In recent years I have seen a disturbing trend of students with intellectual disabilities coming into my office with severe signs of PTSD, and in many cases given limited language abilities the issues can be very intractable. We are becoming much more aware of post-traumatic stress disorder (PTSD), perhaps because of the experiences of our service men and women in overseas deployments, and its devastating effects on those who suffer from it. However, PTSD as a distinct diagnosis did not enter the DSM-3 until 1980. PTSD, which occurs after exposure to such traumatic events as threat to life or severe injury to self or others, occurs in roughly 20 to 30% of people exposed to such traumatic events. Recent research suggests that those individuals with higher IQs are able to weather the effects of such traumatic events better, perhaps due to their ability to process and discuss their emotional reactions, as well as to gather the resources to ensure a support network. But persons with diminished cognitive abilities are not as fortunate, and it is only fairly recently that we have begun to appreciate that those persons with cognitive impairments are affected by PTSD; in fact, lower intelligence may even be a risk factor for PTSD. How often PTSD occurs in this population, however, is uncertain.
That persons with cognitive impairments (CI) or intellectual disabilities experience mental illness has unfortunately alos only recently been recognized. This question was raised in 1983 with the publication of a paper entitled, “Do the mentally retarded suffer from affective disorders?”. Because of impaired receptive and expressive communication skills, persons with intellectual disabilities may be unable to sufficiently communicate their emotional states to physicians. Thus, people with cognitive impairment may primarily express mental illness through their behaviors alone. Because of a phenomenon known as “diagnostic overshadowing,” physicians may be too quick to interpret behavioral changes to the disability itself, rather than a mental illness. Yet, estimates suggest that mental illness occurs in this population at a rate of 2 to 4 times that of the general population. Thus, it should be no surprise at how long it has taken us to appreciate that the people cognitive impairments experience PTSD and to recognize its causes.
The reasons for PTSD in these individcuals are myriad. The same sorts of traumatic events that may cause PTSD in those without cognitive impairments—violence against self or others, natural disasters, illness, bereavement—may also cause PTSD in those with cognitive impairments. However, we may not even recognize when a loved one has experienced a trauma because of their inability to communicate it. As we have discussed previously, the developmentally disabled are extremely at risk for abuse. Numbers are sobering:
- individuals with disabilities are four times as likely to be victims of crime as the non-disabled
- 5 million crimes are committed against those with disabilities
- 64% of children with disabilities are mistreated, with those with cognitive impairments being the most severely abused
- persons with disabilities are 2 to 10 times more likely to be sexually abused (some researchers claim that number is as high as 90%) and
- 99% of abusers are known to and trusted by the child and his or her family.
Some of the trauma experienced by those with disabilities may seem innocuous to us (the “prolonged small traumas” described by Dr. Mevissen) but may be devastating to a person with cognitive impairment. Such traumas may include changes in caregivers, adjusting to a new placement, the ongoing frustration of unsuccessful mastery of a task, or even the dawning recognition that one has a disability. For some individuals that I have seen, the traumatic event is something that objectively may not seem that traumatic e.g. seeing a momentary period of restraint in the classroom or seeing a brief physical altercation between students. It is important to view the issue of trauma through the lens of that person who may have a heightened sensitivity to trauma.
Diagnosis of PTSD for people with disabilities is tricky. Persons with developmental delays may express symptoms of PTSD differently from the general population. For the general population, symptoms of PTSD may include nightmares, jumpiness, and difficulties with sleep. Additionally, one of the characteristic hallmarks of diagnosis is an inability to recall the traumatic event. For those with cognitive impairments who may lack sufficient expressive or processing skills, this diagnostic criteria may be meaningless. Instead, the PTSD may manifest through aggression, disruptive/defiant behavior, self-harm, agitation/jumpiness, distractability, sleep problems, or depressed mood. I have seen students who have suffiered PTSD simply go into a state of shutdown, become selectively mute and withdraw from most activities that previously were enjoyable. The path forward is very difficult.
More and more frequently, parents of my students with cognitive impairments have come into the office and announce that their child has experienced some sort of trauma that has caused PTSD. I always take these narratives very seriously, as I have seen the detrimental effects of trauma, even if the school personnel do not regard it as being very serious. As devastating as this diagnosis may be for these families, at least these parents know the trauma has happened and they know to seek treatment for their children. As we just discussed, many parents don’t know and are left confounded by their child’s increasing aggressive or otherwise changed behavior. Thus, we need to maintain a sufficient index of suspicion whenever we notice significant behavioral changes in our children with cognitive impairments in order to ensure that proper treatment and services are provided.