Mood disorders such as depression may present quite differently in people who have intellectual disabilities when compared to the general population. People with intellectual disabilities usually find it more difficult to communicate their feelings and thoughts verbally to others.
"People with intellectual disabilities may not appear unhappy or sad."
Those with more severe intellectual impairment may only be able to communicate with others using non-verbal methods. Relatives and care staff are usually well placed to notice any subtle changes. For example, it could be that an activity that was previously enjoyed is suddenly withdrawn from, or that the person needs more assistance from staff than usual, or that they start to refuse help with their personal care, or they might start spending more time alone in their room. However, the outward display of emotion and the inner experience of a person with intellectual disabilities can often be quite unrelated.
People with intellectual disabilities can have a much reduced capacity to show a range of emotions. They may not express feelings of despair and hopelessness when they are suffering with depression, and they may not appear unhappy or sad.
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Self-harming behaviours in people with intellectual disabilities can occur when they have a mood disorder and are also more common if they have other conditions such personality disorders and autism. Self-harm involves self-inflicted injuries and/or medication misuse. People with intellectual disabilities can often seriously injure themselves with self-harming behaviours. It is important to assess whether these behaviours might be suicidal in motivation or whether they have another function such as expressing distress or providing self-stimulation for the person. Self-injury can be very challenging to carers and peers, and distressing to watch. Carers working with people with intellectual disabilities that self-injure can feel a great amount or stress and anxiety through their attempts to help the person and staff ‘burnout’ can be frequent.
When a person with intellectual disabilities self-harms, the function of the behaviour should always be considered. Sometimes the function is not clear and it is important to continue to consider all possible reasons or causes. It is important to check whether there are any issues with their physical health or whether they may be in pain as self-injury can be a sign that something is wrong. If the self-harming behaviour is new for a person, it is worth thinking about whether there is any reason in particular for the change in their behaviour. Maybe something in their day to day routine is changed or there has been a change in their care team which is causing some anxiety that they are unable to express.
Approaches to treatment and support
It is then useful to have a full analysis of the behaviour, and this may help establish triggers and make recommendations for a behavioural support plan. Specialist psychology staff can also work with carers on psychological approaches to managing the behaviour.
Social services can review a person’s social care package to see whether additional support is required to meet their social care needs, particularly looking at whether increasing one to one working with a person can be helpful. A psychiatrist who specialises in working with people who have intellectual disabilities can make an assessment to see if there is any likely physical health problems and mental health problems present, and if so, whether treatments, such as medication can be used.
Medications such as antidepressants or mood stabilisers may sometimes be considered appropriate. Psychological therapy, in particular cognitive behavioural therapy or psychodynamic therapy, may be also offered as an intervention.
People with intellectual disabilities who self-injure often have complex needs. A multi-agency approach is needed to support both the individuals and their carers and to get the best outcome. Sometimes a meeting convened with the person who is self-harming, their carers and relatives and all health and social care staff involved can be very helpful in working together to help the person with intellectual disabilities. One way they can help is to reduce inconsistencies of approach and responses to the self-harming behaviours.
Colin Hemmings is the author of Mental Health in Intellectual Disabilities.
A version of this article also appears on our sister site, Learning Disability Today.