ZZZ: Sleep Issues in People With Intellectual and Developmental Disabilities #AtoZChallenge

Hi everyone. Almost every year, my final post in the #AtoZChallenge is about sleep or “ZZZ”. This year is no different.

Sleep problems can affect anyone, disabled or not. However, sleep disorders, including sleep apnea (sleep-related breathing disorder) and insomnia, are more common among people with intellectual disabilities than among the general population. In fact, one review found that as many as 31% of adults with intellectual disability experienced more than one sleep problem. More severely intellectually disabled individuals, those with certain genetic syndromes and those with comorbid neurodevelopmental disorders such as autism, are at particularly increased risk of having more sleep disturbances.

Sleep problems can cause physical and mental health problems in intellectually disabled people just like in the general population. However, they can also contribute to challenging behavior.

There are many factors associated with sleep problems in intellectually disabled people. For example, those with comorbid autism and/or ADHD are at increased risk of having sleep disturbances. Those with certain genetic syndromes, too, may experience certain sleep disorders. I mentioned sleep apnea already in my post on Down Syndrome. People with Smith-Magenis Syndrome, on the other hand, often experience an inverted circadian rhythm.

Environmental factors also need to be considered. For instance, a care home may not be ideal for people with intellectual disabilities to sleep properly due to for example night staff checking on them frequently. This does not happen here. What happens here rather frequently is the reverse, staff leaving clients to “rest” in a sensory room or their bedroom during the day.

The management of sleep disorders in people with intellectual disabilities is somewhat similar to that in the general population. However, more care should be taken to rule out medical conditions such as epilepsy or sleep apnea as the cause for poor sleep. The only medication which is somewhat effective for sleep issues in intellectually disabled people, is melatonin.

Now it’s 10PM and I’m ready for bed myself, I guess.

Youth: Issues Specific to Intellectually or Developmentally Disabled Children #AtoZChallenge

Hi everyone. Phew, we’re almost done with the #AtoZChallenge. For my letter Y post, I thought I’d talk about issues specific to youth with intellectual and developmental disabilities.

Children, disabled or not, by definition, are still growing and developing towards their full potential. As a result, most developmentally and intellectually disabled children and young people will not qualify for long-term care. They are, instead, served under the Youth Act, which falls under the local government. This means that their parents or carers will need to reapply for care at least every year.

Most children with intellectual or developmental disabilities will go to school. Like I mentioned before, those with milder disabilities, due to “suited education”, are forced to go into mainstream classes. This particularly applies to autistic or otherwise neurodivergent children with an average or above-average IQ, but when doing research for this post, I found out that children with a mild intellectual disability (IQ 55-70) won’t qualify for special ed unless they have additional needs too.

Children with moderate to severe intellectual disabilities and those with mild intellectual disabilities and additional issues will usually go into special education. Usually, these schools have different educational levels depending on the severity of the child’s disability. I heard that some schools allow pupils in the highest level to take part in the lowest level regular school, called practice education, part-time. Practice education has only recently become part of the regular, diploma-earning educational system; until I think last year or the year before, pupils in these schools would just earn a certificate.

The most profoundly disabled children, who are deemed “unteachable”, will go to day centers for children and adolescents with intellectual disabilities. Some of these day centers do have a “school prep” group too.

I feel very strongly that “suited education” and the Youth Act leave behind a lot of children with intellectual and developmental disabilities. I mean, the government wants to cut the youth care budget even more and, though I understand this given the fact that one in seven children nowadays receives a form of youth services, this should not affect children with genuine intellectual and developmental disabilities. Like myself twenty to thirty years ago, though in my case being left behind was due to my parents’ denial.

X-Linked Genetic Intellectual Disability #AtoZChallenge

Hi everyone. I can’t remember whether, in my post on the genetics of intellectual disability, I mentioned the difference between autosomal and X-linked genetic causes of intellectual disability. Autosomally genetic conditions are those that are present on one of the autosomes, or non-sex chromosomes, the chromosomes 1 till 22. These present equally commonly in those with two X chromosomes (typically assigned female at birth) as in those with an X and a Y chromosome (typically assigned male). X-linked conditions, on the other hand, present more frequently in either of those groups depending on whether they are recessive or dominant.

