Simonoff, E

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                       King’s Research Portal  DOI:10.1136/bmj.330.7494.742Document VersionPublisher's PDF, also known as Version of recordLink to publication record in King's Research PortalCitation for published version (APA):Simonoff, E. (2005). Children with psychiatric disorders and learning disabilities - Their needs extend beyond theprovisions in national service framework. BMJ, 330(7494), 742 - 743. https://doi.org/10.1136/bmj.330.7494.742Citing this paperPlease note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this maydiffer from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination,volume/issue, and date of publication details. 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Oct. 2023reductions in time spent on ventilators and days inhos-pital, and that most doctors and nurses who have usedthe service find it helpful.9 10 Furthermore, evidenceshows that clinical ethicists score higher in moralreasoning tests than clinicians.11Clinical ethicists could also contribute to thecontinuing education of healthcare staff in medicalethics through lecturing and private consultations.From my own experience in Canada, doctorsexpressed a greater understanding of the ethicalrequirements of informed consent and do not resusci-tate orders after attending lectures on these topics.Ethicists could teach ethics to students and doctors atthe bedside, exploring the links between technical skilland ethical decision making. The hands-on involve-ment of clinical ethicists in teaching is likely to reducethe occurrence or recurrence of ethical violations byhighlighting key ethical issues and drawing lessonsfrom previous cases.The idea of using clinical ethicists gives cause forsome concern. Doctors may offload their ethical prob-lems on clinical ethicists, abnegating their moralresponsibilities too easily. This could be avoidedthrough an awareness of this danger. Some scepticsmay frown at the suggestion of creating yet anotherexpert, but ethical cases, like medicine itself, areincreasingly sophisticated. Questions also exist aboutthe precise role, training, recruitment, and funding ofthese new professionals. Finally, the introduction ofclinical ethicists should be in addition to the training inmedical ethics, clinical ethics committees, and theBMA’s advice centre.In light of the accepted importance and relevanceof medical ethics to everyday practice, the demand forethical support by doctors in the United Kingdom,6 12the impossibility of training medical students anddoctors to sufficient levels of proficiency in ethics, andthe success of clinical ethicists in North America, wenow need to introduce clinical ethicists in hospitals inthe United Kingdom. Doctors cannot possibly dealwith all the ethical problems they encounter in theirprofessional lives, nor can they be expected to analysecomplex ethical issues, and to know how similar caseswere handled elsewhere. Clinical ethics committeescannot alone cope with the demands of ethicallytroubled doctors at the coalface. The use ofclinical ethicists would represent an important stepforward.Daniel K Sokol doctoral candidate in medical ethicsMedical Ethics Unit, Department of Primary Health Care and GeneralPractice, Imperial College, London W6 8RP(daniel.sokol@imperial.ac.uk)Competing interests: None declared.1 Consensus Group of Teachers of Medical Ethics and Law in UK MedicalSchools: Teaching medical ethics and law within medical education: amodel for the UK core curriculum. J Med Ethics 1998;24:188-92.2 Hope T, Savulescu J, Hendrick J. Medical ethics and law: the core curriculum.Edinburgh: Churchill-Livingstone, 2003.3 Sokol D, Bergson G. Medical ethics and law: surviving on the wards and pass-ing exams. London: Trauma Publishing, 2005.4 Slowther A, Johnston C, Goodall J, Hope T. Development of clinical eth-ics committees. BMJ 2004;328:950-2.5 Parker M. Getting ethics into practice. BMJ 2004;329:126.6 BBC. Doctors make medical ethics plea. BBC News 2 December 2003.http://news.bbc.co.uk/1/hi/health/3253786.stm (accessed 11 Feb2005).7 British Medical Association Ethics Department: Medical ethics today; theBMA’s handbook of ethics and law. 2nd ed. London: BMJ Books, 2004.8 Smith R. Medical mishaps. studentBMJ 1998;10:6. (October.)9 Schneiderman L, Gilmer T, Teetzel H, Dugan D, Blustein J, Cranford R, etal. Effect of ethics consultations on nonbeneficial life-sustainingtreatments in the intensive care setting. JAMA 2003;290:1166-72.10 Gacki-Smith J, Gordon E. Residents’ access to ethics consultation: knowl-edge, use, and perceptions. Acad Med 2005;80:168-75.11 Self D, Skeel