Mental Health and Behaviour

Mental Health and Intellectual Disability


It can be difficult to notice mental health difficulties in those with intellectual disability, although depends greatly on how the person is affected by their disability. Individuals with mild intellectual disability and good communication may display the same symptoms of mental illnesses as the general population, but it can be more difficult to identify in individuals with more severe intellectual disability. This is due to several reasons, including difficulties in communicating or expressing feelings and thoughts, co-occurring conditions and related medications, and sometimes difficulties obtaining historical medical and behavioural information.

Due to these reasons, identifying mental illness in people with intellectual disability relies heavily on information from supporters and caregivers, and any differences in the individual’s normal behaviour. Essentially, where in the general population a health professional might be using the presence of symptoms to assess a mental illness, an individual with intellectual disability may already display some symptoms as part of their standard behaviour, and instead a health professional will try to assess whether there is a significant change in their behaviour that may indicate a mental illness. Such may include changes in the intensity or frequency of behaviours, or the addition or elimination of behaviours.

As such, keeping a record of the behaviours of the person you support, including what is normal or not normal behaviour for them can be very helpful for health professionals if you or they suspect that the individual may be suffering from or developing a mental illness. It is also good to note any potential triggers or events that may have resulted in these changes in behaviour. It is important to note that while individuals with intellectual disability can become distressed by any of the same events as the general population (e.g. death of a friend/family member), they may also be more significantly affected by events that would not distress someone without intellectual disability (e.g. a well-liked paid support worker moving on).

Some important things to record are:

  • Their range of emotions and how they are expressed.
  • Their typical level of physical activity and dietary habits
  • Their sleeping and self-care habits
  • Social activities, regular activities, and interactions
  • Communication style
  • Routines and rituals
  • Physical health
  • Key relationships

When recording it is important to be as objective as possible; while our subjective interpretations can be important, being able to differentiate between the two is important for clinicians to come to accurate conclusions. For example, it can be tempting to say that an individual is sad all the time. But the observations that you used to come to this conclusion are equally as important; you know they are sad all the time because they are crying and withdrawn you’ve seen them cry at least once a day and where they used to be active and outgoing, they now stay in their room for 10 hours a day. These details can be very important for clinicians to tell the difference between some mental illnesses.

Depending on the individual, encouraging them to access support may be difficult. Some may not realise that there is something wrong, or that that they can get help, or that the issue will not get better on its own. They may also have anxiety around visiting health workers, going to new places or even leaving the house. In these circumstances it is generally best to get additional support for the individual to enable engagement with health services. Mental health services are most effective when the individual is ready for support and willing to engage.

Some possibilities to consider when an individual is unwilling to go to health services due to anxiety may include telehealth, home visits, or preparation in the form of walkthroughs using images or gradually exposing the person to the clinic environment. However, this is different to an individual not seeing the need for health services. If they don’t feel it necessary, consider whether it appropriate and ethical to inform their GP or health team, and continue to communicate with them.

General Communication Tips

If the person you support has a moderate level of communication, you can use the following general tips to ask them about their mental well-being.

  1. Use appropriate language.
  • Speak clearly and slowly.
  • Use a calm, quiet voice.
  • Use simple, short phrases.
  • Avoid jargon or abstract ideas.
  • Be specific.
  • Use a normal tone.
  1. Ask one question or make one request at a time.
  2. Avoid leading questions.
  • People with ID can be suggestible and may tell you what they think you want to hear, rather than the truth.
  1. Use open questions where possible.
  • Closed questions can be used to clarify but take care that they are not leading questions.
  1. Check the person’s understanding; if you are not sure they have understood something, ask them to explain what you have just asked or told them.
  2. Don’t assume that their ability to express themselves is an indication of how much they understand or vice versa.
  3. Don’t assume they will be able to generalise skills across contexts or situations.
  4. Be patient and give them the time to respond.
  5. Don’t pretend you understand if you don’t.
  6. Be prepared to repeat information.
  7. Listen to the person. Don’t be judgemental, critical, or flippant.
  8. Be calm, relaxed, confident, and reassuring.
  9. Do not make promises that can’t be kept.

If a Person is in Distress

If you have reason to believe an individual with ID or autism is struggling with their mental health, adopting the following framework may be useful in guiding your interactions with the individual to support a positive outcome. Note that these points do not need to be followed in order.


  • Approach: Approach the person you have concerns for. It is best to approach them in an environment where both you and they are comfortable.
  • Assess: Assess whether they are in crisis. When asking questions, try to communicate according to the individual’s preferences, check that they have understood what you are saying, avoid asking leading questions, and check to ensure that that what they say is what they really mean.
  • Assist: If they are in crisis, assist them as much as is appropriate if you can do so safely. Call emergency services if you suspect they pose a risk to themselves or others.
  • Listen non-judgementally: Listen to the individual. Many individuals experiencing distress want to be listened too, rather than being immediately given information or resources. Allowing the individual to be genuinely heard can make it easier for them to talk freely.
  • Encourage them to get appropriate professional or informal support.

Behaviours of Concern

People with intellectual disability experiencing mental or physical distress may engage in behaviours of concern, also known as behaviours that challenge. Behaviours of concern refer to behaviours that are

  • not socially and or culturally acceptable for an individual to display, or
  • are of an intensity, frequency or duration that places the individual or others in danger, or
  • is likely to result in them being refused access to public areas.

It is important not to dismiss a behaviour of concern if it is atypical of the individual’s behaviour; an individual with an intellectual disability may use behaviours of concern to communicate pain or distress and may be a sign or symptom of mental or physical illness. Remember that it is not the individual but the behaviour that is concerning, and that the health and safety of everyone involved should be your top priority.

85% of people with intellectual disability do not engage in aggressive behaviours, but if a person with intellectual disability is exhibiting a behaviour of concern, it can be helpful to respond to the behaviour immediately by following these steps:

  • Diversion: direct the person to the desired behaviour
  • Prevention: prevent further escalation
  • De-escalation: reduce the intensity of the behaviour
  • Minimisation: minimise the likelihood of harm as a result of the behaviour
  • Follow-up: if the behaviour passes, check in with the person and others who may have been affected by the behaviours

Remember that the safety of everyone involved is of primary importance, and if the behaviours escalate in a manner that could result in harm consider whether contacting emergency services is the most appropriate course of action.