Alcohol problems and intellectual disability

case report

Alcohol problems and intellectual disability

J. J. Clarke & D. N. Wilson

Department of Learning Disabilities, University of Nottingham Medical School, Nottingham, UK

Abstract

The present paper discusses some of the difficulties in

working with people with an intellectual disability and an

alcohol problem, and draws on the sparse literature

about alcohol problems in people with intellectual

disability. Four individuals drawn from the current

clinical case loads of medical practitioners in UK

community intellectual disability services are described.

Some suggestions for staff training, patient education and

health promotion, and therapeutic approaches are made.

Keywords alcohol problems, dual diagnosis,problem drinking, substance misuse

Introduction

The early publications on alcohol consumptionamongst people with intellectual disability suggestedthat alcohol problems and intellectual disability werestrongly associated (Goddard 1912), and that peoplewith intellectual disability were more susceptible tothe detrimental effects of alcohol than people ofnormal intelligence (Tredgold & Soddy 1963).However, subsequent authors have not found anysupporting evidence for either of these assertions(Craft et al. 1968; Huang 1981; Krisheff & Di Nitto1981; Krisheff 1986; Welsh Office 1996). These later

authors found the rates of alcohol problems amongstpeople with intellectual disability to be similar to, ifnot less than, those among the non-intellectuallydisabled population. Neither do people with anintellectual disability seem to have a peculiarvulnerability to alcohol, as demonstrated by thesimilar spectrum of alcohol problems which boththis group and the general population exhibit (Craftet al. 1968; Edgerton 1986; Krisheff 1986). Alcoholproblems among those moving from institutionalcare to community care were once predicted to be alikely saboteur of successful independent communityliving, but once again, Edgerton (1986) has foundthis not to be the case.

Comparatively less has been written about howbest to approach a client with both an intellectualdisability and an alcohol problem. Manthorpe(quoted in Harrison 1996; and Manthorpe 1997)reviewed the cultural and social background toalcohol consumption, and described how thisimpinges on the lifestyles of people with intellectualdisability. She emphasised that drinking alcohol is apart of what is considered normal life and can havepositive connotations, whilst acknowledging that itcan also cause problems for people with intellectualdisability and their community care staff. Tyas &Rush (1993) surveyed alcohol and drug treatmentprogrammes in Ontario, Canada, with respect toclients with disabilities of all natures, includingdevelopmental handicaps. The above authors found

Correspondence: Dr David Wilson, Rampton Hospital, Retford,

Nottinghamshire DN22 0PD, UK.

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VOLUME 43 PART 2 pp 135±139 APRIL 1999135

that staff from a significant proportion of theseprogrammes felt that specialist services and extratraining for staff were needed to properly help clientswith developmental handicaps and alcohol problems.

Existing specialist services for both people withintellectual disability and for people with alcoholproblems operate independently to best meet theneeds of their respective client groups. One area inwhich differences are particularly marked is in theresponse to the client who is unwilling to cooperateor engage with the service in spite of an objectivelyidentifiable need to do so. Addiction services may belimited in what they can achieve with an unwillingclient and the response to a client who declines toattend offered appointments or placements is notalways one of aggressive outreach. If there is anidentifiable mental illness which might be underlyingthe alcohol problem and which might respond totreatment, use the of the Mental Health Act mightbe considered. Otherwise, it is often left up to theclient to choose whether or not to come back forhelp at some future time.

On the other hand, services for people withintellectual disability are constantly balancing theneed to respect their clients autonomy against thefact that intellectual disability may impairindividuals' ability to make the best decisions forthemselves. Society has a responsibility in suchcircumstances to take over such decisions on behalfof the person and this responsibility is delegated tothe statutory services for people with intellectualdisability.

This dichotomy of approach is further underlinedin the Mental Health Act, under which a person maybe detained because of mental impairment or severemental impairment, but explicitly may not be sodetained, `by reason only of . . . dependency onalcohol or drugs' (HMSO 1983). However, apotential problem arises when a client with anintellectual disability becomes dependent on alcoholto the detriment of her/his well-being, but declinesany help. The Mental Health Act cannot be invokedto detain or treat such a person against her/his willunless the alcohol dependency can be said to be aconsequence solely of the intellectual disability. Inpractice, it is not usually possible to be sufficientlyconfident that an alcohol dependence problem is theresult solely of a person's intellectual disability. Thiscan leave professionals in intellectual disability

services facing a situation where they feel powerlessto intervene in spite of the obvious alcohol-relatedharm occurring to their client.

