Recognising and Supporting Recognising and Supporting People with a Learning People with a Learning

Disability who Access Mental Disability who Access Mental health serviceshealth services

Ross OrfordRoss Orford

Green Light facilitatorGreen Light facilitator

Session AimsSession Aims

• Definition and recognition of Learning Definition and recognition of Learning DisabilityDisability

• Increased Risk factors for mental Increased Risk factors for mental health Problems in learning disabilityhealth Problems in learning disability

• Common issues in supporting Common issues in supporting someone with a learning disabilitysomeone with a learning disability

• Extra support that may be needed Extra support that may be needed and where to find some of itand where to find some of it

What is a Learning DisabilityWhat is a Learning Disability

• The World Health Organization defines The World Health Organization defines learning disabilities as: learning disabilities as: “a state of arrested “a state of arrested or incomplete development of mind”. (WHO or incomplete development of mind”. (WHO 1993 cited by Gates 2005)1993 cited by Gates 2005)

• Three internationally Three internationally recognisedrecognised criteria criteria regarded as requiring to be met before regarded as requiring to be met before learning disabilities can be identified:learning disabilities can be identified:

• Intellectual impairmentIntellectual impairment• Social or adaptive dysfunctionSocial or adaptive dysfunction• Early onsetEarly onset(BILD)(BILD)

Valuing People 2001defined Valuing People 2001defined learning disability as:learning disability as:

• A significantly reduced ability to understand A significantly reduced ability to understand new or complex information, to learn new new or complex information, to learn new skills (impaired intelligence), with;skills (impaired intelligence), with;

• A reduced ability to cope independently A reduced ability to cope independently (impaired social functioning);(impaired social functioning);

• Onset before adulthood, with a lasting Onset before adulthood, with a lasting effect on development.effect on development.

(DOH 2001)(DOH 2001)

IQ ranges in defining Learning IQ ranges in defining Learning disabilitydisability

• 71-84 Borderline71-84 Borderline• 50-69 Mild50-69 Mild• 35-49 Moderate35-49 Moderate• 20-34 Severe20-34 Severe• Profound for people with additional Profound for people with additional

sensory, physical communication or sensory, physical communication or behavioural complexities where IQ behavioural complexities where IQ assessment would be exceedingly difficultassessment would be exceedingly difficult

(BILD)(BILD)

Learning DifficultiesLearning Difficulties

• Learning disability is different from Learning disability is different from specific learning difficultyspecific learning difficulty which which means that the person finds one means that the person finds one particular thing hard, but manages particular thing hard, but manages well in everything else. well in everything else.

(RCPsych 2004)(RCPsych 2004)

Recognition that someone may Recognition that someone may have a Learning disabilityhave a Learning disability

• Can they read/write.Can they read/write.• Can they communicate.Can they communicate.• Do they understand what is being said and Do they understand what is being said and

can they remember it.can they remember it.• Do they remember things like home address, Do they remember things like home address,

birthday, year. birthday, year. • Do they live in supported care/have Do they live in supported care/have

community support.community support.• Did they attend a special school.Did they attend a special school.

(Adapted from RCN 2007)(Adapted from RCN 2007)

Valuing People 2001 saysValuing People 2001 says

• Ensure that people with learning Ensure that people with learning disabilities, including those from minority disabilities, including those from minority ethnic communities, have the same right ethnic communities, have the same right of access to mainstreamof access to mainstream health serviceshealth services as the rest of the population.as the rest of the population.

• This includes mental health servicesThis includes mental health services

Other Relevant Other Relevant Reports/LegislationReports/Legislation• Mental Health national service framework Mental Health national service framework

(1999) Standards Two and Three(1999) Standards Two and Three

• Valuing people Now (2007)Valuing people Now (2007)

• Good practice in Learning disability Good practice in Learning disability nursing (2007) Benchmark Fivenursing (2007) Benchmark Five

• Services for people with learning Services for people with learning disabilities and challenging behaviour or disabilities and challenging behaviour or mental health needs (Mansell 2007)mental health needs (Mansell 2007)

Increased Risk Factors for Increased Risk Factors for Mental Health ProblemsMental Health Problems

Social and Economic FactorsSocial and Economic Factors

Psychological and Emotional Psychological and Emotional factorsfactors

Increased Risk factors For Increased Risk factors For Mental Health ProblemsMental Health Problems

Socio-economicSocio-economic• Prejudice and DiscriminationPrejudice and Discrimination• Financial DisadvantageFinancial Disadvantage• Smaller Social NetworkSmaller Social Network• ExclusionExclusion• Poor TransitionPoor Transition• Vulnerability to abuse/exploitationVulnerability to abuse/exploitation(Adapted from Hardy et al 2006)(Adapted from Hardy et al 2006)

Increased Risk factors for Increased Risk factors for mental health Problemsmental health Problems

Psychological and EmotionalPsychological and Emotional

• Low self esteemLow self esteem

• Negative Learning experiencesNegative Learning experiences

• BereavementBereavement

• Lack of choicesLack of choices

(Adapted from Hardy et al 2006)(Adapted from Hardy et al 2006)

Issues that people with a learning Issues that people with a learning disability and mental health problems disability and mental health problems may face.may face.• Relationships with staff, family, friends and Relationships with staff, family, friends and

other individuals can become strained. other individuals can become strained. There is a risk that people can become There is a risk that people can become isolated.isolated.

