By Madeleine McMurray
Mental illness is a global concern – it does not discriminate, and anyone can develop a mental illness at any point in their life. Recent research undertaken in Kenya has evidenced the problematic situation in the country – with mental health conditions on the rise and insufficient services to deal with those who are suffering. This is leading to millions of Kenyans struggling in silence, with nowhere to turn, and no way to help themselves.
For the children we care for – those with a wide range of disabilities – mental illness is a particular concern. First, many disabilities come with an increased likelihood of developing a mental health condition – certain mental health disorders are found at a much higher rate in certain disabilities or impairments. Additionally, mental health research is primarily conducted on individuals without special needs – this means that mental health research for people with disabilities is lacking, and the interventions developed can be less effective.
Another issue facing many children with disabilities is something called diagnostic overshadowing – this is where symptoms indicative of mental illness are missed because they are interpreted as symptoms inherent within the child’s disability. An example of this might be increased fatigue for a child with Cerebral Palsy being attributed to the disability, rather than potentially being a symptom of depression. Similarly, a child with an Autism Spectrum Disorder might have symptoms of anxiety missed, because the doctor attributes certain behaviours of anxiety (aggression, rigidity, repetitive behaviours) as solely being attributable to autism.
Autism Spectrum Disorder (ASD)
For people living with ASD, mental health is a serious concern, but it is an issue that is often missed. Due to the varied and atypical presentation, sometimes it is difficult to determine what is a symptom of mental illness and what is a reflection of ASD. As such, children with ASD do not get the treatment they need, and their mental health concerns are left to deepen and worsen over time. Common co-occurring mental health conditions include:
- Anxiety: Compared to roughly 15% of the general population, some form of anxiety has been evidenced in up to 84% of individuals with ASD. Anxiety is more common in children with ASD because they are much more vulnerable to stress – a reliance on routine and order means that there is an exponentially greater number of situations that could induce anxiety. Additionally, research indicates that differences in brain structure contribute to the biological origins of anxiety, origins that are exacerbated by environmental factors increasing symptoms of anxiety.
- Depression: Depression is slightly more common in individuals with ASD than the general population. Depression is more likely in those struggling with anxiety, and – as mentioned previously – anxiety occurs at a significantly higher rate for those on the spectrum. Depression may occur as a result of feeling alienated by their peers or feeling misunderstood by everyone around them, and it can be exacerbated by an inability to label the feelings or communicate the symptoms that occur from depression.
- Obsessive-Compulsive Disorder (OCD): OCD is a specific anxiety disorder, and it shares a significant overlap with some symptoms that occur in ASD. Repetitive behaviours (ASD) and rituals (OCD) can look a lot alike, and the difficulty experienced when those behaviours or rituals are not adhered to induce a comparative level of anxiety and trauma. Research suggests that people with ASD are two times more likely to develop an anxiety disorder in their adult life, where individuals with OCD are four times as likely as the general population to receive an ASD diagnosis.
Children with Down’s Syndrome are born with extra genetic material, and it is this genetic material that causes many health conditions. For children and adults with Down’s Syndrome, there is a 50% likelihood that they will develop a significant mental health impairment at some point during their life – this likelihood increases as the amount of co-occurring medical conditions do.
- Depression: According to a 2015 systematic review, individuals with Down’s Syndrome were more likely to experience depression comparative to both individuals with other learning disabilities. Communication issues and a lack of quality diagnostic tools developed for individuals with Down’s Syndrome means that depression can often go unnoticed and untreated.
- Anxiety Disorders: Individuals with Down’s Syndrome have an increased risk for OCD and other Anxiety Disorders at several developmental stages. Children and adults with Down’s Syndrome have been shown to have increased levels of baseline and situational anxiety, so their anxiety levels are generally elevated, and this elevation is exacerbated by vulnerability to environmental triggers.