The present article seeks to highlight thesedifficult areas using a selection of case vignettesillustrating a variety of scenarios which may developwhen a person with an intellectual disabilityexperiences alcohol-related problems.

Case reports

Case 1

Case 1 is a 28-year-old man was noted to have beenhyperactive and developmentally delayed at the ageof 4 years. He was educated at a residential schoolfor children with mild learning disabilities until theage of 16 years, since which time he has lived athome with his parents. The subject has beendescribed as being minimally brain damaged andhaving Gilles de la Tourette syndrome. At the age of22 years, he began drinking heavily following thebreakdown of a relationship with a girlfriend. Hisdrinking escalated to the point where he wouldspend up to £45 on alcohol over the course of aweekend and was violent towards his parents whenintoxicated. At the end of each weekend binge, hewould experience physical withdrawal symptomsincluding tremors, sweating, malaise and craving foralcohol.

At the age of 24 years, the subject went with hismother to an Alcohol and Drug Team outpatientclinic for assessment. He did manage to cut hisdrinking down somewhat, but subsequently failed tokeep follow-up appointments and was discharged.Aged 26 years, the subject was again referred to thealcohol and drug team, but failed to attend anyappointments. Currently, he is drinking up to threebottles of strong cider per day, but does not drinkevery day, managing a few days of abstinence eachweek. It is felt by professionals involved with his carethat the subject may be drinking partly to relieve thesymptoms of his Tourette syndrome.

Case 2

Case 2 is a 34-year-old man whose onset of speechwas delayed and who attended special schools whilebeing raised at home by his mother. He was noted to

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have been aggressive at school. After leaving school,the subject attended an employment trainingscheme, but was unable to complete this course. Bythe age of 20 years, he was spending all his availablemoney on alcohol. The subject lives on allowances,and therefore, probably drinks between 30 and35 units per week. He is aggressive when intoxicated.When he was 26 years old, his mother was no longerable to cope with him and he was moved to aresidential placement in a social services hostel.Whilst living there, the subject would go to localpubs, where he was vulnerable to exploitation byothers in his attempts to obtain money for alcohol. Itis noted that the subject allowed himself to be setalight for money on one occasion. When intoxicated,he was usually aggressive and frequently incontinentof urine on his return to his hostel. The subject wasadmitted to an inpatient facility for people withintellectual disability twice, but on both occasions,reverted to drinking again on discharge. At the ageof 31 years, he was moved to a different residentialplacement further away from the pubs where he hadbecome well known. Staff at the new placement havetaken a more active role in the control of thesubject's finances, and he now drinks 10±15 unitsper fortnight when he visits his mother, who livesnear his old drinking haunts.

Case 3

Case 3 is a 30-year-old man who suffered birthasphyxia. He was brought up by his parents andattended special schools. The subject failed tocomplete any youth training schemes and hasnever been employed. He lives with his parentsand was taken by his mother to his generalpractitioner because of increasing alcohol intake.His mother used to buy him lager at weekends as atreat, but he began to go to off-licences on his ownto buy wine or cider which he would drink athome, becoming irritable and aggressive. Hisconsumption was estimated at around 60 units ofalcohol per week and his gamma GT was found tobe raised.

The subject was referred to the intellectualdisability services, where he was felt to be at the topend of the autistic spectrum and using alcohol tocope with the high arousal which he experiences. Hewas prescribed a low dose of imipramine to help

with this and he has been able to keep a drink diary.This showed that he reduced his alcohol intake to20 units on a monthly binge. He is currentlydrinking infrequently, but still causes concern to hisparents when he goes out in a state of intoxication tobuy more alcohol and has to cross several busy roadsto reach the off-licence.