J, Jecker N. A comparison of the moral reasoning of physi-cians and clinical medical ethicists. Acad Med 1993;68:852-5.12 Slowther A, Bunch C, Woolnough B, Hope T. Clinical ethics supportservices in the UK: an investigation of the current provision of ethics sup-port to health professionals in the UK. J Med Ethics 2001;27:i2-i8.Children with psychiatric disorders and learningdisabilitiesTheir needs extend beyond the provisions in national service frameworkGlobal learning disabilities, or mental retarda-tion as it is still referred to in the InternationalClassification of Diseases, occur in at least 3% ofthe population. Classification systems vary in terminol-ogy, but most distinguish on the basis of the severity ofthe learning disability. In the United Kingdom,children with milder degrees of learning disabilities arelikely to be educated in mainstream schools and areoften physically well. Children with more severe learn-ing disabilities may attend special schools andfrequently have associated medical disorders andsensory impairments, as either a cause or a correlate ofthe learning disabilities. Learning disabilities are lifelong and reduce life chances of employment and inde-pendent living.Psychiatric disorders are two to four times as com-mon in children with learning disabilities, with 30-50%having a mental disorder.1 While all psychiatricdisorders are over-represented in children withlearning disabilities, autism and hyperkinetic disorderare particularly increased.2 The relation betweenautism and low intelligence quotient has long beenCase example (hypothetical scenario, based onseveral real cases)A 26 year old man is run over by a truck and dies inemergency. His wife, also in her 20s, asks the doctorsto extract her dead husband’s sperm, saying that theyhave always wanted to have children and givesevidence of their treatment for infertility. Theemergency consultant calls the clinical ethicist foradvice. The legal situation is unclear. (The author’sresponse to the hypothetical case example is onbmj.com)EditorialsBMJ 2005;330:742–3742 BMJ VOLUME 330 2 APRIL 2005 bmj.comrecognised, but the eightfold increase in hyperkineticdisorder has largely gone unnoticed. In general,psychiatric disorders are also less likely to be detectedin children with learning disabilities than in the generalpopulation.Diagnostic overshadowing, or the misattributionof psychiatric symptomatology to a manifestation oflearning disabilities, is a well recognised phenomenonand can occur even with experienced mental healthworkers.3 Children are reliant on parents and otherresponsible adults for referral for possible psychiatricdisorder; it may be more difficult for carers to detectsymptoms in children who have reduced verbal com-munication. A similar challenge is posed forprofessionals where traditional psychiatric differentialdiagnosis relies on the patient’s ability to reportsubjective thoughts and experiences. Considerabledispute exists about the use of behavioural equivalentsas an alternative to direct access through language inapplying diagnostic categories.4 Whether or notbehavioural equivalents are incorporated in assess-ments, specialist skills are required to diagnose psychi-atric disorder in people with more severe learningdisabilities. The treatment of psychiatric disorders inchildren with learning disabilities may also be moresuccessful when conducted by professionals with spe-cialist skills.5The psychiatry of learning disability has alwaysbeen a neglected specialty, and the neglect is especiallytrue in child psychiatry. An unspoken view exists thatthe psychiatric treatment of children with learningdisabilities is less worth while because the effects oflong term intellectual disability compromise recovery.However, we have no evidence that children withlearning disabilities differ from children with averageability in the improvement in the quality of life theyexperience by alleviation of psychiatric disorder. Thedevelopment of equal, although differentiated, mentalhealth services for children with learning disabilitiesshould be a priority for the NHS. This aim has beenincorporated in the national service framework forchildren, where standard 9 embraces the mentalhealth needs of children and young people withdisability, along with other groups.6 In addition, stand-ard 8 focuses on the need for high quality services forchildren with disability, and standard 1 highlights theimportance of health promotion and early interven-tion.The identification and successful treatment ofpsychiatric disorders in children with learningdisabilities will require several developments notidentified in the national