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Research

A tool to help identify learning disabilities in homeless people

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The Learning Disability Screening Questionnaire has been shown to accurately identify potential learning disability. It was used in a small pilot study in a homeless service with good results

Abstract

People who are homeless are at higher risk of physical and mental health problems. This risk increases in those who have learning disabilities. Many homeless people may have a learning disability that is not recognised, meaning they miss out on receiving the support they need. However, to be able to help them, we need to start by identifying who they are. This pilot study aimed to evaluate the use of the Learning Disability Screening Questionnaire in a homeless service. Nine service users completed the questionnaire, and researchers and staff members completed it about the service users. The results indicated good feasibility and inter-rater reliability. This article describes the study background, procedure and outcomes, suggests ways of adapting the questionnaire for use in homeless services, and outlines the potential role of nurses.

Citation: McKenzie K et al (2019) A tool to help identify learning disabilities in homeless people. Nursing Times [online]; 115: 8, 26-28.

Authors: Karen McKenzie is professor of psychology and clinical psychologist, Northumbria University; George Murray is honorary clinical psychologist, NHS Lothian; Helen Wilson is clinical psychologist, NHS Borders; Lauren Delahunty is trainee clinical psychologist, Glasgow University.

  • This article has been double-blind peer reviewed
  • Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)

Introduction

The combination of homelessness and learning disabilities compounds health problems and heightens support needs but, to be able to offer support, we first need to identify those homeless people who have learning disabilities. Efforts have been made to help with this by using screening questionnaires overseas – Van Straaten et al (2017) used a screening tool to identify those with potential learning disabilities in homeless services in the Netherlands – but there has been no equivalent research on the tool in the UK.

One screening tool that is increasingly used in a range of community and specialist services in the UK and abroad is the Learning Disability Screening Questionnaire (LDSQ) (Box 1). The aims of our small pilot study were to explore whether it was feasible to use the LDSQ in a homeless service to help identify service users likely to have learning disabilities, and whether the questionnaire demonstrates good reliability in that setting.

Box 1. The Learning Disability Screening Questionnaire

The Learning Disability Screening Questionnaire (LDSQ) comprises seven items that are scored as ‘Yes’ or ‘No’, and converted to a percentage score. People with a score below the cut-off value are determined as being likely to have learning disabilities.

The questionnaire was designed to be used by staff who are not learning disability specialists and can be completed with the person being screened or by someone who knows them well. It takes around five minutes to complete and has been found to be easy to use, to perform well in a number of settings, and identify individuals with and without learning disabilities with high levels of accuracy (McKenzie et al, 2015; McKenzie et al, 2012). Its use has been highlighted and recommended by a number of organisations, including the Royal College of Nursing (2015).

The LDSQ has been used in settings that have similar characteristics to homeless services – for example, non-specialist settings, such as criminal justice services (Healthcare Improvement Scotland, 2014), in which individuals may not have English as a first language and may be vulnerable to stigma and exploitation. These similarities make it suitable for use in homeless services, where staff often do not have time to conduct lengthy assessments and/or do not have specialist knowledge of learning disabilities (Beer et al, 2012).

Homelessness and healthcare

Being homeless has a significant negative effect on physical and psychological health. This is compounded by the fact that people who are homeless experience a number of barriers to accessing healthcare, including poor previous experiences of care, associated costs (for example, travel costs), and the fact that addressing other needs, such as work and shelter, take priority (Roche et al, 2018).

A recent review of healthcare provision for homeless people by Jego et al (2018) showed that the best-performing primary care services were more likely to:

  • Be matched to the needs of that population;
  • Provide a wider range of services on the premises (for example, social care as well as healthcare services);
  • Have a nurse on the team.

Recent legislation in England attempts to improve health service provision for homeless people. The Homelessness Reduction Act 2017 requires local authorities and health services to work together to support homeless people and prevent homelessness in the first place (Paudyal and Saunders, 2018).

A fundamental barrier to achieving these aims is identifying those who are homeless. This may be a particular problem for health services, as the point of contact with homeless people is often emergency services (Roche et al, 2018), where there may not be enough time to identify a person’s homelessness status. The difficulties in identifying homeless people who also have learning disabilities are even greater.

Homelessness and learning disabilities

People with learning disabilities already face health inequalities (Emerson et al, 2012) and a higher risk of exploitation, bullying and abuse (Lougheed and Farrell, 2013) compared with the general population. These risks are even higher if they are homeless.

The exact number of homeless people who have learning disabilities is unknown, as their learning disabilities are often:

  • Unrecognised;
  • Not recorded by services (Emerson et al, 2016);
  • Not disclosed by the person because of embarrassment and/or fear of stigma, abuse or exploitation (Lougheed and Farrell, 2013).

Research suggests there is a higher number of people with learning disabilities in the homeless population than would be expected based on the 2.2% prevalence rate of learning disabilities in the general population, and that these individuals need ongoing support for a longer period than homeless people who do not have learning disabilities (Van Straaten et al, 2017; Beer et al, 2012; Oakes and Davies, 2008).

Having an unrecognised learning disability places people at significant disadvantage. They may:

  • Not receive the support they require for their health and other needs;
  • Have difficulty understanding how to apply for support due to problems with literacy and understanding, processing and remembering information;
  • Miss out on the reasonable adjustments to which they are entitled;
  • Have difficulty accessing specialist learning disability services (Beer et al, 2012).

