Disability as a Risk Factor for Mental Health Difficulties

In 2003, approximately one in twelve Australian children (8.3%) aged up to 14 years old had a disability; of these, 89% were educated full time or close to full time in mainstream schools, including in special classes and mainstream classes, with or without additional support. Around 63% of these children experienced difficulty at school, most commonly intellectual or learning difficulties, fitting in socially, and communication difficulties (Australian Institute of Health and Welfare, 2006). This figure does not include students with identified learning disabilities or difficulties such as dyslexia, dyscalculia or non-verbal learning disability who do not meet the eligibility criteria for disability support in most Australian school systems. Depending on the definition applied, estimates of students with learning disabilities or specific learning difficulties range from 10% to 25% (Westwood, Reference Westwood2011). One in seven Australian children are affected by behavioural and emotional problems (Bayer et al., Reference Bayer, Hiscock, Scalzo, Mathers, McDonald, Morris, Birdseye and Wake2009). Worldwide, around 25% of school-aged children are estimated to experience some mental health difficulties, and approximately 10% meet criteria for a mental illness (Weare & Nind, Reference Weare and Nind2011).

As data are collected and described in different ways and based on varied definitions, ascertaining accurate prevalence rates of mental health difficulties for students with disabilities is not straightforward. Issues related to assessing mental health difficulties in individuals with intellectual disabilities and communication difficulties also pose a challenge. However, data from multiple sources concur that prevalence rates are higher for individuals with disabilities than for the general population. A recent evaluation of the KidsMatter Primary Mental Health Initiative in South Australian schools reported that students with a diagnosed disability have a one in three chance of experiencing mental health problems, compared to a one in eight chance for students without a disability; for students with more than one disability, this risk increases to one in two (Dix, Shearer, Slee, & Butcher, Reference Dix, Shearer, Slee and Butcher2010). Other estimates of the prevalence of mental health difficulties in school children with disabilities range from 40% to 60% (MAC: SWD, 2007). Research into specific disability groups suggest prevalence rates within that range for those with, for example, intellectual disability (AIHW, 2008; Einfeld & Tonge, Reference Einfeld and Tonge1996; Torr, Iacono, Graham, & Galea, Reference Torr, Iacono, Graham and Galea2008), autism spectrum disorders (e.g., Davies, Reference Davies2005; Ghaziudden, Ghaziudden, & Greden, Reference Ghaziudden, Ghaziudden and Greden2002; Strang et al., Reference Strang, Kenworthy, Daniolos, Case, Wills, Martin and Wallace2012), Down syndrome (Spendelow, Reference Spendelow2011; Walker, Dosen, Buitelaar, & Janzing, Reference Walker, Dosen, Buitelaar and Janzing2011), and Fragile X syndrome (Cordeiro, Ballinger, & Hagerman, Reference Cordeiro, Ballinger and Hagerman2011). Increased rates of depression have also been documented in subgroups of children and adolescents with learning disabilities (e.g., Bender, Rosenkrans, & Crane, Reference Bender, Rosenkrans and Crane1999; Kiuru, Leskinen, Nurmi, & Salmela-Aro, Reference Kiuru, Leskinen, Nurmi and Salmela-Aro2011), hearing impairment (e.g., Fellinger, Holzinger, Sattel, Lauch, & Goldberg, Reference Fellinger, Holzinger, Sattel, Lauch and Goldberg2009; van Gent, Goedhart, & Treffers, Reference van Gent, Goedhart and Treffers2011), vision impairment (du Feu & Fergusson, Reference du Feu and Fergusson2003) and chronic epilepsy (Jones et al., Reference Jones, Hermann, Barry, Gilliam, Kanner and Meador2003). In young children, mental health problems identified in the research include social, emotional and behavioural difficulties, which may be classified as ‘subclinical’ or ‘clinical’ depending on severity at that age (Zahn-Waxler, Klimes-Dougan, & Slattery, Reference Zahn-Waxler, Klimes-Dougan and Slattery2000). By adolescence, formally diagnosed anxiety disorders and depression become the most commonly identified mental disorders (Rickwood, White, & Eckersley, Reference Rickwood, White and Eckersley2007).

