1. Recognising and Supporting People with a Learning Disability who Access Mental health services Ross Orford Green Light facilitator

2. Session Aims Definition and recognition of Learning Disability Definition and recognition of Learning Disability Increased Risk factors for mental health Problems in learning disability Increased Risk factors for mental health Problems in learning disability Common issues in supporting someone with a learning disability Common issues in supporting someone with a learning disability Extra support that may be needed and where to find some of it Extra support that may be needed and where to find some of it

3. What is a Learning Disability The World Health Organization defines learning disabilities as: “a state of arrested or incomplete development of mind”. (WHO 1993 cited by Gates 2005) The World Health Organization defines learning disabilities as: “a state of arrested or incomplete development of mind”. (WHO 1993 cited by Gates 2005) Three internationally recognised criteria regarded as requiring to be met before learning disabilities can be identified: Three internationally recognised criteria regarded as requiring to be met before learning disabilities can be identified: Intellectual impairment Intellectual impairment Social or adaptive dysfunction Social or adaptive dysfunction Early onset Early onset(BILD)

4. Valuing People 2001defined learning disability as: A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; A reduced ability to cope independently (impaired social functioning); A reduced ability to cope independently (impaired social functioning); Onset before adulthood, with a lasting effect on development. Onset before adulthood, with a lasting effect on development. (DOH 2001)

5. IQ ranges in defining Learning disability 71-84 Borderline 71-84 Borderline 50-69 Mild 50-69 Mild 35-49 Moderate 35-49 Moderate 20-34 Severe 20-34 Severe Profound for people with additional sensory, physical communication or behavioural complexities where IQ assessment would be exceedingly difficult Profound for people with additional sensory, physical communication or behavioural complexities where IQ assessment would be exceedingly difficult(BILD)

6. Learning Difficulties Learning disability is different from specific learning difficulty which means that the person finds one particular thing hard, but manages well in everything else. Learning disability is different from specific learning difficulty which means that the person finds one particular thing hard, but manages well in everything else. (RCPsych 2004)

7. Recognition that someone may have 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 can they remember it. Do they understand what is being said and can they remember it. Do they remember things like home address, birthday, year. Do they remember things like home address, birthday, year. Do they live in supported care/have community support. Do they live in supported care/have community support. Did they attend a special school. Did they attend a special school. (Adapted from RCN 2007)

8. Valuing People 2001 says Ensure that people with learning disabilities, including those from minority ethnic communities, have the same right of access to mainstream health services as the rest of the population. Ensure that people with learning disabilities, including those from minority ethnic communities, have the same right of access to mainstream health services as the rest of the population. This includes mental health services This includes mental health services

9. Other Relevant Reports/Legislation Mental Health national service framework (1999) Standards Two and Three Mental Health national service framework (1999) Standards Two and Three Valuing people Now (2007) Valuing people Now (2007) Good practice in Learning disability nursing (2007) Benchmark Five Good practice in Learning disability nursing (2007) Benchmark Five Services for people with learning disabilities and challenging behaviour or mental health needs (Mansell 2007) Services for people with learning disabilities and challenging behaviour or mental health needs (Mansell 2007)

10. Increased Risk Factors for Mental Health Problems Social and Economic Factors Psychological and Emotional factors

11. Increased Risk factors For Mental Health Problems Socio-economic Prejudice and Discrimination Prejudice and Discrimination Financial Disadvantage Financial Disadvantage Smaller Social Network Smaller Social Network Exclusion Exclusion Poor Transition Poor Transition Vulnerability to abuse/exploitation Vulnerability to abuse/exploitation (Adapted from Hardy et al 2006)

12. Increased Risk factors for mental health Problems Psychological and Emotional Low self esteem Low self esteem Negative Learning experiences Negative Learning experiences Bereavement Bereavement Lack of choices Lack of choices (Adapted from Hardy et al 2006)

