Anxiety And Intellectual Disability
Anxiety andIntellectual DisabilityMolly Faulkner, PhD, CNP, LISWUniversity of New MexicoContinuum of CareMarch 9, 2015
Learner Objectives Describe incidence of anxiety in individuals withintellectual disability (ID). List two potential causes of anxiety in individualswith ID. Identify symptoms and characteristics of anxietyseen in individuals with ID. Discuss two potential techniques todecrease anxiety for an individualwith ID.
Definitions “Intellectual disability (ID) is the term used todefine a developmental disorder characterized byboth intellectual and adaptive functioningdeficits.” Replaced “mental retardation” in DSM-5 Change led by renaming of organizations President’sCommittee for People With Intellectual Disabilities in2003 and the American Association on Intellectual andDevelopmental Disabilities in 2006.
Identification andCharacteristics ofAnxiety in Adults with ID“Anxiety and anxiety disorders are frequently comorbidwith developmental disabilities including mentalretardation, autistic disorder, Asperger’s disorder andpersons with pervasive developmental disorder nototherwise specified” 1-5
How Many Clientswith ID are Diagnosed with Anxiety Disorder? Adults with autism 3x rate of anxietysymptoms than adults with DDs Children with autism 55.5% met anxietydisorder criteria Studies14% to 26.85% adults with DD hadcomorbid anxiety disorder Associated with level of stress
Why Is AnxietyHard to See in Clients with ID?Anxiety may be overlooked by the DD itselfValid diagnostic information hard to obtainDifficulty describing internalizing symptoms of anxietyDeficits in communication, social skills and intellectualfunctioning.Challenging behaviors may mask anxietyLimited number of empirical studiesLack of standardized assessments specific to diagnosing clientswith IDs and psychiatric co morbiditiesModified diagnostic criteria proposed
Characteristics/SymptomsAnxiety in Clients with ID Phobias Hypervigilant Panic Agoraphobia (afraid ofopen spaces) Obsessive CompulsiveDisorder Screaming Self injury (picking,scratching, biting, sucking) Stereotypies (flapping,shouting, rocking) Generalized AnxietyDisorders Sleep disturbances PTSD Selective Mutism Tantrums Aggression
Generalized AnxietyDSM-5- Definition
Assessment Tools forClients with ID and Anxiety Mood and Anxiety Semi-StructuredInterview (validity, sensitivity, specificity and interpreter reliabilityin ID population) The Fear Survey (children and adults) Anxiety Depression and Mood Scale Glasgow Anxiety Scale Yale Brown OCD Scale (adult clients with autism and OCD have different obsessional content & compulsive behaviors than adults with OCD and no DD)
What CausesAnxiety Disorders in ID?
Neurobiological Dysregulation ofautonomic nervous systemactivity -- abnormal stressand autonomic systemreactivity and brainfunction Sensory disintegration Abnormal cardiovascularand electrodermalresponses Genetic temperament offamily
Structural Abnormalities Abnormalities ofserotonin anddopamine Metabolic deficits infront cortex Structuralabnormalities inamygdala andhippocampus andlimbic system as awhole
Environmental Trauma/bullying Multiple homes Many transitions Stressful work and social situations Illness
Practitioner Issues Practitioners often feel inadequate to assess,diagnose and treat ID population, particularly ifpsychiatric issues in ID population.8 Practitioner anxiety can often interfere withability to provide good care.
Assessment Multi disciplinary Thorough assessmentfor possible physicalcause ofanxiety/agitation Applied behavioralanalysis Multiple resourceshome, work, family,particular those whoknow individual forlong period of time Any recent trauma oranniversary or LOSS?
