Intellectual Disability and Mental Health: A Training Manual in Dual Diagnosis

Citation

Priest, H.M. (2013), "Intellectual Disability and Mental Health: A Training Manual in Dual Diagnosis", Advances in Mental Health and Intellectual Disabilities, Vol. 7 No. 4, pp. 251-252. https://doi.org/10.1108/AMHID-03-2013-0018

This is a useful addition to the expanding literature targeting professional care providers. It aims to provide practical guidelines and tools, with the ultimate aim of establishing more comprehensive care for people with intellectual disabilities and mental health needs. Although written in the USA, and therefore somewhat context specific, there is much here that crosses international borders and is of general relevance. However, the UK/European reader may take issue with some of the terminology used. For example, while the authors do acknowledge its multiple meanings, the use of the term “dual diagnosis” within the title and throughout the text is unhelpful. Furthermore, much of the content and language reflects a medical model approach (e.g. “psychiatric conditions” and “diagnosis” are the terms of choice) which is perhaps at odds with UK and European perspectives and explanations.

The book comprises nine main chapters plus one chapter of illustrative case studies, and an extensive appendix of tools and resources that accounts for more than a third of the book's total content. The book opens with a useful reminder of generally accepted information: that people with intellectual disabilities can and do experience mental health problems and at a greater frequency that in the general population; that they often go unreported and undiagnosed, particularly for those with severe or profound disabilities or expressive language difficulties; and that that they often present in atypical ways. Chapter 2 develops this theme by focusing on the challenges of identifying mental health problems, and reminding us of the many barriers to accurate assessment, diagnosis, and intervention that must be taken into account when working with people with intellectual disabilities. These include not only well‐known barriers such as diagnostic overshadowing and polypharmacy, but also those arising from slower developmental changes, which are perhaps not always recognised by carers, causing frustration, and confusion for all concerned. This chapter also reminds us that relationship issues and differences, expressive and receptive language difficulties, memory impairments, and executive functioning can also inhibit correct identification of problems, and includes useful guidelines to ensure such differences are taken into account. Incidentally, in so doing, it provides a useful overview of good practice in working with people with intellectual disabilities, whether or not they have additional mental health needs.

Chapter 3 outlines atypical presentations of mental health problems, and offers a useful reminder that while the DSM‐IV‐TR (American Psychiatric Association, 2000) manual can be a helpful aid to assessment and diagnosis, even when supplemented by the specific DM‐ID version (Fletcher et al., 2007) it has limitations, and there is much room for subjective interpretation and misinterpretation of observations. Common disorders and their characteristics for the general population are described in turn, with reference to DSM‐IV‐TR criteria, followed by comments on atypical presentations in each case. A particularly helpful comparison chart is presented for features of depression in people with and without intellectual disabilities. It is, however, a real limitation of this chapter that this format is not repeated for other disorders; indeed a general lack of standardisation in presentation makes it difficult to separate out the material that is applicable generally and that which is of particular note for people with intellectual disabilities. It is also disappointing that given the ever‐increasing life expectancy of the population and the associated increase in age‐related mental health problems, dementia is afforded only a passing mention in this chapter.

A fourth brief chapter on medical problems reminds us of the importance of ruling out physical factors that might give rise to mental health symptoms, while Chapter 5, headed “Diagnoses and intervention plans”, focuses largely on the former. It presents a structured approach to assessment and a set of useful prompts to facilitate a comprehensive assessment of needs. Little reference is made to mental health assessment tools to aid this process; indeed only four are mentioned briefly. Despite the title, there is little on intervention in this chapter or in Chapter 9, entitled “Therapy for individuals with dual diagnosis”; this chapter is less about therapeutic interventions and more about the impact of the settings in which people may receive mental health care. However, both Chapters 5 and 9 are complemented by material in an appendix on staff training, which provides practical guidelines for responding to “some common psychiatric disorders” in people with intellectual disabilities. Chapter 8, on transitional planning, while referring to US contexts, is generally useful and makes the important point that times of transition can exacerbate mental health problems or behavioural challenges. The three case studies in Chapter 10 usefully illustrate the sequential steps to be taken to rule out physical, psychiatric and learned explanations of behavioural challenges, and to arrive at an informed “final analysis”. The remainder of the book comprises appendixes of training materials and resources. Some are not specific to mental health problems but could be of more general use by direct care staff.

In summary, this book would appear to be of mixed value in informing readers about the mental health needs of people with intellectual disabilities. Some topics are covered only briefly (e.g. stress and people with intellectual disabilities, assessment tools, and age‐related mental health problems). Some content is not specific to mental health problems but may be useful nonetheless, and some material is summarised from other readily available sources such as DSM‐IV‐TR, rather than focusing specifically on presentations for people with intellectual disabilities. However, the case study chapter and the collection of resources in appendix will be useful in guiding the reader to apply theoretical knowledge to practical caring situations. A particular strength of the book is its strong person‐centred approach; we would all do well to remember to “[…] appreciate the unique expressions of the psychiatric, medical and psychological needs of the individuals with an intellectual disability, and be wiser from their teachings” (p. 156).