Persons with intellectual disabilities present a great need for psychiatric treatment, yet the literature reports few programs addressing this client group. A day hospital in the psychiatric department of the University Hospital of Geneva offers a specific structure for this population. The goal of the study reported here was to evaluate the effects of various treatments within the day hospital for clients with both intellectual disabilities and psychiatric disorders. We targeted our observations on behavioral problems.
The goals of the day hospital are to prevent hospitalizations and to enable clients to return and adapt to their usual environment. The day hospital is open from 8 a.m. to 5 p.m., five days a week, with a daily census of 20 to 30 clients, with nearly 50 different clients served per week. A multidisciplinary team of psychiatrists, nurses, educators, psychologists, speech therapists, physiotherapists, and social workers provides group therapy, individual treatment, and medications as needed. Individualized client programs are based on skills, needs, and, most importantly, interests.
Group therapies allow dynamic peer interaction and also offer a cost advantage (low therapist-to-client ratio). Groups provided include verbal groups (for example, a coffee and cookies welcoming), nonverbal activities (such as swimming and other sports, gardening, and music), and psychoeducational groups (such as a cafeteria or kitchen group). In the verbal groups, adapted to higher-functioning clients, the exchange between the participants is central. The nonverbal activities are for the lower-functioning clients—usually clients who have predominant developmental disorders. The psychoeducational groups offer an open approach for clients of various cognitive abilities, providing a helpful interaction between clients.
The patients have expressed their appreciation of the day hospital's activities. A major advantage of the program, compared with the "outside" environment," is that the clients do not have to confront "goal achievement." From a practical perspective, the keystone is that the team members follow each individual's personal skill level and readiness.
We conducted a longitudinal study to evaluate the quality and effectiveness of the services offered. The study, involving 15 data collections over three months, evaluated the evolution of the day hospital's clients and was approved by the ethics commission of the University Hospital of Geneva. We chose the Aberrant Behavior Checklist (translated into French by the authors) as an evaluation tool. This tool considers five factors: irritability, agitation, and crying (15 items); lethargy and social withdrawal (16 items); stereotypic behavior (seven items); hyperactivity and noncompliance (16 items); and inappropriate speech (four items).
The study included all day hospital clients who had signed up as of March 2000, for a total of 29 clients. Each participant was evaluated a minimum of two times. Twenty-one men and eight women participated in the study, and the average age of the participants was 35 years. Twenty-one of the 29 participants lived in supervised residences. According to the Wechsler Adult Intelligence Scale-Revised (WAIS-R) and ICD-10, eight clients had mild intellectual disabilities, ten had medium intellectual disabilities, five had severe disabilities, and six had profound disabilities. All clients presented with psychiatric diagnoses. According to ICD-10 criteria, 13 clients (45 percent) had pervasive development disorders. The duration and frequency of clients' attendance at the day hospital varied.
For the whole group, Friedman's analysis demonstrated a global improvement on agitation and irritability, stereotypic behaviors, and hyperactivity and noncompliance and a slight decrease in lethargy and social withdrawal. The Wilcoxon signed-rank test confirmed the improvement on agitation and irritability.
On the ABC, scores varied by intellectual disability level. The clients were divided into those with mild or moderate intellectual disabilities and those with severe or profound intellectual disabilities. The two groups differed on all five factors except inappropriate speech, starting at the third assessment and continuing until the end of the study. The group with mild or moderate disabilities showed greater clinical improvement and a decrease in behavioral disorders, whereas those with severe or profound disabilities remained stable.
These findings confirm our clinical impression of general satisfaction and improvement among the clients and of the team's observation that we have not yet completely adapted our approach to the needs of clients with lower cognitive abilities.
Although the day hospital's activities have permitted some clients to satisfactorily adapt to their living environment, the therapies offered affect each patient differently. The group approach seems to be better suited to clients who have mild or moderate disabilities; we believe that clients who have severe or profound disabilities need a higher therapist-to-patient ratio. The results of this study reinforce our view that it is necessary to consider structural modifications to the day hospital, such as providing different activities and possibly creating different therapeutic structures or approaches for different cognitive levels.
The authors are affiliated with the psychiatric department of the University Hospital of Geneva, Avenue Industrielle 7, CH 1227 Carouge Genéve, Switzerland (e-mail, firstname.lastname@example.org).