An example of an X-linked recessive intellectual disability syndrome is Christianson Syndrome. This affects primarily people assigned male at birth because of their XY chromosomes. After all, recessive means that, if a person has an unaffected copy of the X chromosome, that will be dominant and the person (usually assigned female, XX chromosomes) will not have the condition.

At my former care home, there was a man with Christianson Syndrome. He was in his late fifties, which is really old for someone with the syndrome. He, like everyone with the condition, has an intellectual disability. He also has ataxia, although he at least when I still lived there could still walk, unlike most adults with this syndrome. According to the staff, a lot of things made sense now that they knew that he had this syndrome, even his obsession with electronics.

An example of an X-linked dominant intellectual disability syndrome is Rett Syndrome. This only affects people with two X chromosomes (usually assigned female at birth). Fetuses with XY chromosomes and a Rett Syndrome mutation on their X chromosome, will usually be miscarried.

At my old care home, there was another client with Rett Syndrome. I did not know her well though. Rett Syndrome children develop typically until at least six months of age and then regress. They will develop autistic-like behaviors, although social interaction may develop later on. Another typical feature of Rett Syndrome is the loss of hand function. People with Rett Syndrome will usually have involuntary, repetitive hand movements. I do know the client at my old care home loved to play with sensory toys, but I do not know whether she could purposefully manipulate them.

Another syndrome I need to mention is Fragile X Syndrome. This is an X-linked recessive condition, but it does affect some people with XX chromosomes, albeit more mildly. There is also a so-called “premutation”, which is associated with some Fragile X-linked problems later on but not the full syndrome. This “premutation” is differently inherited depending on the sex of the carrier and may lead to a full mutation (Fragile X Syndrome) in their children.

Work: Employment and Day Activities for People With Intellectual Disabilities #AtoZChallenge

Hi everyone and welcome to my letter W post in the #AtoZChallenge. Today, I want to discuss work and day activities for people with intellectual or developmental disabilities.

People with a mild intellectual disability and no additional problems can often work paid jobs that would otherwise be performed by typically-developing adolescents, such as filling shelves in a supermarket or being waiters in a restaurant. They may not be able to complete all duties required for these jobs, but in the Dutch system, if you can do a task that is part of a job and have minimal employee skills (such as coming on time, respecting authority, etc.), you are expected to join the mainstream workforce. I, thankfully, have not been judged to meet these criteria, but then again I’m lucky in that I’ve been on disability benefits since 2004. A few years back, I heard of a profoundly and multiply disabled woman at my day center who somehow was judged to meet the criteria. The work specialist had probably never seen her, as they said she could do simple manual labor, while she had severe spastic quadriplegia.

Alternatively, there are sheltered workshops for people who can work, but need to do things at a slower pace and need some more support than can be reasonably expected within the mainstream workforce. However, these workshops have been facing significant budget cuts.

When this, too, isn’t an option, you enter the world of day activities. Those still can be “work-like”. In fact, most day activities for more cognitively capable intellectually disabled people simulate a work environment. Some of these activities are truly meaningless, in that the staff will let clients fill the same boxes with a number of items repeatedly only to empty them again so that the client can fill them once more. I honestly have very strong opinions on this: if it’s truly what a person wants and there’s no way of making the activity actually meaningful, I’m fine with it. Otherwise, I don’t see why day activities need to be “work” and things like crafting or music can’t be day activities for more cognitively capable individuals.

For more severely disabled individuals, day activities are usually sensorially-based. This includes snoezelen®, which is being in a room where the sensory environment can be completely controlled to suit the individual’s needs. I actually love this, although only for about 30 minutes at a time.

Other activities include cooking and baking, with which the clients usually don’t really help (although some moderately disabled people can) but will experience the sensory stimuli associated with the process. For example, I used to attend a group for profoundly disabled individuals and, when we’d bake something with apples in it, the staff would massage the clients’ arms with an apple. Music, story time, and simple crafts are also common activities for this population.