In addition to mental health difficulties, outcomes for individuals with disabilities across a range of indicators compare poorly with the general population. Australian data indicate that young adults with intellectual disabilities are significantly less likely to complete Year 12, secure and maintain employment, participate in tertiary education, get married, and be wage or salary earners (AIHW, 2008), all of which have both social and economic consequences. Individuals with intellectual disabilities are particularly vulnerable to becoming victims of physical and sexual abuse (Carmody, Reference Carmody1990; Mitra, Mouradian, & Diamond, Reference Mitra, Mouradian and Diamond2011). Students with learning difficulties are significantly over-represented in juvenile detention settings, at rates as high as seven times that in public school settings in the United States; detained and committed youth experience higher rates of academic underperformance, school failure, and identification of mental health needs than their (same-age) peers in the community (Krezmien, Mulcahy, & Leone, Reference Krezmien, Mulcahy and Leone2008). There is some evidence that individuals with learning disabilities are also over-represented in adolescent suicides (e.g., McBride & Siegel, Reference McBride and Siegel1997), with some subgroups potentially at higher risk of suicide (Bender et al., Reference Bender, Rosenkrans and Crane1999). These and other indicators highlight the compounding factors that may exacerbate an individual's risk for developing mental illness over time. Understanding the relationship between mental health and disability entails examining the reciprocal relationship between individual vulnerabilities and the myriad of environmental factors. At the individual level, specific difficulties associated with a disability may impede the student's development of key competencies associated with mental health, while students with disabilities may also be exposed to negative experiences and circumstances at higher rates than their peers without disabilities.

For school psychologists, guidance officers and other school personnel, the challenge is to recognise early patterns of interaction between individual vulnerabilities and environmental factors that may suggest increased risk of subsequent mental health difficulties. An area of particular vulnerability for many students with disabilities occurs in the social sphere; students with disabilities may be particularly susceptible from a young age to bullying, victimisation and ostracism, which increase the risk of later academic, behavioural and emotional difficulties. Students receiving special education services for behavioural or other disabilities are more likely to be bullied, and more likely to bully others, than are students from the general population (Swearer, Wang, Maag, Siebecker, & Frerichs, Reference Swearer, Wang, Maag, Siebecker and Frerichs2012). One study found that being bullied and/or ostracised by peers was the strongest predictor of increased symptoms of depression and anxiety in 8 to 17-year-olds with special educational needs and/or medical illnesses, even for students with a range of severe and complex needs (American Academy of Pediatrics, 2012). Similarly, a study of 11 to 16-year-olds with hearing impairment found that the risk of internalising mental health disorders was three to six times higher for those who had been teased, isolated or maltreated by classmates, regardless of the severity of the hearing impairment, and this outcome was more likely in individuals who experienced difficulty making themselves understood to others (Fellinger et al., Reference Fellinger, Holzinger, Sattel, Lauch and Goldberg2009). Research suggests that young children who display aggressive behaviour or symptoms of anxiety and depression in the first year of schooling are at risk of later being chronically victimised by classmates by Grade 3 (Leadbeater & Hoglund, Reference Leadbeater and Hoglund2009), which adds to a growing body of research suggesting that social and behavioural difficulties in young children are likely to persist throughout schooling and are associated with later poor learning and mental health outcomes, where no targeted intervention has occurred (Darney, Reinke, Herman, Stormont, & Ialongo, Reference Darney, Reinke, Herman, Stormont and Ialongo2013).

Signs of difficulty for young children include externalising problems (such as aggression and hyperactivity) and internalising problems (such as excessive worry, crying, fear, and sadness), both of which are associated with poor social relationships with peers. As noted by Leadbeater and Hoglund (Reference Leadbeater and Hoglund2009), there may be multiple pathways that explain this association. For example, it is more likely that children with poorly developed social and self-regulation skills, which may be associated with a disability, will be rejected or victimised by peers, and this may exacerbate either anxiety and withdrawal (internalising), aggressive behaviours (externalising), or a combination of both, which may further diminish social connectedness. These behaviours may also significantly impact the student–teacher relationship (Eisenhower, Baker, & Blacher, Reference Eisenhower, Baker and Blacher2007). These researchers found that children's adjustment problems in Grade 1 ‘set the stage’ for peer victimisation and were related to subsequent patterns of internalising behaviour (Leadbeater & Hoglund, Reference Leadbeater and Hoglund2009). While cause and effect may be complex to understand, the clear message for educators is to recognise both internalising and externalising problems in young children as worthy of additional attention, given the strong association with ongoing mental health difficulties. This is particularly important for students with disabilities, some of whom may have particular difficulty with self-regulation, impulsivity, social skills, communication, and other social and emotional competencies (Westwood, Reference Westwood2011). A recognised protective factor for mental health is the development of strong social connections, and this relies on well-developed social and emotional skills in addition to supportive environments (Resnick, Reference Resnick, Kline and Kathleen Kovner2008). Many students with disabilities are unlikely to ‘naturally’ acquire social and emotional competencies through exposure to general approaches alone.

