Substance Abuse Treatment For Individuals With Intellectual Disabilities

Introduction

The legal and illegal use of recreational and prescription drugs has significantly increased in recent years all over the world and among most populations. Underrepresented groups, such as people with Intellectual Disability (ID), formerly known as Mental Retardation (MR), may face more challenges than other, more well-researched populations (Lakhan et al., 2019).

Over the last 40 years, people with ID have seen more freedoms and access to community activities and social life (especially those with mild to moderate ID). Because of this increased access to social activity, access to drugs and alcohol has also increased (Elspeth, 2008). When combined with ID, Substance Abuse (SA) is a risk factor for intrusive thoughts, and aggressive and antisocial behavior. Alcohol, tobacco and cannabis were found to be the most commonly abused drugs among the ID population (Lakhan et al., 2019). There are acknowledgements of barriers for people with ID accessing substance abuse treatment. However, despite this recognition, research documenting barriers for accessing SA treatment by people with ID remains scarce (Elspeth, 2008). This literature review aims to define, describe and discuss the problems faced by people with ID and SA issues and to discuss the similarities and differences in treatment involvement and barriers among subgroups of the ID population.

Literature Review

When evaluating people with ID, the actual prevalence of SA appears to be lower than the general population (1-2%) (Chapman et al., 2012). Yet some studies estimate the prevalence of SA at 15-30% in the ID population (Lakhan et al., 2019). Prevalence, however, varies among subgroups in the ID population, where some may have different levels of exposure due to age, location, degree of mental impairment, etc. Among Americans with ID aged 12 or older, prevalence of illicit drug use is lower than the general population (1.5% for cocaine and 13% for marijuana). The use of alcohol was similar to rates seen in the general population (35.5–47%). Smoking rates were also similar to the general population (20.5% in the past 30 days) (Chapman et al., 2012). Because of issues with SA “aggression, fire-setting, window breaking, tantrums and self-destructive acts” are common among the ID population. This can lead to higher involvement in the criminal justice system for people with ID and SA issues (Elspeth, 2008).

Additionally, the risk of a person with ID developing SA is much higher than the general population. Carroll Chapman (2012) found an almost equal percentage of alcohol users and alcohol abusers (21–18% respectively, n = 122) among the ID population. Chapman also found that “being non-White, living in a non-urban area, having a co-occurring mental illness, and living in state with a more generous Medicaid policy for substance abuse treatment” increased the odds of a person with ID having a related SA issue.

The risk of complications from SA in the ID population is only compounded by the population’s high comorbidity with psychotic illnesses. Psychotropic medications used to treat these illnesses are highly abused and have serious negative side effects when combined with alcohol or other drugs (Lakhan et al., 2019). However, it is difficult to get an accurate picture from these statistics. To reduce the risk of sampling bias, it is common for people with ID to be excluded from SA studies (Elspeth, 2010). Additionally, there were no estimates of SA rates among the ID population from China or India, two countries that together account for about a third of the world’s population (Lakhan et al., 2019).

Barriers to Treatment

The ID population faces significant barriers to accessing SA treatment. A 1994 study of social service utilization by ID population showed that only 2.2% had sought Medicaid benefits for SA treatment (Elspeth, 2008). However, this number is likely lower than the percentage of people with ID who need SA treatment. Among the general population “fewer than 25% of those in need of treatment are thought to access it,” according to a report by the Surgeon General of the United States. The report noted that the ID population has more trouble accessing health care resources than the general population, citing barriers such as social stigma and poor financial situations (Elspeth, 2008).

It is also difficult for clinicians to realize when a person with ID is in need of SA treatment. Many clinicians feel they are unable to provide adequate SA treatment for individuals with ID (Elspeth, 2008). Based on a survey of 93 clinicians, an expert panel “suggested the importance of family education, managing the environment for safety, social and communication skills development, and using applied behavior analysis to reduce problem behaviors and increase functional and appropriate skills.” However, none of these suggestions are supported by empirical evidence, and there is still a significant lack of empirical evidence for SA screening or assessment tools, treatment approaches or treatment outcomes in the ID population (Elspeth, 2008).

Women

Very little is known about how women with ID interact with SA treatment. Existing research indicates that women with SA issues often have more severe medical problems and exhibit more psychiatric illnesses than men (Elspeth, 2016).They are also more vulnerable to the negative social consequences that come with SA, including social isolation, withdraw from social activities and the development of negative health conditions.

Additionally, women with ID are more vulnerable to seizures from alcohol and drug use due to the larger number of women with ID on psychotropic medications compared to men. Women with ID are vulnerable to assault and robbery and are more likely than women in the general population to end up in the criminal justice system (Elspeth, 2016).