I, personally, if I had to choose a day activities setting, would choose the one for more severely disabled people. I know I can’t really function in a group setting, which is why I’m stuck at the care home for now, but I honestly have zero interest in meaningless labor.

Self-Injurious, Aggressive and Otherwise Challenging Behavior in People With Intellectual or Developmental Disabilities #AtoZChallenge

Hi everyone and welcome to my letter S post in the #AtoZChallenge. Today, I want to talk about self-harming, aggression and other challenging behavior in people with intellectual and developmental disabilities.

Some people erroneously believe that challenging behavior is an intrinsic part of being intellectually disabled. It isn’t. Neither are self-injurious or aggressive behaviors an intrinsic part of autism. These behaviors, however, do happen more often among people with intellectual and developmental disabilities than among non-disabled people.

The causes and reinforcing factors of challenging behavior are often complex. And though I mention them in one sentence, no, a reinforcing factor is not the same as a cause. Furthermore, if removing a reinforcing factor seems effective at reducing or eliminating the undesired behavior, this does not mean the problem is all solved. After all, especially people with intellectual and developmental disabilities who are at a lower emotional level of development or who struggle with communication are at risk of suffering in silence.

It may be tempting to presume motivators behind challenging behavior that are commonly believed to apply to typically-developing young children, such as attention or “getting their way”. Presuming these motivators, even correctly, is not taking into account the fact that people with intellectual and developmental disabilities are firstly not (necessarily) young children. Secondly, you need to realize that, like all people, they have a need for autonomy and attention and many, especially those living in institutions, are heavily lacking in both.

There are, of course, many other contributing factors to challenging behavior. For example, physical discomfort or pain may be a factor for some, especially those with profound intellectual or multiple disabilities. Others may have experienced trauma and struggle with attachment. I for one have relatively mild attachment issues (at least as apparent in my behavior) compared to some of my fellow clients, hence why I always get stuck with the temp workers. This of late has been causing me a lot of distress and has led to significant challenging behavior, which unfortunately for me isn’t significant enough to warrant any changes. Then again, if it did, those changes might well constitute restrictive measures.

Restraints and Other Restrictive Measures in the Dutch Care System #AtoZChallenge

Hi everyone. Today, it’s time for my letter R post in the #AtoZChallenge. I didn’t know what to write about for this post, so I looked at some books for inspiration. Then, the topic of restraints came up. This is quite a controversial one and sadly restraint and other restrictive measures are still commonly used here in the Netherlands. At least here at my current care home.

In the Netherlands, in 2020, the Care and Force Act replaced the law on exceptional admissions to psychiatric hospitals that previously regulated restrictive measures. Under the old law, only those involuntarily committed to care facilities or psychiatric hospitals could be subjected to restrictive measures against their will. This was not to say people weren’t pressured into consenting to restrictive measures. For instance, when I had been at the locked psych unit for a few months in early 2008, I was significantly dysregulated. My doctor told me she was implementing seclusion and, “if it doesn’t work, we’re going to file for involuntary commitment”. She should have said “if you don’t consent”, but I had no idea I even had a right to consent.

Under the Care and Force Act, anyone receiving care can be subjected to restrictive measures, which are euphemistically and rather incorrectly called “involuntary care”. Yes, even people receiving care in their own homes. And like I said “involuntary care” usually isn’t care at all, but are measures to restrict someone’s freedom, often in the absence of appropriate care. For instance, if a person with dementia lives independently, they can be involuntarily prevented from entering their own kitchen if they’re a risk of leaving appliances on.

I don’t know the exact criteria for people to be subjected to restrictive measures. It has to do something with risk of significant detriment to the client or others. I was, at my old home, subjected to some restrictive measures. For instance, several doors were locked at night because I would enter those areas (eg. the kitchen) and be a danger to myself there. Here at my current home, the door to the living room and all entrances are locked at night anyway and have been from before I came here. I do know at least one fellow resident is locked up in her room at night. This, to me, feels a bit unfair, particularly because there’s no night staff directly available and the ones in the main building usually just tell us to go back to sleep when we press the call button.

