwillingness to seek help because of the
stigma attached to mental health and substance abuse disorders or to suicidal thoughts
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Loss (death, adoption, out of home placement, direct care staff leaves)
Less family support
Less reciprocity in relationships
More rejection
More co-morbid physical disabilities
More stress loneliness and isolation
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Effective clinical care for mental, physical, and substance abuse disorders
Easy access to a variety of clinical interventions and support for help seeking
Family and community support (connectedness)
Support from ongoing medical and mental health care relationships
Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
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15yo female with Mild ID who attends public school, previously described by family & teachers as friendly but anxious. She is increasingly resistant to getting on the bus every morning. She becomes agitated and frequently says she is “nervous” and “they wish I was dead.” Her behavior program rewards her for “using her words” to express anger, so she has increased cursing. She used to bang her head against walls and furniture as a young child, and resumed this behavior within the past two months. She picks at scabs until they bleed and burrows into the lesions. She had been doing so well in school that she was moved into more Gen Ed time so that she could continue to develop socially as well as academically. Now the ARD committee is reconsidering this change and Lily is upset about going back to LIFE Skills full time. She says she’d “rather die than go back” and recently threatened to take all of her multivitamins at one time.
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Suicidal Behavior tends to be minimized
Common reactions ◦ They’re trying to get attention
◦ They don’t understand what they’re saying
◦ They’re not smart enough to do it
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Are we treating… or just blocking?
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Is supervision to prevent self-harm sufficient treatment?
Is the person’s low IQ overshadowing the seriousness of their threat?
Since it “blew over” in the past, are we comfortable in the knowledge that this, too, shall pass?
Does it matter that the person is depressed? Anxious? Threatening to hurt themselves?
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View the world from the person’s standpoint ◦ “What if it was me…?”
Acknowledge
Communicate
Facilitate
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People with IDD and ASD are responsive to treatment. Behavior therapy is not always the treatment of choice. Cognitive behavior therapy has shown promise for
people with ASD and Mild ID Medication may need to be explained to family and
other caregivers ◦ Since the person will usually have communication deficits,
others will need to record data to communicate treatment effects on the person’s behalf
◦ The person who accompanies the individual to appointments MUST know the details of the case and report those details accurately
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Examine the role of trauma ◦ Loss
◦ Abuse
Examine the role of physical ailments and progressive illnesses
Examine the environment and modify as needed to reduce anxiety
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Train health and service providers to recognize signs of depression and anxiety and treat these conditions
Screen for suicidal ideation
Take the signs seriously ◦ Threats
◦ Attempts
◦ Self-injurious behavior
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Suicidal behavior in people with ID and ASD is real.
Depression and anxiety, common correlates of suicidal behavior, may “look” different from what we expect.
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Identify & treat mental illness Identify & treat substance abuse Identify & treat medical conditions Work with individuals and their caregivers to
develop an action plan for crises Use evidence based therapies (e.g. cognitive
behavior therapy) Use trauma-informed, recovery oriented
treatment that involves social networks and family
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Assure good patient-provider communication and data collection
Facilitate multiple points of access to treatment
Integrate and coordinate care across systems & settings
Develop peer support for people with ID and ASD
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“As long as society supports suicide prevention
services for anyone, it is morally and legally
obligated to extend these services to people
who are disabled.”
Carol J. Gill, Ph.D.
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Bachmann S. Epidemiology of Suicide and the Psychiatric Perspective. Int. J. Environ. Res. Public Health. 2018;15:1425. doi: 10.3390/ijerph15071425.
Hudson, C.C., Hall, L. & Harkness, K.L. J Abnorm Child Psychol (2019) 47: 165. https://doi.org/10.1007/s10802-018-0402-1
Koyanagi, C. (2007). Learning from history: Deinstitutionalization of people with mental illness as a precursor to long-term care reform. Retrieved from http://www.kff.org/medicaid/upload/7684.pdf
McGillicuddy, N. B., & Blaine, H. T. (1999). Substance use in individuals with mental retardation. Addictive Behavior, 24(6), 869-878.
Phillips, M. G. (2004). An outpatient treatment program for people with mental retardation and substance abuse problems. NADD Bulletin, VII(1). Retrieved from http://www.thenadd.org/cgi-bin/checkmember.pl?page=pages/membership/bulletins/v7n1a3
Politte, L.C., Howe, Y., Nowinski, L. et al. Curr Treat Options Psych (2015) 2: 38. https://doi.org/10.1007/s40501-015-0031-z
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Quintero, M (2013). Substance abuse in people with intellectual disabilities. Social Work Today, 11 (4), 26.
Sinclair, T. J. (2004). Meeting the needs of persons with mental retardation within a twelve-step program of recovery. NADD Bulletin, VII(6), Retrieved from http://www.thenadd.org/cgi-bin/checkmember.pl?page=pages/membership/bulletins/v7n6a2
Slayter, E. M. (2010). Demographic and clinical characteristics of people with intellectual disabilities with and without substance abuse disorders in a Medicaid population. Intellectual and Developmental Disabilities, 48(6), 417-431.
Strain, E., Buccino, D., Brooner, R., Schmidt, C., & Bigelow, G. (1993). The triply diagnosed: Patients with major mental illness, cognitive impairment, and substance abuse. Journal of Nervous and Mental Disease, 181(9), 585-587.
Substance Abuse and Mental Health Services Administration Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD
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Maria Quintero-Conk, Ph.D.
National Suicide Prevention Lifeline Call 1-800-273-8255 Available 24 hours everyday