Treatments for Anxiety*Environmental Life style Skill building Reduce stimulinoiseclutterlightingtemperature Earphones, earplugs Sunglasses Reduction in transitions Remove aversive stimuliBiological SSRI’s for repetitivesymptoms, stereotypies, selfinjurious, hair pulling Naltrexone- self harmingbehaviors Propranolol generalizedanxiety Rare if ever benzodiazepineuse as can disinhibit May pre medicate for anxietyprovoking situations *often multifocal
Treatments for Anxiety (cont’d)Behavioral Providing activities andopportunities to engage withothers Teaching relatives andcaregivers techniques forimproving communication Setting boundaries,Redirection Positive reinforcement ofdesired behaviors, Noncontingentreinforcement procedures, Activity schedules Task correspondencetraining.
InterventionsInterventions will be moresuccessful if they not only reducethe risk factors, but also promotethe protective factors observed inresilient adults.
Group Home Interventions Create a peaceful, calm and relaxing homeenvironment Support positive behavior when anxious- Monitor behavior especially during common problem times- acknowledge and reward positive behavior- use reminders and review of behavior expectations. Respond to problem behavior consistentlyand effectively- Use consistent procedures in responding to minor andserious problem behaviors. Institute procedures forproblems solving meetings.
Group Interventions Establish and teach the house rules and proceduresaround creating and maintaining a calm, supportiveand relaxing home for all. Be aware and proactively manage common stressfultimes: transitions, unstructured times, newsituations Promote social and emotional functioning Use rewards effectively Manage angry/acting out behavior
Individual Interventions Analyze specific behaviors related to anxietyand trigger Consistently reinforce positive, calming,relaxing behavior and use of skills Use of proactive and instructive modelingstrategies to encourage positive behaviorsand problem solve with the client Teach client with ID to self-monitor anxietyand cue when needed
Piecing it All Together:What Does All of this Mean?
Family Involvement Parents- use a “partnership approach” toclient’s success with managing anxiety Provide daily calendar to record anti anxietyexercises to reinforce desired behavior. Encourage positive parentalreinforcement of specificdesired behaviors
What Direct Care Professionalsand CliniciansShould Avoid Use of only reactive behavioral strategies Model antisocial behaviors by yelling orinsulting client with ID Use of harsh punishment Only coercive interactionswith client with ID
What Direct Care Professionalsand Clinicians Should Do Understand that working with ID with anxiety (andpossible CB) can be frustrating and exhausting Directly TEACH good emotional self care skills as amatter of routine and part of structure of the day Model and teach good self care skills, ie. relaxation,and downshifting skills and have them do returnteaching Develop and use individualized interventions foranxiety in ID Understand how the helper-clientanxiety and conflict cycle startsand how to derail or de-escalate it
Implications for Practice: Be aware of the complex relationship betweenpsychopathology/anxiety and CB in patients with ID. Analyze complex relationships in those with ID Perform thorough diagnostic procedures. Attention to different dimensions of functioning, i.e.biological/physiological, psychological, social &environmental dimensions. Requires a multidisciplinary and multidimensionalapproach to explore the dynamics betweenpsychopathology/anxiety and ID
Questions?
Learning to Relax When I get worried, anxious,angry or tense my body can feelmany different ways. My teeth may be clenched My hands may feel sweaty My hands may be in a fist My face may feel warm My muscles may be tight andhurt When I begin to feel angry ortense there are many ways tohelp me relax Close my eyes and take 5 deepbreaths Ask to take a break Ask to take a walk Ask to stand up and stretch Get a relational fidget
Questions?
