Hong Kong J Psychiatry 2001;11(1):21-24


The provision of specialized psychiatric services for people with learning disability (mental retardation) in Hong Kong

HWM Kwok

pdf Full Paper in PDF


Prevalence studies have indicated that people with learning disability (mental retardation) are at significantly higher risk of developing psychiatric and behavioural disorders. This is one of the main reasons for the failure of community placements. With the promotion of the concept of normalisation and integration, patients’ mental health needs are increasingly acknowledged by our community. This paper focuses on the development and provision of specialised psychiatric services for people with the dual diagnosis of learning disability and psychiatric problems. The models of service delivery and resource implications are discussed, with overseas figures quoted for reference. A hospital-based system with multidisciplinary input and strong community ramifications is recommended for the local setting in Hong Kong.

Key words: Community, Learning disability, Psychiatric service


History tells us that the ‘medicalisation’ of learning disability (mental retardation) probably started as early as the 17th century, and ‘psychiatrisation’ by the 19th century.1 However, most psychiatrists later lost interest in this field and learning disability almost disappeared from the psychiatric scene. This was partly due to the therapeutic pessimism that followed the developments in neuropathology which saw learning disability as an incurable brain disorder and partly due to the domination in psychiatry by psychoanalysis that saw normal intellectual and language abilities as a prerequisite to successful treatment. As a result, the progress in this branch of psychiatry was slow until the past 2 to 3 decades when there was a reactivation of psychiatric enthusiasm in this area.

The resurgence of interest is firstly attributed to the general recognition of the right of people with learning disability to appropriate care in both physical and mental health. Secondly, the concept of normalisation has become widely accepted. People with learning disability are expected to live in the community and to use community facilities. Poor mental state is one of the major reasons for the failure of their integration into the community and this could mean further rejection and social discrimination. At the same time, the role of psychiatrists has also changed dramatically during the past 20 years, from simply making the diagnosis and the administration of residential facilities to more active and direct clinical involvement, including the treatment of psychiatric and behavioural disorders, promotion of mental health, family intervention and contribution to planning and management of services.


Individuals with lear ning disability are at higher risk of developing mental health problems. There are many factors to account for this increased vulnerability, including:

  • Brain damage resulting in learning disability may also predispose the individual to mental disorder.
  • Some syndromes are known to be associated with behavioural abnor malities and psychopathology. For example, Down’s syndrome has been associated with early onset of Alzheimer’s disease and Lesch-Nyhan syndrome is associated with self-injurious behaviours.
  • Low self-image and chronic frustration caused by repeated failures and multiple disabilities.
  • Limited repertoire of coping strategies and defence mechanisms.
  • Stigmatisation, rejection, and social isolation.
  • Inappropriate expectation, and inconsistent care or overprotection by multiple carers.
  • Poor access to community resources resulting in a restricted and disadvantaged lifestyle.


People with learning disability are growing in number. Children who might have died in infancy now survive to adulthood, and adults are living longer because of better living conditions and more advanced health care. Although early mortality is still a feature of many who are more severely disabled, those who are less impaired have a life expectancy near that of the general population

In Hong Kong, no survey has been conducted to find out the number of people with learning disability in our population so overseas prevalence rates are used to estimate the local incidence. According to government statistics, there were approximately 125,327 persons with learning disability in Hong Kong in 1998 (Table 1).2

The prevalence of psychiatric problems according to the studies varies enormously depending on the exact assessment procedure, the sample selection, the definition of mental disorder, and whether severely retarded people were included. Review of the literature found a prevalence rate ranging from 13 to 58% (Table 2). Menolascino used the term ‘dual diagnosis’ to refer to this group of people with both learning disability and psychiatric disorders.3


It has become increasingly clear that generic psychiatric services cannot satisfactorily meet the complex needs of people with a dual diagnosis.12,13 These patients do not mix well with other mentally ill patients and are vulnerable and generally disadvantaged in such settings. The pace of ward life is too fast for them and it is difficult to provide therapeutic interventions because of their different level of competence.

On the other hand, special knowledge and skills are required for the accurate diagnosis of mental illness in people with learning disability because of their different presentations or communication difficulties. The physical environment of the ward should not be the same as the general psychiatric wards and extra facilities for time-out and sensory stimulation are necessary to meet their special needs. Therapeutic processes also require modification to take into account of their intellectual limitation. Staff should be familiar with co- existing physical disabilities and conditions such as epilepsy, which often complicate learning disability. There should be no doubt that specialised services increase staff competence and skills, bring benefits of cumulative experience, accept ‘ownership’ of the task in hand, and increase the probability of effective and successful treatment.14 The Royal College of Psychiatrists has strongly emphasised the need for specialist psychiatric services for adults and young people with learning disability.15 An in depth review of the service needs of people with learning disability by a study team of the Department of Health of the British Government also concluded that there is a long ter m requirement for specialist mental health provision and doctors specialising in the psychiatry of learning disability.16