service framework. Firstly,the awareness needs to increase of the possibilityand manifestations of psychiatric disorder througheducation and training of the professionals whomcarers consult regularly—general practitioners,teachers, and disability social workers. Secondly, theskills shortage in the United Kingdom in psychiatryand allied health professions in the assessment andtreatment of child psychiatric disorders in childrenwith learning disabilities must be addressed.7Currently, many child and adolescent mental healthservices feel unable to evaluate or treat learningdisabilities adequately and considerable variationexists in the services offered. The national serviceframework states that disabled children should be ableto access mainstream services. Such a view ispraiseworthy, but these services need to includeadequate specialisation to meet the needs of childrenwith learning disabilities.Service infrastructure needs to support thepsychiatry of childhood learning disabilities. Integra-tion of services between child health, community pae-diatrics, and child and adolescent mental healthservices is likely to be an effective way forward and is inline with the children’s national service framework.Many children with moderate to severe learningdisabilities will have come to the attention of childhealth services; this is the group most in need ofspecialist psychiatric services.While the national service framework deliversa blueprint for what services should look like, anddelineates the responsibilities of health, education andsocial services, little attention is given to the training,research, and development required to achieve thestandards. Training requires expertise in generic childpsychiatric skills and the presentation, assessment, andtreatment of psychiatric disorder in children withlearning disabilities. Well validated instruments existto evaluate psychiatric disorder in children of averageability and in adults with learning disabilities,8 butcurrently we only have questionnaires for childrenwith learning disabilities, which are insufficient fordiagnostic purposes. Research into treatment of childpsychiatric disorders is beginning to accumulateadequate evidence. With limited exceptions,9 fewstudies consider children with learning disabilitieswho are likely to differ in their response topsychological and pharmacological interventions.Meeting the needs of children with learningdisabilities will require a comprehensive approach toincreasing awareness, enhancing professional skills,developing service infrastructure, and investing inresearch.Emily Simonoff professor of child and adolescentpsychiatryDepartment of Child and Adolescent Psychiatry, Institute ofPsychiatry, King’s College London(e.simonoff@iop.kcl.ac.uk)Competing interests: None declared.1 Dekker MC, Koot HM. DSM-IV disorders in children with borderline tomoderate intellectual disability I: Prevalence and impact. J Am Acad ChildAdolesc Psychiatry 2003;42:915-22.2 Emerson E. Prevalence of psychiatric disorders in children andadolescents with and without intellectual disabilities. J Intellectual Disabil-ity Res 2003;47:51-8.3 Reiss S, Szyszko J. Diagnostic overshadowing and professional experiencewith mentally retarded persons. Am J Mental Deficiency 1983;87:396-402.4 Royal College of Psychiatrists. Diagnostic criteria for psychiatric disorders foruse with adults with learning disabilities/mental retardation. London: Gaskell;2001.5 Lowe K, Felce D, Blackman D. Challenging behaviour: the effectiveness ofspecialist support teams. J Intellectual Disability Res 1996;40:336-47.6 Department of Health. National Service Framework for Children,2004. www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/ChildrenServicesInformation/ChildrenServicesInformationArticle/fs/en?CONTENT_ID = 4089111&chk = U8Ecln(accessed 18 Feb 05).7 Bernard SH. Mental health services for children and adolescents withlearning disabilities. Learning Disability Rev 1999;4:43-6.8 Moss S, Prosser H, Costello H, Simpson N, Patel P, Rowe S, et al. Reliabil-ity and validity of the PAS-ADD checklist for detecting psychiatric disor-ders in adults with intellectual disability. J Intellect Disability Res 1998;42:173-83.9 Aman MG, Buican B, Arnold LE. Methylphenidate treatment in childrenwith borderline IQ and mental retardation: analysis of three aggregatedstudies. J Child Adolesc Psychopharmacol 2003;13:29-40.Editorials743BMJ VOLUME 330 2 APRIL 2005 bmj.com

Children with psychiatric disorders and learning disabilities - Their needs extend beyond the provisions in national service framework

Emily Simonoff

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