• Their behaviour may jeopardise their Their behaviour may jeopardise their places at day services, employment and places at day services, employment and residential establishments.residential establishments.

• They are less likely to access the same They are less likely to access the same treatment facilities as other local people treatment facilities as other local people without a learning disability. More likely to without a learning disability. More likely to be placed in ‘specialist units’be placed in ‘specialist units’

Issues ContinuedIssues Continued

• They may develop physical health problems, They may develop physical health problems, e.g. due to self-neglect, and may try treating e.g. due to self-neglect, and may try treating themselves by increasing alcohol, drug or themselves by increasing alcohol, drug or cigarette use.cigarette use.

• There may be an overuse of medication and There may be an overuse of medication and limited use of other treatments, such as limited use of other treatments, such as psychological interventions.psychological interventions.

• They may have less choice and have fewer They may have less choice and have fewer opportunities to express their views and opportunities to express their views and opinions. opinions.

(Adapted from Hardy et al 2006)(Adapted from Hardy et al 2006)

Issues arising in supporting Issues arising in supporting someone with a learning disability.someone with a learning disability.

• Communication/UnderstandingCommunication/Understanding

• Delivery of psychological therapiesDelivery of psychological therapies

• Challenging BehavioursChallenging Behaviours

• Physical Heath IssuesPhysical Heath Issues

• Mental Capacity Act and Deprivation Mental Capacity Act and Deprivation of liberty safeguards 2005of liberty safeguards 2005

What Additional Input May be What Additional Input May be required?required?

• Alternative or supported communication Alternative or supported communication (accessible writing, Carer support, visual aids, (accessible writing, Carer support, visual aids, more time) more time)

• Adapted Therapeutic approachesAdapted Therapeutic approaches• Input from Learning Disability Community Input from Learning Disability Community

Partnerships (LDCP)Partnerships (LDCP)• The Green light teamThe Green light team• Additional resources books, internet, Additional resources books, internet,

colleaguescolleagues• Knowledge and skills trainingKnowledge and skills training

Communication issuesCommunication issues

• People with Learning disabilities may:People with Learning disabilities may:

• struggle to communicate their needs struggle to communicate their needs and emotions. and emotions.

• appear to understand what is being said appear to understand what is being said when in reality they have not when in reality they have not

• use verbal visual and social ‘cues’ to try use verbal visual and social ‘cues’ to try and fit inand fit in

• Illiteracy may be a factorIlliteracy may be a factor

Adapting your Adapting your communicationcommunication• Remove sources of distractionRemove sources of distraction• Use gesture and facial expression to Use gesture and facial expression to

support what you are trying to say. support what you are trying to say. • Don’t use jargon or abbreviations.Don’t use jargon or abbreviations.• Ask open questions if possible.Ask open questions if possible.• Don’t ask questions with lists or multiple Don’t ask questions with lists or multiple

statementsstatements• Check that the person has understood Check that the person has understood

what you have said (Get them to repeat what you have said (Get them to repeat back or paraphrase it)back or paraphrase it)

Adapting CommunicationAdapting Communication

• Use easily referenced dates and times Use easily referenced dates and times eg birthdays, Christmas, before lunch, eg birthdays, Christmas, before lunch, “on the same day as” (a regular event) “on the same day as” (a regular event)

• Use objects, photos, drawing etc to help Use objects, photos, drawing etc to help to get your message across to get your message across

• Think about any written communication, Think about any written communication, can this be simplified or provided in can this be simplified or provided in another formatanother format

(Adapted from Cornwall NHS Trust 2006)(Adapted from Cornwall NHS Trust 2006)

Issues concerning Delivery of Issues concerning Delivery of TherapiesTherapies• Impaired communicationImpaired communication

• Lack of understanding Lack of understanding

• Poor communication of feelingsPoor communication of feelings

• Potential Vulnerability in Relationships Potential Vulnerability in Relationships with Otherswith Others

• Lack of Choices and ControlLack of Choices and Control

(RCPsych 2003)(RCPsych 2003)

Adapting therapiesAdapting therapies

• SimplifySimplify

• Reinforce through homework and Reinforce through homework and practice taskspractice tasks

• Be flexibleBe flexible

• Involve carers/support staff (where Involve carers/support staff (where appropriate)appropriate)