References1. Stavrakaki C, Lunsky Y, Bouras N, et al.: Depression, Anxiety and Adjustment Disorders in People withIntellectual Disabilities. Psychiatric and Behavioural Disorders in Intellectual and DevelopmentalDisabilities, 2nd edn. New York, NY, US, Cambridge University Press, 20072. Saulnier C, Volkmar F, Bouras N, et al.: Mental Health Problems in People with Autism and RelatedDisorders. Psychiatric and Behavioural Disorders in Intellectual and Developmental Disabilities, 2ndedn. New York, NY, US, Cambridge University Press, 20073. Schlauch RC, Gordon KH, Schmidt NB, et al.: The Assessment, Diagnosis, and Treatment ofPsychiatric Disorders in Individuals with a Dual Diagnosis: The Co-occurrence of DevelopmentalDisorders and Psychiatric Disorders. Mental Health Care for People of Diverse Backgrounds. Abingdon,United Kingdom, Radcliffe Publishing, 20074. Tantam D: Psychological disorder in adolescents and adults with Asperger syndrome. Autism 4(1):47–62, 2000. doi: 10.1177/13623613000040010045. Masi G, Favilla L, Mucci M: Generalized anxiety disorder in adolescents and young adults with mildmental retardation. Psychiatry 63(1):54–64, 2000.6. Davis, E., Saeed, S. A., & Antonacci, D. J. (2008). Anxiety disorders in persons with developmentaldisabilities: empirically informed diagnosis and treatment. Reviews literature on anxiety disorders in DDpopulation with practical take-home messages for the clinician. Psychiatric Quarterly, 79,249–263.7. http://greatist.com/happiness/reduce-anxiety
References8. Agarwal, R., Guanci, N., & Appareddy, V. L. (2013). Issues in treating patientswith intellectual disabilities. Psychiatric Times, ies#sthash.ARN9g3AJ.dpuf
Learner Objectives Describe incidence of anxiety in individuals with intellectual disability (ID). List two potential causes of anxiety in individuals with ID. Identify symptoms and characteristics of anxiety seen in individuals with ID. Discuss two potential techniques to decrease anxiety for an individual with ID.
Anxiety and sleep questionnaires Spielberger State-Trait Anxiety Inventory The STAI [35] assesses self-reported anxiety (both state and trait anxiety) using a validated 40-item Likert scale questionnaire. State anxiety reflects transient (i.e., current moment) emotional anxiety due to situational stress. Trait anxiety assesses an individual’s .
using Zung Self-Rating Anxiety Scale (SAS), self-reported anxiety assessment arranging severity into 4 indexes ranging from normal range, minimal to moderate anxiety, marked to severe anxiety, and extreme anxiety. The study examined how each of the 18 individual EMSs serves as predictors of anxiety symptomatology in college
the State-Trait Anxiety Inventory (STAI), however in this study we will only be examining trait anxiety because trait anxiety is a measure of personality and state anxiety measures anxiety in specific situations (Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983). Reducing trait anxiety would hopefully translate into a long term change in .
If you have social anxiety disorder, there are a number of strategies that you can use to learn to overcome your fear of social situations. For social anxiety disorder, tools in the toolbox include: TOOL #1: Observing your social anxiety. An important first step in learning to manage social anxiety involves better understanding your social anxiety.
Zung Self-Assessment Anxiety Scale is a 20-item self-report assessment questioner built to measure anxiety levels. From the present analysis, it can be concluded that in overall respondents, 74.65% are normal with no anxiety and 21.24% are mild to moderate anxiety levels and 4.11% marked to severe anxiety levels and there
Subjective feelings of apprehension and fear associated with language learning and use. Foreign language anxiety may be a situation-specific anxiety, similar in that respect to public speaking anxiety. Issues in the study of language anxiety include whether anxiety is a cause or an effect of poor
organizations. Anxiety refers to the organism’s response to real or current threat. Bowen sees that there are two kinds of anxiety: acute anxiety and chronic anxiety. Acute anxiety occurs when the threat is real, and is short-lived. Acute anxiety is about one’s reactions to stress.
Tourism and Hospitality Terms published in 1996 according to which Cultural tourism: General term referring to leisure trav el motivated by one or more aspects of the culture of a particular area. ('Dictionary of Travel, Tour ism and Hospitality Terms', 1996). One of the most diverse and specific definitions from the 1990s is provided by ICOMOS (International Scientific Committee on Cultural .