Restraint specifically – restricting someone’s physical movement – is also commonly used here. I, thankfully, have only been physically dragged by several people a few times and was never shoved to the ground or forcibly held in position.

The author of the book I read, which is a parent’s guide to autism, recommends not reacting to a disabled person’s meltdown at all unless in such a way absolutely necessary to keep them and others safe. I am not sure I agree, since honestly I don’t feel that many people with developmental disabilities do have the self-regulation skills necessary to calm themselves. In my experience, “crying it out” will not teach them those skills, but will teach them that you’re not available. In the same way, I honestly don’t feel that someone will actually have a meltdown just so they can be restrained, as the author claims. I, honestly, have never felt that having my movement restricted was comforting.

Quality of Life As It Relates to Intellectual and Developmental Disabilities #AtoZChallenge

Hi everyone and welcome to my letter Q post in the #AtoZChallenge. Today, I want to talk about quality of life. This is a concept often used in medical ethics to determine whether someone’s life is “meaningful”, in this sense, “meaningful” enough for life-saving treatments. For instance, when I was a baby and sustained a brain bleed, my parents wondered whether I would later have sufficient quality of life for life support to make sense.

People with intellectual and other disabilities are, in this respect, often seen as having a lower quality of life regardless of their subjective experience compared to people without disabilities. After all, many people with intellectual disabilities cannot work, live independently or have long-term romantic relationships. That is, not in the same ways that non-disabled people can.

However, if we judge people’s quality of life by their earnings, their ability to live independently without any supports, and non-disabled people’s ideas of what constitutes a “normal” long-term romantic relationship, we are discriminating against rather than affirming people with disabilities.

Another way of employing the concept of quality of life is to look at what exactly brings meaning to each individual’s life, rather than to measure how meaningful each life is by how well-accomplished an individual is. This way, quality of life is useful even for people with profound intellectual and multiple disabilities. The Dutch Center for Consultation and Expertise has created a questionnaire on quality of life, which should be used as a stepping stone for first determining a person’s quality of life and then ways in which it can be improved.

For people with profound intellectual and multiple disabilities, quality of life really is often determined by tiny things. I mean, even for them self-determination and independence might be underlying values, but these are reflected in very small things. For example, I read about a discussion on the quality of life questionnaire between a family member and staff of a profoundly and multiply disabled person. The topic concerned his daily walks. One of the people involved said the client probably preferred to be taken on walks at least twice a day, while the other said he seemed not to like his walks at all. The difference turned out to lie in the way the people approached the walks: the person with whom the client didn’t seem to want to walk, pushed the wheelchair at a rapid pace without stopping, while the other walked slowly and took frequent breaks to show the client his surroundings. This shows how quality of life may be as simple as a slower walking pace.

Older People With an Intellectual Disability #AtoZChallenge

Hi everyone. I’m halfway through the #AtoZChallenge and this means I’m getting a bit weary of it. Today’s post for the letter O is going to be short I think, as I covered issues around cognitive decline in older people with intellectual disabilities already yesterday. However, today I want to focus on aging in general.

People with intellectual and developmental disabilities are at increased risk of developing chronic health conditions at a younger age compared to those without disabilities. These risks sometimes vary depending on the cause of someone’s intellectual disability. For instance, people with Down Syndrome, like I said yesterday, are at increased risk of developing early-onset Alzheimer’s Disease. People with Fragile X Syndrome are at increased risk of heart problems. People with cerebral palsy (which isn’t in itself an intellectual disability, but can be comorbid with it) are at increased risk of developing type 2 diabetes, high blood pressure, stroke and various issues related to their mobility impairment, such as bone problems.

I once heard my staff at my previous care home say that, for people with significant intellectual disability, you need to add at least ten years to their chronological age to get their biological, health-related age. Of course, this doesn’t mean no severely intellectually disabled person can live into their eighties or even nineties – several at the care home next door did. However, it’s a rarity.

