ASSESSMENT AND DIAGNOSES

So far, it has been established that mental health is a major issue for people with learning disabilities and there are a large number of people with learning disabilities who suffer from a variety of mental health conditions. However, the true extent of the problem cannot be known, due to difficulties in assessment, and it is estimated that the actual numbers are far greater than those cited here. This is largely due to the service users being unable to sufficiently communicate their symptoms; it follows that the more severe the communication problems, the more difficult it is to gain a true assessment. In these circumstances, much of the assessment is reliant upon observations from carers, i.e. changes in behavior. This presents its own problems, as difficulties arise from differentiating which behaviors are indicative of mental health problems and which are attributed to the symptoms of the person’s learning disability (Priest & Gibbs 2004). These problems are demonstrated in the case study of Sarah.

Case study

Sarah, aged 48 years, has a moderate learning disability and very limited communication skills. She is in a community home, where she has lived happily for 15 years. Recently, the care team in the home have been concerned about her behavior, which appears to be very ‘obsessional’. For example, Sarah is spending up to an hour folding her clothes in her ward robe and she closes doors very slowly and if she is interrupted, she becomes very upset. The staff referred Sarah to the psychiatrist within the local community learning disability team. Sarah attended an outpatient appointment, accompanied by her key worker. The psychiatrist suggested that as Sarah has been previously diagnosed with autism, it is expected for her to have ‘routine behavior’ and this would account for her activities. The carers responsible for Sarah took her home; 2 months later, they referred Sarah once more to the team, as her behaviors had increased in frequency and duration. The previous psychiatrist had since left the service and Sarah was seen by another doctor. Her opinion was different and she diagnosed Sarah with obsessional compulsive disorder (OCD). Sarah was prescribed the appropriate medication (normally, an anti-depressant) and asked to return in 6 weeks. By the time of the next appointment, Sarah’s behaviors had completely disappeared and the prescribed medication was the only intervention required.

Sarah’s poor communication skills provided the psychiatrist with a further barrier in the process of assessment, as much of the process is heavily reliant upon information received from the patient. In the absence of Sarah’s ability to communicate her thoughts and emotions, often a third party needs to be involved – someone who knows Sarah well, an example being a family member or a carer. However, this places great importance upon the carer’s views and observations; the person providing this information may not have had sufficient education in this area and may omit or misinterpret important information. Often in these circumstances, a psychiatrist will call upon the assistance of a learning disability nurse to help organize a more effective way of observing the patient and completing the assessment process. Wallace (2002) argues that learning disability nurses are receiving more and more referrals for service users with potential mental health problems, but lack sufficient skills to assess them accurately. It appears there are question marks over the abilities of RN’s to work with these service users; this problem may well lie with their pre-registration education programs in learning disability nursing, which are commonly limited concerning aspects of mental health.

The Foundation for People with Learning Disabilities (2005) reported that research conducted to investigate how family carers and care staff identify and respond to changes in the mental and emotional well-being of young people with profound learning disabilities, i.e. those who are assessed as having a very low intellectual ability, found that the majority of the carers were able to identify specific signs that alerted them to changes in emotional and mental well-being and some of the reported symptoms were consistent with psychiatric indicators contained in standard diagnostic instruments.

Accurate diagnosis is important, for several reasons. The nature of the clinical condition is necessary to establish appropriate treatment regimes and any possible causes and risk factors that may require interventions (Hardy & Bouras 2002). In the general population, i.e. people without learning dis abilities, mental health problems are largely diagnosed using two diagnostic instruments:

1. ICD-10 – the International Classification of Disorders, section 10, which categorizes mental and behavioral disorders; this was published by the World Health Organization in 1992.

2. DSM-IV – the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, which was published by the American Psychiatric Association, Washington, DC, in 1994.

These and others in use have been applied to people with learning disabilities, but not without difficulty. They often fail to consider behaviors that are attributed to a person’s learning disability; altered paths in development are largely based on those who can articulate their feelings. Therefore, in 2001, the Royal College of Psychiatrists published the Diagnostic Criteria for Psychiatric Disorder for Use with People with Learning Disabilities (DC-LD) (Royal College of Psychiatrists 2001). This has addressed the above-mentioned problems associated with the generic tools and has given the psychiatrist a greater opportunity for making a correct diagnosis. There are, however, some psychiatrists who still use the older systems and this was the case in Sarah’s scenario – errors are not unusual. Even with the DC-LD, inaccuracies occur and it is important to note that the assessment tool is only as good as the person using it.