Method

Participants

Participants in our pilot study were nine homeless people who used a drop-in homeless service in a large urban area in south-east Scotland. They were aged 28-52 years and eight were male. Three were not British and English was not their first language. Five had attended mainstream schools and four had attended specialist schools (two because of behavioural difficulties and two because of difficulties with learning).

Six participants had one or more problems including:

  • Mental health problems (n=4);
  • Substance misuse (n=3);
  • Previous offending (n=4);
  • Physical health difficulties (n=2);
  • Challenging behaviour (n=1).

Service users volunteered for the study but were excluded if they were under the influence of drugs and/or alcohol, if they were aggressive, or if staff indicated that participation could be detrimental (for example, if the person was experiencing an acute mental health problem) at the time of completing the LDSQ. One person was excluded.

For each participating service user, a member of staff who knew them well completed the LDSQ about them to give a measure of inter-rater reliability. All staff had worked at the homeless service for at least six months.

Procedure

Ethical approval was obtained from the first author’s university ethics board; permission was obtained from the homeless service to conduct the research on their premises. Two of the researchers visited the service on multiple occasions and provided information about the study to staff and service users. The information was provided in an accessible format – orally and writing – and the researchers were available to explain further and answer questions.

The LDSQ was used to provide an indication of whether a person was likely to have learning disabilities or not. All service users visiting the service whenever the researchers were present were invited to participate. Those who wished to participate were asked to complete and sign a consent form. If the LDSQ score indicated that a person was likely to have learning disabilities, they were offered an assessment of their intellectual and adaptive functioning (to be conducted at a later date at the homeless service) to determine whether they met the diagnostic criteria for learning disability. If they did, with their permission, their GP was advised of the results of the assessment.

Results

LDSQ percentage scores ranged from 14% to 100% (mean 69.7%, standard deviation [SD] 36.9). The scores showed that three participants were likely to have learning disabilities:

  • One was known to learning disability services;
  • One, not known to learning disability services, was subsequently assessed and found to meet the diagnostic criteria for learning disability;
  • The third was not known to learning disability services and did not attend the diagnostic assessment offered.

Kappa (κ) was used to assess the extent to which staff and service users agreed on their responses (inter-rater reliability). There was statistically significant agreement on all items and complete agreement on five of the seven items (κ value of 100). An item relating to time had a x value of 0.61 and one relating to writing had a κ value of 0.71. Based on the classification by LDSQ percentage score, there was also complete agreement on the three participants likely to have learning disabilities.

Pearson’s correlations were used to assess agreement between staff and service users on LDSQ total and percentage scores. Statistically Significant and high correlations were found between LDSQ total scores and percentage scores.

Discussion

The results of the study have to be considered in the context of the limitations of a small sample size and single location.

The study identified three of the nine participants (33%) as likely to have learning disabilities. This figure is consistent with that found by Van Straaten et al (2017), who reported that 29.5% of people in their Dutch homeless sample had probable learning disabilities, but it is higher than the 12% (6 out of 50 participants) found by Oakes and Davies (2008) in their UK study. Participants in the study by Oakes and Davies (2008) had been recruited via a primary care practice, whereas we recruited our participants in a homeless service; our result may reflect that our participants were self-selecting – service users who had concerns about having learning disabilities may have been keener than others to participate.

One of the three service users found to potentially have learning disabilities did not attend the assessment that was offered. This highlights one of the challenges of providing good healthcare to homeless people who may have learning disabilities. Integrated, flexible and responsive services are needed so people can access them when they are on site.

The study found complete agreement between staff and service users on all LDSQ items except two: those relating to telling the time and writing. Closer inspection of the responses showed degrees of, rather than absolute difficulty with, a skill. For example, one service user noted that he could write but would need help with spelling, whereas the staff member considered that the person was able to write. One service user could only tell the time on a digital clock, which may have led to differences in scoring.

The LDSQ provides instructions on scoring that address many such degrees of difficulty. Although the tool was designed to be used without the need for training, the results suggest that some additional input into scoring may further improve its reliability. Some participants may try to hide or minimise their difficulties through embarrassment or fear of stigma (McKenzie et al, 2019) and those using the LDSQ need to take this into consideration.

The role of the nurse

The input of nurses in developing and implementing screening for learning disability in collaboration with homeless services would help ensure the needs of homeless people with learning disabilities are identified and met. The role of the nurse is outlined in Box 2.

Box 2. The nurse’s role: identifying the needs of homeless people

  • Jego et al (2018) suggest that nurses are key professionals in primary care services that offer the best healthcare provision for homeless people
  • Nurses can administer the Learning Disability Screening Questionnaire as part of a basic health-needs assessment, and interpret the results using their knowledge of the health needs of homeless people
  • Nurses are well placed to liaise with specialist learning disability services
  • Nurses are skilled in discussing sensitive topics and may, therefore, more likely to get an honest report of a person’s difficulties

Conclusion

There was a high level of agreement on the total and percentage LDSQ scores and, importantly, on who was identified as likely to have learning disabilities. The LDSQ may, therefore, offer a quick, easy and reliable means of helping to identify people using homeless services who have learning disabilities. Further research with a larger sample across a range of services is, however, needed to confirm this. 

Key points

  • People with learning disabilities who are homeless face increased health risks
  • Identifying homeless people with learning disabilities is difficult, which can lead to their missing out on support
  • The Learning Disability Screening Questionnaire has been shown to accurately identify potential learning disabilities
  • The questionnaire is easy to use and quick to complete
  • In a small pilot study in a homeless service, the questionnaire showed good feasibility and reliability
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