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Author(s): |
Elizabeth Campbell |
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Reprinted with Permission From: |
Learning Disabilites Association of America (info) |
Printed Date: May 1999
Date Posted on this Website: June 11 2002
There's an issue so obvious that it doesn't get discussed enough. I wish to address here the concurrence of adult learning disabilities and clinical depression. Though I'm talking mainly here to those involved in delivering services to these folks; it's relevant to persons with learning disabilities themselves and their families.
What can the specialist do to assist adults with learning disabilities who are entangled in depression? What if, further, this interaction appears to be affecting vocational or academic adjustment and life success? Related questions include, How do we know when to involve other service providers, such as physicians and mental health professionals? How should learning disabilities experts establish the boundaries of their abilities and/or responsibilities for meeting the needs of adults with learning disabilities adequately?
Nick's Story
Nick is a college student who tells his story. I've struggled with learning disabilities all my life. Now I find that getting through college is a nightmare. I'm one of six children, four of whom have had problems with learning. My parents divorced when I was five, just starting my formal schooling. I can't say I even missed my dad. He'd never been around much anyhow. All the time I was growing up, we were constantly moving from one place to the other. I never started a second year in the same school. Nick battles a classic potpourri of learning disability characteristics. He focuses on facts at the expense of the overall picture, processes slowly, concentrates badly, perseverates, going over and over material in order to learn it, labors long and hard with poor results, learns patterns weakly, distinguishes differences with difficulty, recognizes symbols intermittently, and fears tests.
He continues his story. In high school, with my miserable reading I just couldn't cut the mustard. So I dropped out to go to technical school. Even though I liked the hands-on approach there, the training didn't really challenge me. Worse, it didn't lead to a well paying job. I have a family now, premature twins with lots of expensive medical problems. The stress has been terrible! I find myself short tempered, even yelling. I walk around blaming everyone and everything. Since my mother-in-law's recent death, I've been even worse. I'm forgetful, absent minded, and testy. I'm like my mom. She gets down and frustrated all the time the way I do.
The feelings he describes are many: discouragement, anger, pessimism, humiliation, disappointment, guilt, worthlessness, and inadequacy. An evaluation easily confirmed Nick's learning disabilities. Wait a minute, though! What about the obvious symptoms of depression? Two things:
Learning Disabilities - Depression
Notice how the two lists relate. Which is the Chicken and which is the Egg? Can we say one is primary? Suppose we start with learning disabilities. Nick probably has familial incapacities. He has processing issues. His narrow, rigid, molasses-slow perceptual procedures and laggard thinking, coupled with comprehension and memory difficulties, could easily cause pronounced and chronic stress. This, in turn, could operate on his mood, causing him to be pent-up and heartsick. Feelings would trigger coping strategies, such as acting out with anger and blame or holding in with anxiety and despondency. These tactics are commonly associated with major depression.
Or suppose we start with the depressive symptoms. He's stressed and grieving. He reacts with sorrow, disappointment, guilt, humiliation, discouragement, frustration, and pessimism. He then responds by lashing out with anger, shortness, and blame. He implodes with absentmindedness, forgetfulness, poor focus, perseverative fretting, narrowed perceptions, torpidity, bewilderment, and fear.
Depression occupies, by far, the largest piece of the psychopathology pie. We have to realize that depression is a generic term that includes a lot of different kinds of emotional malfunctioning. Like pain or disease, it comes in all shapes, degrees, perversities, and durations. Some depression comes and stays. We call it Dysthymia. Some comes with such intensity and suddenless that it strikes like an illness, totally flattening us: Major Depressive Disorder. Some oscillates with tornadoes of mania, followed by utter desolation: Bipolar Disease. Other times it rears its head as the kinds of moody ups and downs that keep us in the alert never knowing how or when it will strike: Cyclothyrnia. It's been twinned with medical conditions since prehistoric times. It can occur as a result of the very healing regimen prescribed to regulate or alleviate some other condition, latrogenia. And it can be the spouse of insanity. It's always associated with some sort of brain chemistry imbalance, but we can no more say that is its cause, than we can say learning disabilities is its root, or it precipitates learning disabilities.
There's all sorts of research in the field to suggest and support the concomitance of learning disabilities and mental health problems. Several recent studies show that 50% of individuals diagnosed with learning disabilities have scores above the clinical range on a well known depression scale. One thing we know is that attentional problems are a common feature of both. Another study summary says, Teachers have long known and reported that students with learning disabilities at lower educational levels have similar but more, and more severe, depression, than their peers without learning disabilities. There's no reason to think this link disappears with age. In fact, it becomes more urgent. And the stakes are higher. Failure to remediate at this adult stage has more serious consequences.