- Dementia: In later life, individuals with Down’s Syndrome face a significantly increased risk for developing a variation of Dementia that is comparative to Alzheimer’s disease – 30% of those in their 50s and 50% of people in their 60s develop Alzheimer’s dementia. It is believed that this elevated risk – along with a multitude of other health concerns – is an outcome of the extra genes present in people with Down’s Syndrome.
Mental and physical health have a reciprocal relationship – poor physical health conditions lead to increased mental health impairment; similarly, increased mental illness results in decreased physical health overall. Young children with Cerebral Palsy are more vulnerable to developing mental health conditions like anxiety and depression, because they face higher rates of stress, are more likely to struggle with chronic pain and fatigue, and they are not being equipped with the coping skills they need to navigate the specific transitional struggles they face at certain developmental stages.
Unlike the above disabilities, hearing impairments are pretty unitary disabilities – symptomatically they relate mostly to the physical symptom of impaired hearing or total loss of hearing. This means it is easier to discern mental health issues in children with hearing impairment, because there aren’t as many symptoms to complicate a diagnosis.
- Depression: For children with hearing loss, communication and socialisation can be difficult when they aren’t in a situation with other hearing-impaired individuals. Research has indicated a significant association between hearing impairment and moderate to severe depression, and this may stem from the isolation that occurs from being unable to communicate with those around you. It is easy for children with hearing loss to feel left out from a world that does not include them, a world where they cannot hear the people they are surrounded by.
- Anxiety: Anxiety is more common in hearing-impaired populations compared to the general population, and it increases as the severity of the impairment does. It is easy to understand why this might be – removal of one of the senses a majority of people use to navigate the world is inherently anxiety-inducing, you face a significant disadvantage and are less able to notice potential threats.
- Psychosis: Research suggests that hearing impairments come with an associated risk of developing psychosis – hearing loss in the early years corresponds with an increased possibility of schizophrenia later on. Problematically, very little is known about the relationship between hearing impairment and psychosis. One perspective is that hallucinations and delusions stem from a misinterpretation of an individual’s environment – without sound, the social environment is less easy to understand, so the person’s brain may potentially try and fill in the gaps themselves.
The above are just a few examples of disabilities that increase problematic mental health outcomes. In reality, a majority of disabilities come with an associated risk of an increased likelihood of mental illness. Why?
Many children with disabilities, especially in some contexts, are isolated. They are not understood by the people around them, they find it harder to make and maintain friendships with peers who are not like them, or they are treated as an outsider because of their disability. Social isolation comes with a significantly increased risk for negative mental health outcomes, and it can lead to damaged self-esteem, which itself exacerbates the potential for mental illness.
Trauma and Abuse
In our previous blog, we explored the increased rates of abuse faced by children with disabilities. The devastating fact is that children with many types of disabilities are significantly more likely to face trauma in their young life, instances of trauma and ongoing abuse set the foundation for pervasive mental health problems later in life.
Pain and Fatigue
Many chronic physical, and some intellectual, impairments come with increased chronic pain (i.e. Cerebral Palsy) or fatigue (i.e. Down’s Syndrome). Problematically, both pain and fatigue make an individual more vulnerable to stressors and less able to cope with difficult situations, situations that are more likely to occur for them as a result of their disability.
It is essential that mental health research increases its inclusivity – both extending outwards into other geographical contexts and by including a more diverse range of people in the research undertaken. In doing this, we can ensure that those who live their life with a disability have specialised diagnostic tools and interventions that are developed uniquely for them.
For children with disability, so much of their lived experience comes with extra challenges attached – it is our duty to alleviate some of these problems and to empower children with disabilies, so that they can achieve their unique potential.
Madeleine McMurray has a BA in Liberal Arts from Leiden University and an MSc in Psychology from the University of Nottingham. She has a heart for mental health and disability in developing contexts and she spent the past year interning at two organisations in East Africa. Madeleine currently divides her time at home in England between assisting Kuhenza (Kenya) and EMFERD (Tanzania) on their communications and data analysis.