COMORBIDITIES

Ethnic minority groups,learning disability andmental healthIqbal Singh

Adedamola Orimalade

AbstractThe presence of a learning disability in an individual from an ethnic

minority group raises several issues that, if not recognized and

addressed, can be detrimental to the mental health of the affected indi-

vidual. Affected individuals have been said to face a double disadvan-

tage, arising from having a learning disability and being from an ethnic

minority group. This disadvantage has been largely neglected both in

terms of research and service provision. In order to cater effectively for

people with learning disabilities from ethnic minority groups, several

obstacles have to be recognized and addressed, specifically and deliber-

ately. More research is required in this area.

Keywords advocacy; Asian; cultural; ethnic minority; interpreter;

language; migration; religion

Definition of ethnic minorities

An ethnic minority group is a non-indigenous, sociological group

that does not constitute a politically dominant voting majority of

the population of a given society. With regard to the UK, clari-

fication is already needed with this definition. A sociological

minority is not necessarily a numerical minority: some ethnic

groups may be dominant numerically, but still constitute

a minority with respect to education, employment, political

power, and socio-economic status. On the other hand, some

ethnic groups in some parts of the country are the majority both

numerically and economically, so that the term ‘minority’

becomes somewhat paradoxical. Perhaps a more accurate defi-

nition is: a group that has different national or cultural traditions

from the majority of the population.

Iqbal Singh MBBS FRCPsych is Consultant Psychiatrist at Hillingdon

Hospital, and Honorary Clinical Senior Lecturer at the Imperial School of

Medicine, London, UK. His research interests include biological

psychiatry and service development. Conflicts of interest: none

declared.

Adedamola Orimalade MRCPsych is Senior Specialty Trainee in the North

London Learning Disability Psychiatry Scheme, UK. He completed his

basic psychiatry training in the Guy’s, St Thomas’ and Lewisham

rotation. His special interests are autism spectrum disorder, epilepsy,

and mental health. Conflicts of interest: none declared.

PSYCHIATRY 8:10 405

Epidemiology

A report from the Office for National Statistics in 2002 looking at

the characteristics and circumstances of the UK’s minority ethnic

groups found that the size of the minority ethnic population was

4.5 million in 2001e2002, or 7.6 per cent of the total population

of the UK. Indians were the largest minority group, followed by

Pakistanis, Black Caribbeans, Black Africans, and those of mixed

ethnic backgrounds. In England, nearly half (48 per cent) of the

total minority ethnic population lived in the London region.

The prevalence of learning difficulties in South Asians aged

between 5 and 32 years is up to three times higher than that in

other communities.1 Lower rates of prevalence in the under-5s

are likely to be a result of under-diagnosis before school incep-

tion.2 Of the South Asian families caring for family members with

learning difficulties, 19% had more than one member with

a learning difficulty. Prevalence within other minority ethnic

groups is not so well documented. Anecdotal evidence, however,

suggests a relatively high prevalence within the African Carib-

bean community too.

In the UK, there is clear evidence that people from ethnic

minority groups experience discrimination and disadvantage in

almost every aspect of their lives, including housing, employ-

ment, education, and health.3 There is also a stigma attached to

having a learning disability. Therefore, being from an ethnic

minority group and having a learning disability can mean

a double disadvantage. This could even become a triple dis-

advantage, for example with regard to gender discrimination in

certain cultures. Ethnic differences in rates of mental illness, and

access to and experience of mental health services, have been

a focus of widespread and long-standing debate and concern in

the UK. It is widely reported that black and minority ethnic

groups in England, especially African Caribbeans, have adverse

experiences of mental health services.4 It is perhaps worth noting

at this point that there has been far more research in this area

concerning South Asian communities than the African Caribbean

population.5 In addition, little information is available about the

needs of people with learning disabilities from other groups, such

as the African, Chinese, Irish, or Jewish communities, refugees or

travellers.

This article seeks to address the factors that can account for

this disadvantage, as well as ways in which it can be minimized.

Causes of disadvantage in people with learning disability from

ethnic minority groups

Cultural and religious attitudes

Cultural and religious attitudes are important in how care is

sought, delivered and accepted. In a study by Fatimilehin and

Nardishaw,6 several differences in culture and attitude were

reported between South Asian and white English families. South

Asian families were less aware of what their child’s problem was

called and believed in a spiritual explanation or cause for their

child’s learning disability. They had more contact with a ‘holy’

person and believed that religion had something particular to say

about learning disability. Some 50% said that they did not know

the cause of their child’s learning disability. Their faith helped

them to cope but offered little social or practical support. They

wanted care to be provided by a relative when they were no

longer able to provide it themselves.