(Adapted from Hurley et al 1998 cited by Whitehouse et al (Adapted from Hurley et al 1998 cited by Whitehouse et al 2006)2006)

Challenging BehavioursChallenging Behaviours

• Are not just assaultative behavioursAre not just assaultative behaviours

• May serve as part of the persons May serve as part of the persons communicationcommunication

• May have physical causes (pain,)May have physical causes (pain,)

• Can lead to isolation and lack of servicesCan lead to isolation and lack of services

• May be caused or increased by mental May be caused or increased by mental health issueshealth issues

Physical healthPhysical healthPeople with learning disabilities mayPeople with learning disabilities may• find it much harder than other people to find it much harder than other people to

access assessment and treatment for access assessment and treatment for general health problems that have nothing general health problems that have nothing directly to do with their disability.directly to do with their disability.

• be more likely to have tooth decay, loose be more likely to have tooth decay, loose teeth, gum disease, higher levels of teeth, gum disease, higher levels of untreated disease and a larger number of untreated disease and a larger number of extractions. This can be due to lack of extractions. This can be due to lack of access to dental care and poor oral hygiene.access to dental care and poor oral hygiene.

(Micheal 2008)(Micheal 2008)

VulnerabilityVulnerability

• Problems often arise when people Problems often arise when people with Learning disabilities and mental with Learning disabilities and mental health problems are admitted to health problems are admitted to generic mental health wards. generic mental health wards. Vulnerable clients can be put at risk Vulnerable clients can be put at risk of abuse from other clients.of abuse from other clients.

(Bouras (Bouras et alet al 2003) 2003)

Mental Capacity Act 2005Mental Capacity Act 2005

• Does the person have capacity to make Does the person have capacity to make decisions about their caredecisions about their care

does a capacity assessment need to does a capacity assessment need to be be carried out.carried out.

are you acting in their best interestsare you acting in their best interestsdoes an IMCA need to be appointed.does an IMCA need to be appointed.

• Are your decisions depriving them of their Are your decisions depriving them of their liberty and does authorisation need to be liberty and does authorisation need to be sought under the Mental Capacity Act sought under the Mental Capacity Act 2005 deprivation of liberty safeguards2005 deprivation of liberty safeguards

What to do when completing What to do when completing assessmentsassessments• Communicate at a level that means Communicate at a level that means

you’re understood – get support from you’re understood – get support from other disciplinesother disciplines

• Allow more time than you generally Allow more time than you generally might also allow time to go back and might also allow time to go back and check that the person has check that the person has understood you. understood you.

• Involve carers or family where Involve carers or family where appropriate but ensure that you take appropriate but ensure that you take time to listen to the individualtime to listen to the individual

Completing Assessments Completing Assessments continuedcontinued

• Find out if the person has a person Find out if the person has a person centred plan or a health action plan centred plan or a health action plan that gives some pointers.that gives some pointers.

• Use the CPA process (MH+LD= Use the CPA process (MH+LD= Complex needs) get everyone involvedComplex needs) get everyone involved

• Get as complete a history as you Get as complete a history as you possibly can in order to see changes in possibly can in order to see changes in the persons presentationthe persons presentation

Where to StartWhere to Start

Books beyond words – published by Books beyond words – published by the Royal College of Psychiatry the Royal College of Psychiatry www.rcpsych.ac.ukwww.rcpsych.ac.uk

• Easy to understand leaflets about Easy to understand leaflets about medication www.elfrida.commedication www.elfrida.com

• www.easyhealth.org more accessibly www.easyhealth.org more accessibly written material (and lots of it is free)written material (and lots of it is free)

Suggested readingSuggested reading

• Mental Health Nursing of Adults with Learning disabilitiesMental Health Nursing of Adults with Learning disabilities From www.estiacentre.org look in free publications (in From www.estiacentre.org look in free publications (in conjunction with RCN)conjunction with RCN)

• Meeting the health needs of people with learning Meeting the health needs of people with learning disabilities. From disabilities. From www.estiacentre.org look in free www.estiacentre.org look in free publications (in conjunction with RCN)publications (in conjunction with RCN)

• Supporting Complex Needs A practical guide for support Supporting Complex Needs A practical guide for support staff working with people with a learning disability who staff working with people with a learning disability who have mental health needs.have mental health needs. From www.estiacentre.org look From www.estiacentre.org look in free publicationsin free publications

• Practice guidelines for the assessment and diagnosis of Practice guidelines for the assessment and diagnosis of mental health problems in adults with intellectual disability. mental health problems in adults with intellectual disability. From www.estiacentre.org look in free publicationsFrom www.estiacentre.org look in free publications

• Make it Clear. A guide to making easy read information Make it Clear. A guide to making easy read information from www.mencap.org.ukfrom www.mencap.org.uk