We act as whole beings. When something affects us, it spills over into every portion of our lives. What psychology has learned about development tells us that life gets more demanding, speeds up, and becomes more complex as we mature. What wasn't mastered earlier compromises our functioning. Nick now has adult commitments. With his sluggish and narrowed perceptions, he's challenged to attain intimacy when he isn't yet truly independent to parent challenged preschoolers when he hasn't met his own developmental tasks; while surfeited with relationship loss, to face one more; to display competency without the skills to do so. He's on a razor's edge. We can't help Nick without addressing both sides of the coin. He has complex multiple learning disabilities interacting with a depressive disorder.
What can the specialist do who works with an adult like Nick? Trained to deal with the education side, we overlook the obvious melancholic millstone he carries. Even if we suspect its presence, we aren't trained to do anything about it. How do we know it's depression? When and how do we involve other service providers who would know what to do? How would we go about referring Nick for these services? How do we communicate with these professionals once they're on board? How would we intervene as a team? What are the procedures we need to explicate in order to get that done? What are the boundaries of our expertise and responsibilities? How do we figure out how all this applies to Nick's learning and life adjustment?
The minimal first step is triangular, I believe. First, we can include a simple depression screening in our intake and/or evalu- ation forms. Next, we can raise awareness through inservice for learning disability specialists and clinic personnel to raise aware- ness that depression more often than not partners adult learning disabilities.
More complex but even better is to involve mental health professionals as a part of our treatment. This could be a loose association with a public clinic or college counseling department. In this instance, we would make referrals. We could request that these professionals educate themselves in the characteristics of learning disabilities and agree to report back pertinent information to us. Best of all we could actually create a specialized, mul- tispecialty team. Nick would, of course, be part of it.
Physician Referral
A great idea, but suppose there's no help available? What's a learning disability specialist to do? Fortunately, like learning disabilities, depression is a chemical disorder. Unlike learning disabilities, though, there's medicine that will help, if not cure it. Talk with Nick about going to his medical doctor. You can leave it at that, assuming the physician will take over from there.
Personal Plan
Another way to go is to make a plan for ourselves: How will I go about linking Nick to appropriate services? First, you can make sure you know what and where the resources are. Besides Division of Rehabilitation Services and Mental Health Clinics, we must build a file of contacts, phone numbers, services, and specialties. We can emphasize those who have experience in working with adults with learning disabilities. Second, we need to personally consult beforehand (even in a crisis situation) with the provider. We can talk about the possible referral, what is needed, and what can be offered. Third, we should prepare Nick for the referral. At this point we're specific and honest with our reasons for suggesting this plan. Fourth, we may need to coach Nick in how to self-advocate and set goals for himself. Fifth, we need to follow up with Nick (and the professional, if appropriate).
Steps in Conducting a Simple Referral. Identify resources; select and consult with provider; coach the adult for effectiveness; discuss the referral with the adult.
Guidelines. It's important to develop guidelines or policies that address how and under what circumstances we would handle the depression of adults like Nick. These can be solely for the learning disability specialist. If possible., though, they should be done institutionally. Where does our responsibility begin and end? This should involve a code of ethics, even if only an unofficial one.
Training.It's important to find pre and inservice training. At minimum it can be a personal reading plan. A step-up would be attending special workshops. We could even take courses. We can be a cheerleader for others to attend, including Nick. The more we know, the more effective we can be. This is true whether we're cooperating with others or acting alone.
Materials. We can also campaign for more materials to be developed, used, and evaluated in this arena. We can beg, demand, or solicit coursework at the college level to train and sensitize others who interact daily with adults with learning disabilities and depression.
Research. We must take the plunge. Conduct some research on our own about this coupling. First of all, we don't know enough about adult learning disabilities. Even worse, we have a great scarcity of knowledge about how depression interacts with learning disabilities in adulthood. Even simple surveys, informal interviews, or concomitance incidence information would add greatly to our knowledge.
Support Groups. We need to sponsor, encourage, and promote support groups with a focus on handling depression, that handmaiden of adult learning disabilities.
Feedback. We need to solicit feedback, whenever possible from adults with learning disabilities and depression. These people can tell us which resources, techniques, coping skills, materials, supports, and experiences have been most effective in meeting their needs.
In conclusion: From every comer of our field, literature, clinical experience, and individual reports, it's clear that depression significantly affects the lives of adults, like Nick, with learning disabilities. It's important for professionals who work with them to become aware of this fact. What are the implications? How can we address them? Depression/learning disabilities is a complex interaction. It is intertwined with their academic, personal, vocational lives. Mental health and/or medical professionals and learning disabilities service providers need to work together to provide support and guidance for these individuals. We need to think holistically. Addressing learning disabilities without treating the depression can become an exercise in frustration. The opposite is just as true. Treating the depression without concern for the learning disabilities can be ineffective. We must treat both conditions simultaneously. Easier said than done. It will require significant changes in the way we serve the depressive adult with learning disabilities.