By analyzing Medicaid data, Elspeth (2016) determined that women with ID were less likely than men with ID to receive SA treatment. In many other categories, however, women scored similarly to men. For example, analysis of the data showed that the average age for both men and women with ID and SA issues was 36, and 56% of men and women with ID and SA were White.Despite these similarities, women were substantially less likely to be eligible for Medicare (26% of women vs. 39% of men). Of eligible women, 24% started treatment, but only half of those who started (48%) continued to utilize treatment. These rates were slightly higher among men, with 25% starting treatment, and 55% of those continuing treatment (Elspeth, 2016).

Youth

Like other subgroups of the ID population, youth have become more active in the community and have increased participation in social activities. As with other subgroups, increased social activity is associated with the potential for drug and alcohol problems. Little is known, however, about youth with both ID and SA issues (Elspeth, 2010).

By analyzing Medicaid data, Elspeth (2010) determined that youths (aged 12 to 21) with ID and SA issues were less likely to start or continue SA treatment than youths in the general population. Youths were more likely to continue treatment if they were male and non-white. Elspeth found that “youth with mild to moderate levels of MR (versus severe to profound levels) are posited to be most likely to access alcohol and other drugs and be at greater risk for developing SA disorders.” Elspeth’s analysis found that 20.2% of youths with SA issues started treatment and 52.5% of them would continue treatment. Like other members of the ID population, youth were at an increased risk of seizures from the negative side effects of combining psychotropic medications with drugs and alcohol. Similarly, ID youth are more likely to engage in criminal behavior such as assault and robbery and are more likely to end up in the juvenile justice system (Elspeth, 2010).

Effective Treatment

There is a significant debate among clinicians on what constitutes effective treatment for individuals with ID and SA issues. There has been some agreement among clinicians that reinforcement and punishment approaches are more effective than cognitive behavioral approaches, counseling, classical conditioning or psychotherapy. However, there is still no empirical evidence to support these claims (Elspeth, 2008).

Because of human rights protections, specifically a right to self-determination, people with ID and SA issues cannot be institutionalized against their will even when it may be in their best interest (Elspeth, 2008). Additionally twelve-step programs and cognitive behavioral therapy, which are effective methods of SA treatment for the general population were not effective at treating individuals with ID and SA issues (Elspeth, 2010).

An effective part of SA treatment is being able to diagnose SA issues. The DSM-5 has proposed a new diagnosis for SA related problems: substance use disorder (SUD). SUD can be classified into mild, moderate, and severe categories. Additionally the DSM-5 redefines ID from below-average intelligence to “(1) deficit in intellectual functioning (reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and experiential learning); (2) impairment in adaptive functioning (communication, social skills, personal independence in home and community, and school and work functioning); and (3) occurrence in developmental period.” This definition provides more criteria for distinguishing the ID population from the general population. However, complications in diagnosis can arise because individuals with ID will automatically meet some diagnostic criteria for SUD (impaired control and social impairment). Because of this, a new diagnostic criteria is required (Lakhan et al., 2019).

Discussion

Limitations

All of the reviewed studies share similar sampling limitations. Each relies on demographic data that does not represent the entire ID population. The reviewed studies attempt to draw conclusions about appropriate SA treatment options and outcomes for the ID population but acknowledge that there is little research to back up their claims.

Methodological Limitations.

Most of the available data on the treatment seeking behavior of the ID population comes from Medicaid reports. The findings thus, are not necessarily applicable to ID individuals with other types of health care or no health care at all.

Demographic limitations

Because most of the available data is from Medicaid reports, most of the analyzed population is from the United States. There is little accurate data on SA treatment-seeking behavior for ID individuals in many middle- or low-income countries. Additionally, it is difficult to determine the effect of location on SA treatment, because ID individuals living in urban areas are likely to have more access to drugs and treatment options than individuals living in rural areas (Elspeth, 2010).

Conclusions and Future Study

The the conclusions drawn from the reviewed studies indicate that to ensure proper engagement with treatment, social workers who work with the ID population should be trained to screen for SA issues. Additionally the development of better assessment tools designed to be specifically for people with ID should be prioritized. Currently SA treatment programs, diagnostic methods and screening tools are not easily available to clinicians who work with the ID population (Elspeth, 2008 & Elspeth 2010).

Further studies on the effectiveness of cognitive behavioral or 12-step group models are needed to see if they can be adapted to provide the same benefit to the ID population as they do the general population. However current clinical consensus does not support the idea that 12-step groups or cognitive behavioral therapy are effective. There some clinical consensus around the idea that longer-term programs or programs that are made more accessible by using appropriate language show more engagement with treatment and better outcomes (Elspeth, 2008).

In order to ensure the development of these assessment measures will be empirically based, further studies are needed to look at the treatment engagement and outcomes for members of the ID population that are Women, young, poor or middle income and not eligible for Medicaid. More data on treatment engagement and outcomes needs to be gathered from countries other than the United States. However it may be difficult to draw comparisons between the results given how many low and middle income countries use the ICD-10 to diagnosis SA issues instead of the DSM-5 (Lakhan et al., 2019).