A specialist psychiatric team should have service provisions for the following clinical groups of people with learning disability living within a defined catchment area:

  • Those having super-added mental illness, acute and chronic, including adjustment disorder, neurotic problems, psychotic disorders, and personality problems.
  • Those with challenging behaviours: behaviours of such an intensity, frequency, or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities.12
  • Those who offend against the law.
  • Those with brain damage, epilepsy, or other associated physical handicaps resulting in poor social adaptation, and at risk of developing psychiatric problems

Apart from the full range of formal psychiatric treatment, intervention programmes should also include opportunities for social skills and vocational training, further education, and recreational activities whenever necessary.

How such specialist psychiatric services are best delivered to target patients remains a matter of discussion. Over the years, a variety of models have been developed. They can broadly be divided into hospital- and community-based services. The former17 emphasises the need for specialist inpatient facilities whereas the latter18 utilises beds in generic psychiatric units for inpatient treatment and focuses more on home-based intervention in the community.

Advantages of a hospital-based service include ability to provide close observation, thorough assessment, intensive therapeutic programmes, and an ability to cope with a high level of disturbed and violent behaviours. Resources and facilities can be used more efficiently and may be tailored to match patient needs, e.g. time-out rooms and durable furni- ture. Staff training, support, and supervision can all be made easier within this framework.

On the other hand, a community-based service will no doubt invest more time on people living in the community. Proponents of this model argue that patients should be treated in their own homes as far as possible. They work closely with the carers, social services, and voluntary organisations to ensure that the mental health needs of patients are met at the community level and keep the necessity for admission to hospital to a minimum.

In Hong Kong, the mental hospitals and psychiatric units are accommodating a considerable number of people with learning disability. Most of these patients have a dual diagnosis, including some serious mental illnesses and severe challenging behaviours. Our community is not yet ready to accept all of them due to inadequate social infrastructure and lack of experienced fr ont line staff. Therefore, initially. it is appropriate and logical for our services to be based at the hospital while community work should play an increasingly important role as our society matures.



In general, thresholds for admission tend to be lower than in general psychiatry because of the complex nature of this group of patients. Besides, a longer duration of stay is usually necessary because more time is needed for a comprehensive assessment and to establish a firm diagnosis. The demand for respite care beds is also expected to be higher.

In an opinion survey of the Consultant Psychiatrists working in Mental Handicap in the UK, Piachaud found that the average recommended bed ratio was 0.19 per 1,000 catchment population.19 In the USA, Menolascino proposed a similar ratio of 0.15 – 0.19 per 1,000 population based on services developed in an American project.3 Alternatively, in Day’s proposal for a comprehensive national model for the UK (Table 3), he suggested a higher ratio of 0.28 beds per 1,000 population, but this figure includes forensic beds for offenders.17,20


It is essential that specialist psychiatric services are staffed by properly trained and experienced psychiatrists, nurses, psychologists, occupational therapists, social workers, and other staff. The lack of specialist staff, particularly psychiatrists, is reported to be the major barrier to the development of this subspecialty in many countries.21

The ratio of full time consultant psychiatrists in learning disability recommended by the Royal College of Psychiatrists was one per 100,000 population.15 Their role includes the following:

  • provide medical leadership and development of services in the organisation
  • function as a clinical specialist in the recognition and treatment of mental illness and challenging behaviours in persons with learning disability
  • act as an advisor to the public and various organisations of the mental health issues of people with learning disability.
  • act as a trainer for the professional training of staff working in this subspecialty.
  • provide a contribution in academic, teaching, and research activities.

Nurses are important because they can help patients mitigate the effect of disability, achieve optimum health, develop personal autonomy, and increase participation in community life. They can also make a key contribution as managers or advisers in the construction of appropriate standards of care and support for this group of patients. They are needed not only in hospitals, but an increasing demand for their expertise will come from day centres, group homes, family homes, and other agencies. It is expected that with further development of community care, community psychiatric nurses will eventually play a major part in supporting people in the domicillary setting. The work of occupational therapists is equally important. Through their broadly based knowledge and expertise, they help their clients to function purposefully in daily life and achieve a bal- ance in personal and domestic care, leisure, and productivity.

Similar to other branches of psychiatry, it is obvious that this specialised service is multidisciplinary and all staff should receive appropriate education and training to enable them fulfil their duties and make innovative contributions. High- quality staff make for high-quality services

The staffing figures recommended for the UK and the USA are for reference only and it is unrealistic to suggest that Hong Kong establish a similar number of hospital beds and consultant posts. However, in an era when our government is actively trying to persuade and educate society to stop prejudice against the learning disabled and ex-mentally ill people, the recognition of this subspecialty is timely and justified.