13. Issues that people with a learning disability and mental health problems may face. Relationships with staff, family, friends and other individuals can become strained. There is a risk that people can become isolated. Relationships with staff, family, friends and other individuals can become strained. There is a risk that people can become isolated. Their behaviour may jeopardise their places at day services, employment and residential establishments. Their behaviour may jeopardise their places at day services, employment and residential establishments. They are less likely to access the same treatment facilities as other local people without a learning disability. More likely to be placed in ‘specialist units’ They are less likely to access the same treatment facilities as other local people without a learning disability. More likely to be placed in ‘specialist units’

14. Issues Continued They may develop physical health problems, e.g. due to self-neglect, and may try treating themselves by increasing alcohol, drug or cigarette use. They may develop physical health problems, e.g. due to self-neglect, and may try treating themselves by increasing alcohol, drug or cigarette use. There may be an overuse of medication and limited use of other treatments, such as psychological interventions. There may be an overuse of medication and limited use of other treatments, such as psychological interventions. They may have less choice and have fewer opportunities to express their views and opinions. They may have less choice and have fewer opportunities to express their views and opinions. (Adapted from Hardy et al 2006)

15. Issues arising in supporting someone with a learning disability. Communication/Understanding Communication/Understanding Delivery of psychological therapies Delivery of psychological therapies Challenging Behaviours Challenging Behaviours Physical Heath Issues Physical Heath Issues Mental Capacity Act and Deprivation of liberty safeguards 2005 Mental Capacity Act and Deprivation of liberty safeguards 2005

16. What Additional Input May be required? Alternative or supported communication (accessible writing, Carer support, visual aids, more time) Alternative or supported communication (accessible writing, Carer support, visual aids, more time) Adapted Therapeutic approaches Adapted Therapeutic approaches Input from Learning Disability Community Partnerships (LDCP) Input from Learning Disability Community Partnerships (LDCP) The Green light team The Green light team Additional resources books, internet, colleagues Additional resources books, internet, colleagues Knowledge and skills training Knowledge and skills training

17. Communication issues People with Learning disabilities may: People with Learning disabilities may: struggle to communicate their needs and emotions. struggle to communicate their needs and emotions. appear to understand what is being said when in reality they have not appear to understand what is being said when in reality they have not use verbal visual and social ‘cues’ to try and fit in use verbal visual and social ‘cues’ to try and fit in Illiteracy may be a factor Illiteracy may be a factor

18. Adapting your communication Remove sources of distraction Remove sources of distraction Use gesture and facial expression to support what you are trying to say. Use gesture and facial expression to 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 statements Don’t ask questions with lists or multiple statements Check that the person has understood what you have said (Get them to repeat back or paraphrase it) Check that the person has understood what you have said (Get them to repeat back or paraphrase it)

19. Adapting Communication Use easily referenced dates and times eg birthdays, Christmas, before lunch, “on the same day as” (a regular event) Use easily referenced dates and times eg birthdays, Christmas, before lunch, “on the same day as” (a regular event) Use objects, photos, drawing etc to help to get your message across Use objects, photos, drawing etc to help to get your message across Think about any written communication, can this be simplified or provided in another format Think about any written communication, can this be simplified or provided in another formatwrittencommunication,writtencommunication, (Adapted from Cornwall NHS Trust 2006)

20. Issues concerning Delivery of Therapies Impaired communication Impaired communication Lack of understanding Lack of understanding Poor communication of feelings Poor communication of feelings Potential Vulnerability in Relationships with Others Potential Vulnerability in Relationships with Others Lack of Choices and Control Lack of Choices and Control (RCPsych 2003)

21. Adapting therapies Simplify Simplify Reinforce through homework and practice tasks Reinforce through homework and practice tasks Be flexible Be flexible Involve carers/support staff (where appropriate) Involve carers/support staff (where appropriate) (Adapted from Hurley et al 1998 cited by Whitehouse et al 2006)

22. Challenging Behaviours Are not just assaultative behaviours Are not just assaultative behaviours May serve as part of the persons communication May serve as part of the persons communication May have physical causes (pain,) May have physical causes (pain,) Can lead to isolation and lack of services Can lead to isolation and lack of services May be caused or increased by mental health issues May be caused or increased by mental health issues