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COMORBIDITIES

This was in contrast to white British families, most of whom

received a medical explanation for their child’s disability without

offering a spiritual explanation for it. Only one family felt that

they did not know the cause of the child’s learning disability.

Religion or faith provided social support, and most wanted their

child to be cared for in a community home provided by statutory

or voluntary services.

There is also a belief amongst several ethnic minority cultures

that learning disability can be cured, and families tend to favour

keeping children at home rather than in independent or resi-

dential living. Living at home with the family, although to be

encouraged, can sometimes result in excessive levels of carer

burden, ultimately impacting upon the quality of life of the

person with a learning disability. In addition, racial or ethnic

differences in service use may arise in part from different

propensities to interpret emotional symptoms as reflecting one’s

mental health and then to seek professional intervention for

emotional problems.7

Ethnic and racial identity

People with learning disabilities and their families from ethnic

communities have a strong sense of racial and ethnic identity.

This experience can sometimes clash with the prevailing culture

existent in most services in the UK. Components of this identity

include dress, hair and skin care, personal hygiene, and food.

The younger generation, especially those born in the UK, might

hold less firmly to these practices, for example arranged

marriages, gender roles, and taboos. The Forced Marriage (Civil

Protection) Act 2007 aimed to protect vulnerable people from

being forced into arranged marriages.

A lack of sensitivity to and provision for issues of ethnic

identity such as food, gender roles, and taboos can lead to

Important factors to consider in services for ethnicminority groups

C Culturally sensitive advocacy

C Ensure good publicity of services to ethnic minority

communities

C Ensure staff are well trained in cultural, ethnicity, and diversity

issues

C Recognize the impact of racism and stigma in person-centred

planning

C Development of single-culture facilities, including self-help

groups, in-patient and residential facilities, etc.

C Development of same-gender facilities, especially female

facilities

C Recruitment of staff from ethnic minority groups at all levels

C Focus on housing, employment, and placement opportunities

within the ethnic minority community

C Increased research in the area of learning disability and

ethnicity

C Liaison with agencies and communities, including those

abroad, that have a cultural focus

Box 1

PSYCHIATRY 8:10 406

placement breakdowns. This is commonly found when people

are placed out of borough and far from their ethnic communities.

Racism and stigma

The stigma of learning disability can be profound in any culture,

but can be even more so in several ethnic minority communities

in the UK.8 There is a fear of rejection of the individual within the

family as well as a rejection of the family with the child(ren) with

learning disabilities. The resulting alienation can be a factor in

the perpetuation of mental illnesses, including depression and

psychosis.

Direct racial attacks are less common and important than

what is described as ‘institutional racism’. This manifests itself in

perceived discrimination in interpersonal communication and

inequity in the receipt of services and justice.9

Issues specific to immigration

In the first place, migration to the UK is a stressful life event

that can trigger episodes of mental illness in an individual with

a learning disability, whether the migration was forced or

voluntary. Depending on the age of the individual upon

migration, there is the effect of the uprooting of meaning, with

disruption of lifelong attachments and external stability.10

There is also a paucity of high-quality medical records, if any at

all, from some of the countries of origin of the affected

individuals.

The language barrier

This factor represents one of the most important hindrances to

effective and high-quality service provision for people with

learning disabilities from ethnic minority groups. Many speak

very little English, if any at all. This makes assessment of prob-

lems and needs very difficult. It raises the issue of interpreters

and their own inherent problems (no skills with learning-

disabled people, getting information second hand from the

interpreter, etc.).11 Stereotyped assumptions may result, with

some practitioners having low expectations of language devel-

opment in South Asian children, for example, which affects the

children’s ability to benefit from speech therapy.12

Advocacy

The government White Paper Valuing People highlights advocacy

as one of the ways by which people with learning disabilities

could access more choice and control in their lives.13 It recom-

mends that individuals should choose which kind of advocacy

best suits their needs. However, people from black and minority

ethnic communities are not well served by current provision of

mental health advocacy.14 In particular, this has been the finding

in people with learning disabilities from ethnic minority groups,

where there is a lack of culturally sensitive advocacy.

Better services for ethnic minority groups

Taking into account the factors accounting for a ‘double dis-

advantage’ for people from ethnic minorities with a learning

disability, services ought to be planned and delivered with

cultural sensitivity in mind e achieving so called ‘cultural

competence’.10 Box 1 provides a summary of the important

factors to consider. A

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COMORBIDITIES

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