Intended for healthcare professionals


People with intellectual disabilities

BMJ 2004; 329 doi: (Published 19 August 2004) Cite this as: BMJ 2004;329:414

Unidentified emotional needs of children with intellectual disabilities

Editor—This communication in response to the recent editorial by
Sally-Ann Cooper, Craig Melville and Jillian Morrison on people with
intellectual disability and health inequality (1).

Cooper et al write that, “ The amount of evidence relating to people
with intellectual disabilities is less than other groups” and “High
quality research needs to be supported to develop the evidence base.”

In recent years we have been flooded with dozens of health policy
documents highlighting the needs of children with intellectual
disabilities. Although these documents recognise that the physical and
emotional needs of these children are different from the rest of the
population yet little is known about the emotional and behavioural
problems in this deprived and disadvantaged group. Sub average
intelligence (intellectual disability) has traditionally been used as
exclusion criteria in most research studies. Neither the ICD-10
(International Classification of Diseases 10th revision) nor the DSM-IV
(Diagnostic Statistical Manual of Mental Disorders, fourth edition) give
adequate consideration to the diagnosis of psychiatric disorders in
children with intellectual disabilities. At one time, clinical lore
believed that children with intellectual disabilities did not suffer from
behavioural problems and that any inappropriate behaviour they displayed
was secondary to their mental handicap. This view is not supported by
current evidence and recent studies have shown that these children are
prone to emotional and behavioural problems (2). But often they are
underdiagnosed due to issues such as “diagnostic overshadowing”, the
tendency of clinicians to overlook additional psychiatric diagnosis once a
diagnosis of intellectual disability is made (3); or “masking” in which
the clinical characteristics of emotional and behavioural problems are
masked by a cognitive, language or speech deficit (4).

While available evidence suggests that emotional and behavioural
problems are more common among children with intellectual disabilities,
research has been hindered, as most studies in this group of children do
not use standardised diagnostic interviews and criteria. Also this sub-
group of children are excluded from virtually all aetiological and
treatment studies. This has ethical implications as not much is known
about the diagnosis and treatment in this group of children and hence they
are frequently undiagnosed and untreated.

The need to prevent further inequalities to these children is
important. Unfortunately most funding bodies and ethic committees are
reluctant to support research in children with intellectual disabilities
but attempts need to be made to promote high quality research in this
disadvantaged group.


1. Cooper A-A, Melville C, Morrison J. People with intellectual
disabilities. Their health needs differ and need to be recognised and met.
BMJ 2004; 329:414-5.

2. Dekker MC, Koot HM. DSM-IV Disorders in children with borderline to
moderate intellectual disability. I: Prevalence and impact. Journal of
American Academy of Child and Adolescent Psychiatry 2003; 42(8): 915-922.

3. Reiss S, Levitan G, Szysko J. Emotional disturbance and mental
retardation: Diagnostic overshadowing. American Journal of Mental
Deficiency 1982; 86:567-574.

4. Fuller CG, Sabatino DA. Diagnosis and treatment considerations with
comorbid developmentally disabled populations. Journal of Clinical
Psychology 1998; 54(1): 1-10.

Competing interests:
None declared

Competing interests: No competing interests

24 August 2004
Alka S Ahuja
Specialist Registrar in Child & Adolescent Psychiatry
University Hospital of Wales, Cardiff CF14 4XN