Services for psychiatrically disordered mentally handicapped adults — A U.K. perspective

The provision of psychological therapy to people with intellectual disabilities: an investigation into some of the relevant factors

BACKGROUND

Five factors are proposed as important in influencing the provision of psychological therapy to people with intellectual disabilities (IDs): the perceived effectiveness of psychological therapy, individual clinician competence, service resources (number of trained clinicians), the level of the client's disability and the diagnostic overshadowing bias.

METHOD

A prospective questionnaire design was used. A survey style questionnaire was sent out to clinical psychologists (n = 412) and psychiatrists (n = 274) working in ID services in the UK. Responses were received from 133 psychologists and 90 psychiatrists.

RESULTS

Perceived competence, the level of the client's disability and the diagnostic overshadowing bias all appeared to be important factors. The perceived effectiveness of psychological therapy with this client group and service resources appeared less important than hypothesized.

CONCLUSION

Whereas the debates in research publications tend to focus on broad issues of effectiveness, clinicians themselves appear more concerned with their personal skill levels. The issue of the appropriateness of psychological therapies for people with more severe levels of disability remains largely unresearched.

Mental health services for adults with learning disabilities

Services for people with learning disabilities have been transformed since the late 1960s by the move from institutional to community care. (Learning disabilities is the term currently used in the UK in preference to mental retardation, developmental disabilities and mental handicap.) Important changes include the progress towards integration, participation, inclusion and choice for people with learning disabilities, which have occurred in the context of the broader civil and human rights movements. It is time to examine the services delivered to people with learning disabilities and comorbid psychiatric disorders (mental illness, personality disorders, behavioural problems with aggression) and the evidence for their effectiveness.

Services for people with mental retardation and psychiatric disorders: US-UK comparative overview

Mental health services for people with mental retardation have been receiving greater attention over recent years following a long period of inactivity. The main policy factors which influenced the developments of services were in the USA, the emphasis on deinstitutionalisation and normalisation, and in the UK the focus on social care. Progress in the assessment of psychiatric disorders and improved diagnostic techniques have stimulated the development of a wide range of mental health services for people with mental retardation, compatible with current ideology of community care on both sides of the Atlantic. Specialist multidisciplinary, community based and easily accessible mental health services should be available for people with mental retardation. Economic cost, quality of care, and training of professionals and direct care staff, remain some of the challenges faced by purchasers and providers of mental retardation and mental health services in both countries.

The Developmental Behavior Checklist: the development and validation of an instrument to assess behavioral and emotional disturbance in children and adolescents with mental retardation

Describes the development and validation of the Developmental Behavior Checklist (DBC), a standardized instrument completed by lay informants to assess behavioral and emotional disturbance in children and adolescents with mental retardation (MR). Items describing common behavioral and emotional problems in this population were generated by extracting descriptions from 664 case files of children and adolescents with behavior disorders seen at a specialist developmental assessment service over 12 years. These items were reduced to a set of 96 items administered to a sample of 1,093 children and adolescents with mental retardation and then submitted to a principal components analysis. Six interpretable and partly validated subscales were obtained which explained 36% of the total variance and had satisfactory internal consistency. Interrater and test-retest agreement were satisfactory for both total scale score and for scores on each of the subscales. Good evidence of concurrent validity was provided by substantial positive correlations between total scores on the DBC completed by lay informants and the ratings of experienced psychiatrists based upon interviews and scores on two standardized instruments that must be completed by health professionals. The discriminative validity of the total score as assessed by area under the ROC curve was excellent (92%). Standardized norms for the DBC are derived from an epidemiological study of behavior problems in children and adolescents with mental retardation undertaken in two Australian States. Norms are available for the mild, moderate, severe, and profound MR groups and for the MR population as a whole.

Mental health services for people with mental retardation: a framework for the future

The mental health needs of mentally retarded people cannot be met satisfactorily with generic mental health services. Specialized services are required. A number of different service models have evolved which require evaluation. They include subregional units, community-based services with a small admission facility, integrated services and specialist teams. Staff working in specialist mental health services must be appropriately trained.

Clinical assessment of psychiatric symptoms in mentally retarded individuals

Mentally retarded Australians with emotional and behavioural disorders are seriously under-served by psychiatrists, despite such individuals being as prevalent as those with schizophrenia. These disorders have serious consequences for the individual, family and carers, and the community as a whole. In the psychiatric assessment of mentally retarded persons, a key principle is that while intellectual handicap increases vulnerability to psychiatric illness, it does not of itself cause psychopathology. A biopsychosocial framework provides a model whereby those factors which are contributing to psychopathology can be systematically elucidated. Biological factors include brain pathology associated with particular mental retardation syndromes, drug side-effects and epilepsy. Psychological factors include temperament, a history of abuse, and current life stresses. Social factors include distortions in family roles and hostel or workshop conflicts. Although clinical assessment can be challenging, and confident syndrome diagnosis is not always possible, a systematic approach to the analysis of symptoms will provide a guide to useful interventions.

Psychometric assessment of psychiatric disorders in people with learning difficulties (mental handicap): a review of measures

Instruments designed to assess psychiatric disorders in people with learning difficulties (mental handicap) were critically reviewed from a psychometric perspective. Major trends were found in the assessment of psychopathology related to DSM-III and depressive disorders although research in other areas was patchy. Although some psychometrically sophisticated measures were identified the area was characterized by an absence of important psychometric data for many measures. Future research should attend to developing assessments of schizophrenia, psycho-sexual disorders, adjustment disorders and the validation of screening procedures and instrument formats. Future studies should include more people with severe and profound learning difficulties.