Definitions matter in mental health. That may seem counterintuitive in a field where labelling is sometimes seen as adding to stigmatisation and exclusion.
Yet understanding exactly what the issue is marks the first step towards personalised treatment strategies that recognise the enormous complexity of mental illness and the uniqueness of every patient.
The same goes for learning disabilities, an area that shares certain characteristics, such as, channels for diagnosis and management, with mental health but is actually something quite different.
Under the amended Mental Health Act 2007 for England and Wales, for example, learning disabilities do not qualify for detention or treatment unless they are associated with “abnormally aggressive or seriously irresponsible conduct”.
The fact that 25-40% of people with learning disabilities also have mental health problems only underlines the need to separate out any overlapping conditions and give each the attention it deserves.
What do we mean by learning disabilities?
The term ‘learning disability’encompasses a wide range of states, from the mild to the moderate and severe. Learning disabilities are likewise associated with a broad spectrum of conditions, including autism, Down’s syndrome, Williams syndrome, cerebral palsy, Fragile X syndrome and global development delay, as well as challenging behaviour.
Mencap, which had a number of events and activities planned for this year’s Learning Disability Week between 18 and 24 June, describes learning disabilities as reduced intellectual capacity and difficulty with everyday activities such as socialising or household tasks.
Notably, these problems are lifelong, different for each person affected, and cannot simply be resolved through treatment. That distinguishes them immediately from mental health issues, which can affect anyone at any time but the vast majority of which are also amenable to successful therapy.
According to the Foundation for People with Learning Disabilities, around 1.5 million people in the UK fall under that definition. It includes some 286,000 children aged 0-17 years with a learning disability.
The problems start very early in life, sometimes during pregnancy (e.g., if the mother has a particular illness), sometimes at birth (e.g., through lack of oxygen or head trauma) or shortly afterwards, as a result of childhood illness or seizures. Genetic and hereditary factors may also be involved.
Learning disabilities usually have a permanent effect on intellectual function. Mental health problems, by contrast, often emerge after childhood, may be only temporary, and can change over time.
Delayed diagnosis of learning disabilities and mental health problems
Despite these early origins, it may be some time before learning disabilities are diagnosed, particularly if parents are reluctant to acknowledge that a child’s developmental progress is lagging that of his or her peers. Alternatively, a diagnosis of learning disability may come at birth or never at all.
That learning disabilities can remain unrecognised for years is particularly troubling when we consider their potential impact. Only one in three people with a learning disability in the UK are engaged in some form of education or training, 50,000 adults with a disability are supported by day-care services, and 40% of children with a disability live in poverty. Learning disabilities are also a magnet for bullying and sexual abuse.
Getting the right type and level of support is imperative. People with a learning disability may take longer to absorb information, learn new skills or build relationships. All the more reason, then, to have a clear picture from the start of differences between learning disabilities and mental health problems, as well as how these two fields interact.
In children and adolescents, for example, the prevalence rate for diagnosable psychiatric disorder is 36% in those with learning disabilities compared with 8% in those without. At the other end of the scale, dementia prevalence is around 22% among older people with learning disabilities versus 6% in the general over-65 population.
Complex interrelationships of mental health diagnoses
Even now, it is important to recognise that too narrow a focus on learning disabilities may lead to mental health issues being overlooked in the same patient.
This confusion deepens if healthcare providers or carers put mental health symptoms down to learning disabilities, or if mental-health and learning-disability services are not properly coordinated, with discrete models for managing challenging behaviour.
At the same time, though, it is acknowledged that certain characteristics of learning disabilities aggravate the risk of mental-health issues. These include:
- Increased susceptibility to physical health problems such as being underweight, or suffering from epilepsy or respiratory disease.
- A higher incidence of negative life events, such as deprivation, poverty or social hostility.
- Isolation and loneliness. Nearly one in three young people with learning disabilities spend less than an hour outside their home on a typical Saturday.
- Limited access to resources and skills for coping when things go wrong.
These complex interrelationships make clear that full understanding of learning disabilities as distinct from mental health issues will benefit the diagnosis and treatment of both. Conflating mental health problems and learning disabilities also has political implications, particularly if welfare policy and benefits are shaped by the misperception that learning disabilities can simply be ‘put right’.
In both cases, for people with learning disabilities, and for those with mental health issues, the right approach to supporting patients and managing the daily challenges they face will depend on a number of key variables, such as age, severity, confidence or communication skills.
Only by understanding the particular circumstances and features of learning disabilities, can carers and healthcare professionals tailor their support and therapeutic strategies precisely to each individual, optimising both effectiveness and outcomes.
In some cases, patients may need little more than practical help with filling in a form, accessing healthcare services or using public transport. In others, more formalised interventions such as cognitive behavioural therapy, physiotherapy, psychotherapy or speech and language support may be required.
The overarching objective should be to integrate people with learning disabilities as much as possible into the community, enabling them to neutralise stigmatisation through increased visibility, familiarity and interaction, while leading fulfilled and productive lives – ideally on their own terms.
Without real sensitivity to the nuances of learning disabilities and mental health issues, though, healthcare professionals, families, carers and the general public are at risk of selling everyone short.