People with mild learning disabilities, i.e. those whose intellectual abilities range between IQ scores of 50 and 69, are often interviewed as part of the psychiatric assessment process in the same way as people from the general population (Royal College of Psychiatrists 2001). Hardy and Bouras (2002) suggest that with the necessary support and correct approach, people with learning disabilities can generally describe symptoms such as hallucinations, delusions and feelings associated with low mood. However, care must be taken to ensure that the symptoms mentioned by the service users are their own ideas. For example, the author has witnessed such interviews involving service users who are only too happy to answer ‘yes’ when the assessor makes suggestions about their symptoms; this is because they feel very uncomfortable with the interview and are making attempts to accelerate the process. For people with severe and profound learning disabilities, i.e. those with lower intellectual ability, changes in behavior and functioning are often the key symptoms and signs of mental illness that their carers need to be aware of (see Table 1).

Symptoms outlined in Table 1 should be recorded according to frequency, severity, duration and the time of day that these changes occur. It may also be evident that certain factors have an influence and may exacerbate or alleviate such changes, such as a person with obsessional compulsive disorder who becomes very anxious if she or he is prevented from fulfilling a compulsion. It is important to present this information to another healthcare professional in the form of a ‘pattern’, if indeed one exists. This information can be used to eliminate causes that are not associated with mental health, such as a service user being particularly irritable or even aggressive on a Tuesday; if this was established, the care team can discover what is different on a Tuesday from any other day. If this pattern in behavior is not recorded sufficiently, an incorrect decision about a solution could well be the outcome.

Table 1 Symptoms and signs that may be associated with mental illness

• Social withdrawal

• Physical appearance, such as changes in pallor, blood-shot eyes

• Sleep pattern, appetite and weight gain or loss

• Loss of skills, such as psychomotor, hand and eye coordination

• Reduction in communication skills

• Onset of or increase in challenging behaviors (not only aggression, but any unusual behaviors)

• Changes in perception of people or environment

• Irritable in mood

• Memory loss

• Changes in energy levels

• Reduced concentration span

Throughout this section, it has been shown that there are many barriers facing both service users and carers in relation to the assessment of mental health needs. Communication methods need to be developed, and the use of non-verbal communication systems may need to be introduced into the assessment process. The following are examples of some techniques used to improve communication and understanding:

• art therapy

• music therapy

• drama therapy

• Makaton, i.e. a sign language designed for use with people with learning disability (Gates 2003).

Additionally, the development of joint working between health and social care professionals and carers needs to be encouraged, to produce meaningful assessments that will assist in correct decisions being made about care pack ages and diagnosis.

اخر الاخبار

اخبار العتبة العباسية المقدسة

قسم التطوير يقيم دورة تدريبية عن إعداد المراسلات والمخاطبات الإدارية

وزارة التعليم العالي تكرم جامعة العميد لحصولها على جائزة المكتبة الأكاديمية المتميزة

جمعية العميد تناقش استعداداتها لانطلاق فعاليات المؤتمر العلمي الرابع لإحياء تراث أمير المؤمنين (عليه السلام)

أكاديمية التطوير الإداري تواصل برنامج الخطة الخمسينية لعدد من ملاكات العتبة العباسية المقدسة

المزيد

الآخبار الصحية

الرياضة وحدها لا تكفي.. كيف يؤثر الجلوس الطويل على الصحة؟

دراسة: بدائل السكر ليست آمنة على الكبد

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احذر مشاركتها مع الآخرين.. 3 أدوات شائعة قد تنقل أمراض خطيرة

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الآخبار التكنلوجية

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باحثون: تشات جي بي تي ونماذج الذكاء الاصطناعي يمكن "تسميمها"

عالمان في الأعصاب يرفعان دعوى قضائية ضد شركة آبل

المزيد

مواضيع ذات صلة

ELECTROCONVULSIVE THERAPY (ECT)

ANXIOLYTIC MEDICATION

MOOD-STABILISING AGENTS

ANTI-DEPRESSANT MEDICATION

ANTI-PSYCHOTIC MEDICATION

PSYCHOTROPIC MEDICATION

THERAPEUTIC INTERVENTIONS

SERVICE PROVISION

CHALLENGING BEHAVIOR

SCHIZOPHRENIA

DEMENTIA

ANXIETY DISORDERS