Case 4

Case 4 is a 52-year-old woman with mildintellectual disability who lived for many years in ahospital for people with intellectual disabilities.With the advent of community care, it was felt thatshe was able to live independently and she wasdischarged. Following her discharge, the subjectmarried and has lived for the last few years inrented accommodation with her husband, who hasa physical disability. She suffers from a chronicpsychotic illness and is treated with depotantipsychotic medication which, when she is notdrinking, effectively relieves her psychoticsymptoms. She also has hyperthyroidism and istreated with carbimazole.

Her husband drinks alcohol to excess andintroduced her to spirits, which he initially forcedher to drink, but now she drinks as much and asoften as possible. The subject experiences physicalwithdrawal symptoms of tremor and restlessnesswhen the money for drink runs out. Whilstintoxicated, she and her husband can be violenttowards each other and have caused considerabledisruption in their neighbourhood; for example, bybrawling outside their home in the early hours of themorning. The professionals from the intellectualdisability service (a community psychiatric nursevisits twice weekly and home care aid daily) areextremely concerned about the risks of falls, fires(she and her husband are both smokers), and thedeterioration in both her physical and mental health(the former through inadequate diet and insanitaryconditions in the home, the latter seen in theincreased frequency of reports of auditoryhallucinations). The subject shows little inclinationto do anything about her alcohol intake despitebeing able to recite the associated risks. With thesupport of her community nurse, she has recentlymanaged to go for longer periods each day beforehaving her first drink.




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Discussion

There is a need for training both for intellectualdisability staff in managing alcohol problems andalso for addiction service staff in working withpeople with intellectual disability. As well asimproved training, closer liaison or even jointworking between staff in the two services wouldimprove the care given to people with intellectualdisability and alcohol problems. This might havebeen helpful in case 1. This need for improved carefor people with substance misuse disorders andanother mental disorder is not confined to thosewith intellectual disability (Hall & Farrell (1997).

The fact that people with intellectual disabilityoften do not live completely independently of otherpeople can be used to therapeutic advantage in theirmanagement. It might be appropriate when workingwith some individuals to involve their family andcarers in addressing their alcohol problem in a waythat is not usual with non-intellectually disableddrinkers. This was the case in case 3.

Professionals who work with people withintellectual disabilities need to be able to recognizethat clients who are capable of living independentlyof full-time carers may sometimes make decisionsthat are not ultimately in the best interest of theirhealth. It is important that staff involved with theircare have a perspective which allows them to assesseach individual situation and accept that there willbe times when they cannot control all aspects oftheir client's behaviour. The Mental Health Act doesnot allow a person to be detained simply becausethey are dependent on alcohol; however, some staffmight wish to be able to take control of somepeoples' behaviour when it is obviously detrimentalto their well-being.

Little is known about the knowledge and beliefsabout health of people with intellectual disability.We do not know whether the healthy lifestylemessages presented to the general public areaccessible to people with intellectual disability.There is little work investigating health behaviour inthis context. The Health of the Nation: A Strategy forPeople with Learning Disabilities (DOH 1995) makesreference to helping people to make healthy choicesabout alcohol and suggests that this is an issue forhealth promotion. If easily understood materialabout safe drinking and the dangers of excessive

alcohol were available to people with intellectualdisability, then at least people with intellectualdisability would have the correct information onwhich to base a choice about drinking alcohol.

Once they are effectively engaged withappropriately trained services, there are differentways of working with individuals with intellectualdisabilities and alcohol problems. Lindsay et al.(1991) described an alcohol education service forpeople with intellectual disability which employs acombination of educational sessions and behaviouralwork with variable success. A cognitive behaviouralapproach is commonly used, but there are no studiesof its outcome in the intellectually disabledpopulation. Paxon (1995) proposed that a suitablymodified group model might be used to reduce therate of relapse into drinking amongst people withintellectual disability once abstinence has beenachieved.

Further research is needed to evaluate theeffectiveness of health promotional material aboutalcohol among the intellectually disabled, to clarifythe optimum way of organizing services to helppeople with intellectual disability and alcoholproblems, to establish the most effective modality oftreatment, and to determine the best way ofpreventing relapse.

Acknowledgements

The authors would like to thank Drs Jo Jones, FionaMackenzie and Richard Lansdall Welfare forallowing the case descriptions of their patients to beincluded.

References

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Received 30 January 1998; revised 15 October 1998




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Alcohol problems and intellectual disability