People with mild intellectual disability even more so than those with more severe disabilities often live into old age. This poses challenges to the healthcare system as well as causing these individuals dual risk of discrimination, based both on their age and their disability. Additionally, some older adults with mild intellectual disability, who may or may not have been identified as such, are caregivers to their even older parents.

Some people with unidentified mild intellectual disability end up in nursing homes as they age, where staff are not equipped to support them with their disability-related needs. Here in the Netherlands, thankfully, the intellectual disability care system is quite good, and most agencies have homes for older adults.

Neurocognitive Disorders: Dementia in People With an Intellectual Disability #AtoZChallenge

Hi everyone and welcome to my letter N post in the #AtoZChallenge. Today, I want to talk about cognitive decline and neurocognitive disorders – dementia in particular – as they relate to people with intellectual disabilities.

People with an intellectual disability are at increased risk of developing dementia at a relatively young age compared to the general population. Particularly Down Syndrome is a significant risk factor for early-onset dementia, especially Alzheimer’s Disease. Autopsies discovered that almost all individuals with Down Syndrome show physiological signs of Alzheimer’s by the age of forty. This, however, does not mean all individuals will actually have the symptoms of dementia.

In people with intellectual disability not due to Down Syndrome, the risk of developing dementia is also increased. Risk factors in this population include epilepsy, head injury, sensory impairments, poor mental or physical health, as well as an increased prevalence of general risk factors such as poor diet and lack of exercise.

With the higher risk of developing dementia for individuals with intellectual disability, it is all the more important that it be recognized early on so that effective support strategies may be implemented. This is especially hard in more severely intellectually disabled people. I mean, I remember a woman with Down Syndrome being assessed for dementia at my previous care home and the staff commented about the screening tool: “Does she know the name of her support coordinator?” The staff snorted here, as the woman couldn’t even speak. It is still important, however, to recognize when even the most severely disabled people might be declining cognitively.

Signs of possible dementia in people with intellectual disability include increased irritability, passivity and withdrawal, no longer wanting to go to daily activities and increased difficulty with activities of daily living such as self-care. However, these can also be signs of other underlying medical or psychosocial issues.

Mental Health in People With Intellectual or Developmental Disabilities #AtoZChallenge

Hi everyone. I once again didn’t have time for writing my letter M post in the #AttoZChallenge yesterday, because I was at the countrywide cerebral palsy day and then at my in-laws and was too tired once I came back to the institution to write my post. Let me for this reason write it today. For my letter M post, I am going to write about mental health as it relates to people with intellectual and developmental disabilities.

People with an intellectual disability are more likely to have mental health problems, including severe mental illness, than the general population. However, in the general psychiatric system, these people are not usually adequately helped. This means that early recognition of people with an intellectual disability is very important. Here in the Netherlands, some psychiatrists actually advocate for administering a simple screening tool for mild intellectual disability to each person coming into care with significant mental health issues. That way, if a person is identified as potentially having an intellectual disability, treatment can be adapted for them.

Other issues in mental health services for people with intellectual disabilities include the need for more trauma-informed care, since intellectually disabled people are at increased risk of being victims of abuse. Of course, trauma treatment, as well as therapy in general, needs to be specifically adapted to meet the intellectually disabled person’s needs. With EMDR, this is possible even with severely intellectually disabled people. Other forms of treatment, such as dialectical behavior therapy and schema-focused therapy, are, with some modifications, useful for people with mild intellectual disability.

In most countries, people with mild intellectual disability are usually seen by general psychiatric providers. However, here in the Netherlands, at least some mental health agencies have specialized teams or even an entire separate agency serving those with mild intellectual disability and co-occurring mental health issues.

Though autism as a co-occurring developmental disability with mental illness really poses some of the same challenges as does intellectual disability, this is not widely recognized. I mean, most mental health agencies here do have autism teams, but these are often dedicated to diagnosis and short-term psychoeducational support of autistic adults. There are a few specialist treatment centers for autistics with highly complex needs due to comorbid mental illness and/or severe autism, but these are inpatient units with long waiting lists. As far as I’m aware, there hardly seems to be any outreach-based, long-term treatment specifically for autistics with complex care needs.