The RCPsych Article of the Month for June is ‘Psychological interventions for depression in children and young people with an intellectual disability and/or autism: systematic review’ and the blog is written by authors Richard Hastings and Kylie Gray published in BJPsych.

Fortunately, we have moved on from a time when individuals with intellectual disability may have been considered incapable of experiencing mental health problems. However, in the context of current talk about mental health crises, the mental health of children and young people with intellectual disability is perhaps the biggest crisis of them all. Children with intellectual disability face a quadruple inequality in relation to their mental health.

First, children and adolescents with intellectual disability have 4-5 times the rates of mental health problems compared to other children. One in seven of the population of children with mental health problems will also have an intellectual disability.

Second, there is a lack of tools to assess and identify mental health problems in children and young people with intellectual disability; especially for those with more severe intellectual disability. Identification is a key step on the pathway to treatment and support. Without effective screening and diagnostic tools, there is an inequality in the identification of the mental health needs of children with intellectual disability.

Third, families of children with intellectual disability who have mental health problems report considerable challenges accessing mental health services. Only 28% of children with intellectual disability and mental health problems in our research had access to specialist mental health services in the preceding 12 months.

This triple inequality in experience of mental health problems, identification of mental health problems, and problems accessing services and supports is considerable. However, it is further compounded by a general lack of, and lack of high quality, evidence for effective intervention approaches. With a focus on psychological interventions for depression, our systematic review in the British Journal of Psychiatry this month found only 10 studies internationally, with no Randomised Controlled Trials, and with moderate to high risk of bias across all studies. Compared to the evidence base for children and young people in general, this represents a dire and stark evidence inequality. For children with more severe intellectual disability, this inequality is even worse with essentially no evidence for effective mental health treatments.

More research across all four fronts is clearly needed. It is also important to ask whether the lack of evidence in relation to effective psychological interventions matters. We argue that the answer is a clear Yes. The cognitive, communication, and social needs of children with intellectual disability mean that at the very least adjustments and adaptations to psychological interventions are needed. For children with severe to profound intellectual disability, creative and quite different solutions for psychological support are needed. Without an urgent effort to develop and robustly test such adapted or bespoke interventions, children with intellectual disability will continue to experience mental health inequalities.

‘Some areas in mental health deserve particular support and research funding. Rates of depression are almost twice as high in children and adolescents with intellectual disabilities and autism spectrum disorders (ASD). As for everyone else, guidelines recommend talking therapies as an initial intervention: the problems are that the specific evidence base for this is far sparser for these populations, and historical practice has relied more on medication. Cameron et al (pp. 305– 314) systematically review the best current data, identifying ten relevant studies. However, ‘best current data’ are not as good as we might hope for: four were case reports, and six were quasi-experimental – all had moderate to high risk of bias. The authors rightly note that we need randomised controlled trials in these more vulnerable groups of young people, particularly evaluating any adaptations and specific tailoring of therapy. They also highlighted the current lack of exploration of the experiences of those with intellectual disabilities and ASD undergoing therapy, as well as those of their families and therapists.’

Dr Derek Tracy,

Editor for Public Engagement and Education, BJPsych