The SMA Centre for Medical Ethics and Professionalism (SMA CMEP) and College of Psychiatrists, Academy of Medicine, Singapore (AMS), jointly organised a webinar on 3 October 2020 titled “Health Needs for Persons with Intellectual Disabilities in COVID-19 Era and Beyond”. A line-up of speakers comprising practitioners in this field talked about various aspects of care involving persons with intellectual disabilities (PWID) and this was followed by a panel discussion. There were a total of 220 attendees, of which 200 were doctors.
Establishing the level of familiarity
A poll was conducted at the start of the webinar to better understand the current situation and the learning needs of our audience and healthcare professionals. The following is a summary of the results in response to the poll questions:
- “What proportion of patients in your practice are PWID?”; nearly 90% indicated that it was “0-20%”.
- “How comfortable are you to manage the psychological/mental needs of PWID?”; over 50% responded that they were “very uncomfortable”.
- “How comfortable are you to manage the physical/medical needs of PWID?”; about 50% indicated that they were “comfortable” but there was another sizeable proportion of about 40% who indicated they were “very uncomfortable”.
- “How familiar are you with various community services available for PWID and their families?”; over 60% indicated that they were “very unfamiliar”.
It appears that among the audience, they saw only a small proportion of PWID in their practice, were more comfortable managing the physical rather than the psychological needs of PWID, and were unfamiliar with the community services available for this population.
Understanding the needs of PWID in a pandemic
Dr Bhavani Sriram, head of the Movement for the Intellectually Disabled of Singapore (MINDS) Developmental Disabilities Medical Clinic, began by presenting an overview of PWID in Singapore. She talked about the 3rd Enabling Masterplan (2017-2021) by the Ministry of Social and Family Development which leads the development of programmes and services in the disability sector, and the UN Convention on the Rights of Persons with Disabilities which was ratified by the Singapore Government in 2013 with the imperative to “provide persons with disabilities the same range, quality and standard of free or affordable health care and programs as provided to other persons”.
Dr Bhavani covered the definition of intellectual disability (ID; IQ of 70 or below on an individually administered IQ test, accompanied by significant limitation in adaptive functioning in at least two skill areas), and highlighted the prevalence of 13.3% in the adult population and 3.2% in pre-school children when considering all disabilities. No specific aetiology was found in about 75% of those with mild ID and in 30% to 40% of those with severe impairment. She then described the approach to take in evaluating a child presenting with developmental delay, and shared on current services available to support PWID, including the MINDS Developmental Disabilities Medical Clinic that she manages.
Dr Giles Tan, developmental psychiatrist at the Institute of Mental Health (IMH) then presented on the needs of the adult PWID in times of COVID-19. These PWID were particularly vulnerable as their baseline mortality rates are already substantially higher compared to adults in the general population, with death coming 20 years earlier on average. PWID were at greater risks of contracting COVID-19 and developing complications as they had higher prevalence of comorbid physical health problems and behaviours that challenge safe practices. He shared tips on how that risk could be mitigated, including recommendations on (i) following national guidance on management of suspect and confirmed cases; (ii) encouraging families and caregivers to teach and support PWID to wash their hands regularly, don masks and maintain safe distancing; and (iii) using telephone contact and technology to maintain contact with PWID. He also discussed the use of telemedicine and suggested adaptations to the inpatient and community services to deal with the increased demands.
Dr Tan also looked into the impact of COVID-19 infection and how the associated restrictions imposed to combat it may have a profound effect on the mental health of PWID and their caregivers. He suggested that professionals (i) offer direct support to PWID and their caregivers who are experiencing mental health difficulties; (ii) make use of professional contacts with PWID and their caregivers as opportunities to ensure that they have accurate information; and (iii) develop and share resources on well-being suitable for use by PWID and their caregivers. He described an approach of working collaboratively with PWID and their caregivers to develop a COVID-19 care plan to support the needs of PWID in a more holistic fashion.
Dr Tan also briefly touched on the ethical issues to bear in mind when managing PWID during this time of COVID-19, which in the wider public health perspective included considerations of (i) proportionality, effectiveness and necessity of interventions; (ii) public justification and maintaining trust; (iii) fair and respectful treatment; and (iv) solidarity and ensuring the just sharing of burdens. He also shared some self-care tips for healthcare and social care staff to look after their personal well-being as they faced the challenges and pressures brought on by COVID-19.
Handling the needs of adult and ageing PWID
Dr Wei Ker Chiah, head of the Adult Neurodevelopmental Service at IMH talked about what the family doctor could do to meet the health and support needs of adult PWID. PWID should be managed to the same standard as anyone else and he suggested some approaches that GPs could take, including being aware of syndrome-specific conditions and commonly missed conditions. He also shared an approach to evaluating behavioural changes in PWID and the adaptations required in providing counselling and psychotherapy to PWID. He introduced the Books beyond Words series of illustrated books which help convey information on important topics using only pictures.
Dr Chen Shiling, physician with Tsao Foundation and Ms Ruby Lee, deputy director of the Singapore Management University Pro Bono Centre, talked about aspects of ageing with ID. Dr Chen shared a case she had managed of an adult PWID and his elderly parents to highlight the complexities that such cases can present with. She discussed the biopsychosocial approaches of managing the adult PWID together with their ageing and elderly caregivers as an integral unit, and emphasised the importance of person-centred care and of doing person-centred planning. Ms Lee then discussed the current legal issues faced by the elderly caregivers in the case presented by Dr Chen, including the issue of determining appropriate care provisions, the possible future legal challenges that may be encountered when one or both elderly caregivers pass on, and the consequences for the adult-dependent PWID.
Resources for every stage of life
The panel discussion, which included the five speakers and Dr Aaron Ang (senior consultant at Tan Tock Seng Hospital), Dr Tan Liat Leng (family physician) and Ms Teo Ginnyueh (principal medical social worker at IMH), addressed various questions raised by the audience. During the discussion, Ms Teo elaborated on the social and education services available to PWID over their life course from childhood to adulthood through to their senior years, and highlighted the resources available through ComCare, SG Enable, and Mindline.sg.
SMA CMEP in collaboration with the College of Psychiatrists will continue to run educational and training events in this coming year, so look out for them in April and September 2021!