Debate: Diagnostic overshadowing

Health care settings are unfamiliar places. We only tend to go to them when we are unwell, either physically or mentally, so finding our way through what can seem like a maze is hard. For people with learning disabilities, it can feel like a particularly frightening environment.

These same feelings are frequently experienced by health professionals when seeking to assess and treat people with learning disabilities and ensure they receive safe, reasonable care. Too often, the training undertaken by clinical staff has not prepared them for this work. This is a particular issue for general health care staff, who may have a very limited knowledge about learning disability. Clinical staff can be unfamiliar with the legislative framework, and may fail to understand that a right to equal treatment does not mean treatment should be the same, but may need to be adapted to meet specific needs.

Diagnostic overshadowing occurs when a health professional makes the assumption that the behaviour of a person with learning disabilities is part of their disability without exploring other factors such as biological determinants. It has been defined in the following way: “once a diagnosis is made of a major condition there is a tendency to attribute all other problems to that diagnosis, thereby leaving other coexisting conditions undiagnosed.” (Neurotrauma Law Nexus).

Nurses can play a crucial role in reducing clinical risks such as diagnostic overshadowing, ensuring that health professionals see the person and not just their disability.

Emerson and Baines (2010) have highlighted that when treating a person with a learning disability, “Symptoms of physical ill health are mistakenly attributed to either a mental health/behavioural problem or as being inherent in the person’s learning disabilities.”

Gates and Barr (2009) have noted that diagnostic overshadowing is particularly pertinent when new behaviours develop or existing ones increase. People with learning disabilities have a much higher risk of experiencing a variety of diseases or conditions, and it is vital that physiological or pathological determinants in behaviour change are explored. If they are not, people with learning disabilities can suffer poor care and avoidable deaths may even occur.

Gastrointestinal cancers are approximately twice as prevalent in people with a learning disability; coronary heart disease is the second highest cause of death for people with a learning disability; and approximately 70% of people with a learning disability experience gastrointestinal disorders (Blair, 2015).

In Wales, the Mental Health Act 1983 Code of Practice came into force in October 2016. The Code was updated to reflect changes to the law and the requirements of the Mental Health (Wales) Measure 2010 and acknowledges diagnostic overshadowing as a particular risk relating to people with learning disabilities or Autism Spectrum Disorder. 

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