In addition to social and relationship skills, contemporary efforts to build positive mental health (and therefore to prevent mental health difficulties) emphasise the development of personal psychological resources such as resilience, self-efficacy, coping skills and problem solving skills (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, Reference Durlak, Weissberg, Dymnicki, Taylor and Schellinger2011). In part, this approach is grounded in the well-established link between social and academic competence, both of which rely on effective problem solving (Welsh, Parke, Widaman, & O'Neil, Reference Welsh, Parke, Widaman and O'Neil2001); this approach will be described in subsequent sections on whole-school interventions. Once again, these may be areas of particular vulnerability for students with some disabilities, including those with attention deficit/hyperactivity disorder, specific learning difficulties, intellectual disability, and autism spectrum disorders, due in part to the reliance on skills of executive functioning and self-regulation (Westwood, Reference Westwood2011). In addition though, it is important to consider the relationship between experiences of successful learning and mastery and the development of self-efficacy and resilience. While issues of curriculum and teaching are often considered separately from issues of mental health, a student's daily experiences of academic tasks and classroom practices afford multiple opportunities for the development of capacities related to mental health; conversely, there is also potential for repeated experiences of failure and disengagement to undermine the development of important psychological resources (Jarvis, Reference Jarvis, Shute, Slee and Murray-Harvey2011).

In examining signs of depression in students with learning difficulties, Bender, Rosenkrans, and Crane (Reference Bender, Rosenkrans and Crane1999) found that the impact of learning difficulties on depressive symptoms was mediated by feelings of inadequacy as a student; that is, learning difficulties predict students’ feelings of inadequacy, which in turn contribute to elevated depressive symptoms. A profile of disengagement and learned helplessness has been found to characterise many students with learning difficulties, who may learn to quickly give up in the face of difficulty, based on a perceived lack of control over their circumstances (Hallahan, Kaufmann, & Pullen, Reference Hallahan, Kauffman and Pullen2012). In some cases, students with specific learning difficulties or disabilities repeatedly face classroom environments in which teaching is inflexible, tasks are inaccessible and achievement seems out of reach, where expectations are low, or where responses to their behavioural difficulties do not address underlying learning needs (Westwood, Reference Westwood2011). In order to build self-efficacy and resilience, students must be consistently exposed to tasks that enable them to experience a sense of mastery, and therefore personal agency, through effort (Bandura, Reference Bandura and Ramachaudran1994). Through repeated opportunities to select, practice, and apply the right strategies at the right time, and to experience mastery as a result, students are well placed to develop effective executive functioning skills that are critical to both academic learning and social problem solving (Meltzer, Reddy, Pollica, & Roditi, Reference Meltzer, Reddy, Pollica and Roditi2004). Providing ongoing, effective learning experiences for diverse students, and explicitly targeting executive functioning and problem-solving skills for students with particular needs in this area, is particularly important in supporting both academic achievement and mental health for students with disabilities. Sousa and Tomlinson (Reference Sousa and Tomlinson2011) also note that when teachers provide flexible, appropriate learning opportunities that support all students’ progress, this communicates a sense of respect and caring to students.

However, it is well documented that many teachers feel unprepared and unsupported to effectively differentiate their teaching for diverse students in mainstream classrooms (e.g., Forlin, Reference Forlin2001). Where this is the case, the relationship between teacher and student is likely to deteriorate, and both academic and behavioural problems are likely to intensify, particularly for a student who is already experiencing symptoms of depression and anxiety. It is important to note that heightened anxiety impedes effective problem solving, not only for students but also for teachers (Young, Wu, & Menon, Reference Young, Wu and Menon2012; Schwabe & Wolf, Reference Schwabe and Wolf2010). Both teachers’ attitudes towards and preparedness to teach students with disabilities are likely to play important roles in both mental health and academic outcomes for students. Building teachers’ capacity to effectively teach and support students with disabilities should not be considered solely in terms of academic outcomes, but also as an investment in mental health promotion. Effective, inclusive teaching strategies and classroom environments should be acknowledged as critical protective factors for students with disabilities. School psychologists, guidance officers, special education personnel and school leaders should be particularly cognisant of the quality of teaching and classroom practices experienced by students with disabilities, acknowledging the link between academic learning and social, emotional and behavioural competence.