Mental health problems are common among people with learning disability. The presence of concomitant severe behavioural or psychiatric disorders is one of the main reasons for the breakdown of their community placements. It is necessary to recognise at all levels of health administration and among the general public that this comorbidity is not merely a collection of special cases. In fact, they represent a sizeable, vulnerable, and notoriously underserved group that requires new initiatives in both service development and service delivery. Proper provision for these people is an essential component of a comprehensive mental health service. Arguments in favour of provision within the general psychiatric services are essentially ideological, a misinterpretation of the nor malisation philosophy, and are failing in practice.13

Specialisation is a legitimate response to special needs and it is the preferred option in many countries

An ideal psychiatric service for people with learning disability should be a comprehensive, coordinated, effective, and efficient service incorporating the principles of normalisation and integration, and delivered in ways which preserve the clients’ dignity and value as equal citizens. It should possess the multi-disciplinary skills required for assessment, diagnosis, treatment, care, and rehabilitation. Running such a service will no doubt be a great challenge for professional staff — adequate resources, manpower, and training are needed to make it successful.


  1. Berrios GE. Mental illness and mental retardation: history and concepts. In: Bouras N, editor. Mental health in mental retardation. Cambridge: Cambridge University Press; 1994;5-18.
  2. Hong Kong Government. Services for mentally handicapped persons. In: rehabilitation programme review 1994-1998. Hong Kong: Health and Welfare Branch, Government Secretariat; 1996;110-131.
  3. Menolascino FJ. Model services for treatment of the mentally retarded mentally Com Ment Health J 1989;25:145-155.
  4. Rutter M, Tizard J, Yule W, Graham P, Whitmore K. Isle of Wight studies 1964-1974. Psychol Med 1976;6:313-332.
  5. Primrose DA. A survey of 502 consecutive admissions to a sub- normality hospital from 1st Jan, 1968 to 31st Dec, 1970. Br J Ment Subnormality, 1971;17:1-4.
  6. Ballinger BR, Reid AH. Psychiatric disorder in an adult training centre and a hospital for the mentally handicapped. Psychol Med 1977;1:525-528.
  7. Corbett JA (1979). Psychiatric mobility and mental retardation. In: Psychiatric illness and mental handicap. London, Gaskell: 11-25.
  8. Lund J. The prevalence of psychiatric morbidity in mentally retarded adults. Acta Psychiatr Scand 1985;72:563-570.
  9. Day K. Psychiatric disorder in the middle-aged and elderly mentally handicapped. Br J Psychiatry 1985;147:660-667.
  10. Iverson JC, Fox RA. Prevalence of psychopathology among mentally retarded adults. Res Dev Disabilities 1989;10:77-83.
  11. Reiss S. The prevalence of dual diagnosis in community based day programmes in Chicago metropolitan area. Am J Ment Retardation 1990;94:578-585.
  12. Emerson E, Toogood A, Mansell J, et al. Challenging behaviour and community services: introduction and overview. Mental Handicap 1987;15:166-169.
  13. Day KA. Mental health services for people with mental retardation: a framework for the future. Proceedings of the Symposium of the European Association for Mental Health in Mental Retardation: the Mental Health of Europeans with Learning Disabilities; 1992, Oct 8-9; The Netherlands. J Intellect Dis Res 1993,37 (Suppl. 1): 7-16.
  14. Clements J. Units and teams: challenges in common. Mental Handi- cap 1987:113-119.
  15. Royal College of Psychiatrists. Psychiatric services for mentally handicapped adults and young people. Bull Royal College of Psych- iatrists 1986;10:321-322.
  16. Department of Health. Needs and responses: services for adults with mental handicap who are mentally ill, who have behaviour problems or who offend. Report of a Department of Health Study Team. Middlesex, UK: Department of Health; 1989.
  17. Day KA. Services for psychiatrically disordered mentally handicapped adults — a UK perspective. Aust NZ J Develop Dis 1988;14:19-25.
  18. Bouras N, Drummond C. Community psychiatric service in mental handicap. Health Trends 1989;21:72.
  19. 19. Piachaud J. Calculating the medical time required in the psychiatry of mental handicap. Psychiatr Bull 1989;13:481-489.
  20. Day K. A hospital based psychiatric unit for mentally handicapped adults. Mental Handicap, 1983;11:137-140.
  21. Dosen A. Community care for people with mental retardation in the Netherlands. Aust NZ J Develop Dis 1988;14:15-18.

Dr HWM Kwok, MB BS, MRCPSYCH (UK), FHKCPSYCH, FHKAM (Psychiatry), Senior Medical Officer, Psychiatric Unit For
Learning Disabilities, Kwai Chung Hospital, Hong Kong, China.

Address for correspondence: Dr HWM Kwok
Senior Medical Officer
Psychiatric Unit For Learning Disabilities
Kwai Chung Hospital
Hong Kong, China.

View My Stats