23. Physical health People with learning disabilities may find it much harder than other people to access assessment and treatment for general health problems that have nothing directly to do with their disability. find it much harder than other people to access assessment and treatment for general health problems that have nothing directly to do with their disability. be more likely to have tooth decay, loose teeth, gum disease, higher levels of untreated disease and a larger number of extractions. This can be due to lack of access to dental care and poor oral hygiene. be more likely to have tooth decay, loose teeth, gum disease, higher levels of untreated disease and a larger number of extractions. This can be due to lack of access to dental care and poor oral hygiene. (Micheal 2008)

24. Vulnerability Problems often arise when people with Learning disabilities and mental health problems are admitted to generic mental health wards. Vulnerable clients can be put at risk of abuse from other clients. Problems often arise when people with Learning disabilities and mental health problems are admitted to generic mental health wards. Vulnerable clients can be put at risk of abuse from other clients. (Bouras et al 2003)

25. Mental Capacity Act 2005 Does the person have capacity to make decisions about their care Does the person have capacity to make decisions about their care does a capacity assessment need to be carried out. are you acting in their best interests does an IMCA need to be appointed. Are your decisions depriving them of their liberty and does authorisation need to be sought under the Mental Capacity Act 2005 deprivation of liberty safeguards Are your decisions depriving them of their liberty and does authorisation need to be sought under the Mental Capacity Act 2005 deprivation of liberty safeguards

26. What to do when completing assessments Communicate at a level that means you’re understood – get support from other disciplines Communicate at a level that means you’re understood – get support from other disciplines Allow more time than you generally might also allow time to go back and check that the person has understood you. Allow more time than you generally might also allow time to go back and check that the person has understood you. Involve carers or family where appropriate but ensure that you take time to listen to the individual Involve carers or family where appropriate but ensure that you take time to listen to the individual

27. Completing Assessments continued Find out if the person has a person centred plan or a health action plan that gives some pointers. Find out if the person has a person centred plan or a health action plan that gives some pointers. Use the CPA process (MH+LD= Complex needs) get everyone involved Use the CPA process (MH+LD= Complex needs) get everyone involved Get as complete a history as you possibly can in order to see changes in the persons presentation Get as complete a history as you possibly can in order to see changes in the persons presentation

28. Where to Start Books beyond words – published by the Royal College of Psychiatry www.rcpsych.ac.uk www.rcpsych.ac.uk Easy to understand leaflets about medication www.elfrida.com Easy to understand leaflets about medication www.elfrida.comwww.elfrida.com www.easyhealth.org more accessibly written material (and lots of it is free) www.easyhealth.org more accessibly written material (and lots of it is free) www.easyhealth.org

29. Suggested reading Mental Health Nursing of Adults with Learning disabilities From www.estiacentre.org look in free publications (in conjunction with RCN) Mental Health Nursing of Adults with Learning disabilities From www.estiacentre.org look in free publications (in conjunction with RCN)www.estiacentre.org Meeting the health needs of people with learning disabilities. From www.estiacentre.org look in free publications (in conjunction with RCN) Meeting the health needs of people with learning disabilities. From www.estiacentre.org look in free publications (in conjunction with RCN)www.estiacentre.org Supporting Complex Needs A practical guide for support staff working with people with a learning disability who have mental health needs. From www.estiacentre.org look in free publications Supporting Complex Needs A practical guide for support staff working with people with a learning disability who have mental health needs. From www.estiacentre.org look in free publicationswww.estiacentre.org Practice guidelines for the assessment and diagnosis of mental health problems in adults with intellectual disability. From www.estiacentre.org look in free publications Practice guidelines for the assessment and diagnosis of mental health problems in adults with intellectual disability. From www.estiacentre.org look in free publicationswww.estiacentre.org Make it Clear. A guide to making easy read information from www.mencap.org.uk Make it Clear. A guide to making easy read information from www.mencap.org.uk