Learning Disabilities

Question 1

Intellectual Disability:

what is the ICD 10 Definition?

Answer 1

‘A condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence i.e. cognitive, language, motor and social abilities’

Question 2

what is the criteria that has to be met in order for some to have an intellectual disability?

Answer 2

1. Intellectual impairment (IQ < 70) (e.g., Wechsler Adult Intelligence Scale)
2. Social or adaptive dysfunction (Vineland Adaptive Behaviour Scale):
   - Deficits/Impairments in 2 or more of following adaptive skills: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure & work
3. Onset in the developmental period (before age 18):

To have an intellectual disability, the onset must be in the developmental period and we count that as being before the age of 18

Question 3

how od you gather information about someone when assessiong if they have an intellectual disability?

Answer 3

Most of these tests are done by asking someone who knows the individual well, a series of quite detailed questions

Question 4

what is the prevelence of intellectual disabilities?

Answer 4

•Statistically the prevalence of people with IQ<70 should be 2.5% (2SD from mean) but in practice is 1-2%, because of:

• Differential mortality (the more severe the degree of intellectual disability, the higher the mortality c.f. general population)
• The role of functioning - those with IQ<70 but no problems functioning within their environment would not be defined as having a learning disability

Question 5

As well as diagnosing we also characterize the severity of intellectual disability

Both Intellectual and Adaptive functioning is used to classify severity of LD:

what is mild LD?

Answer 5

IQ: 50 - 69 or functional age 9-12yrs

But in terms of the the functional and adaptive behaviours that you would expect to see in some with a mild learning disability, they tend to be similar to people around nine to twelve years old

Question 6

Both Intellectual and Adaptive functioning is used to classify severity of LD:

what is moderate LD?

Answer 6

IQ: 35 - 49 or functional age 6-9yrs

Question 7

Both Intellectual and Adaptive functioning is used to classify severity of LD:

what is severe LD?

Answer 7

IQ: 20 - 34 or functional age 3-6yrs

Question 8

Both Intellectual and Adaptive functioning is used to classify severity of LD:

what is profound LD?

Answer 8

IQ: <20 or functional age <3yrs

most people with profound learning disability will need a very high level of 24 hour support in order to manage state state

Question 9

Aetiology of Intellectual Disabilities:

What are the main causes of intellectual disability?

Answer 9

so we tend to break it down into inherited causes, and acquired causes

Question 10

Aetiology of LD: what are the Inherited causes?

Answer 10

• Single gene: Fragile X (most common), PKU, Retts Syndrome
• Microdeletion/duplication: DiGeorge Syndrome (22q11 – common cause of inherited schizophrenia), Prader-Willi, Angelman syndrome
• Chromosomal abnormality: Down Syndrome (Trisomy 21 – most common genetic cause of learning disability in the UK)

Question 11

Aetiology of LD: what are the Acquired causes?

Answer 11

• Infective: e.g Rubella, Zika virus (not common in UK)
• Traumatic: hypoxic injury during birth, head injury in childhood
• Toxic: Foetal alcohol syndrome
• Idiopathic: for most patients the cause of LD is unknown

Question 12

what Health Inequalities are present in those with LD?

Answer 12

• Social exclusion - Harder for them to make friends, reliant on others
• Socioeconomic deprivation - Unable to support themselves financially
• Inaccessible services - Trouble accessing services
• Discrimination - It is not uncommon for people with intellectual disability not to be offered tests because of the distress it might cause, or they will not be offered treatment because of concerns over the difficulties that people would have in managing to accept it or to go along with it
• Challenges to communication - Often challenging describing what is wrong in the first place
• Lack of appropriate knowledge and skills of professionals
• Minimal evidence base from research - minimal evidence base to treat the kinds of problems that we see in people with intellectual disability. People with intellectual disability struggle to consent to taking part in research

Question 13

what are Common and/or important physical conditions associated with ID?

Answer 13

• Epilepsy – increased incidence and complexity with severity of learning disability (10-50%)
• Sensory impairments – hearing (40 %) and vision (20%), earwax
• Obesity – predisposes to other health problems (Not much control of weigh as other feeding you and letting you out to exercise)
• Gastrointestinal – swallowing problems, reflux oesophagitis, Helicobacter pylorii, constipation
• Respiratory problems – chest infections, aspiration pneumonia
• Cerebral palsy – especially with severe learning disability
• Orthopaedic problems – joint contractures, osteoporosis
• Dermatological and Dental problems- 33% unhealthy gums, for Down’s Syndrome, 80%

Question 14

what is the commonest cause of mortality in the learning disability population?

Answer 14

Respiratory problems are amongst the commonest causes of mortality in a learning disability population

Question 15

Why is there a psychiatric specialty for those with ID?

Answer 15

• Higher incidence of psychiatric disorders in those with LD
• More severe the LD - higher prevalence of psychiatric disorder
• People with mild learning disability may present in broadly similar way to the general population
• Presentation of mental illness different especially in moderate-profound LD
• “Difficulties in describing internal world” e.g. less complex delusions
• Those with lower IQ/ communication difficulties often present with ‘challenging behaviour’
• ‘It’s all about baseline’
• Where there is less verbal communication, observable signs are relied on more in making the diagnosis:
• e.g. weight loss, withdrawal, agitation, tearfulness in depression
• behavioural disturbance in psychotic disorder
• Special training for Psychiatrists
• Multidisciplinary working

Question 16

Psychiatry of LD - wht are the assessment areas?

Answer 16

• Presence and severity of LD
• Aetiology of LD
• Associated biomedical conditions
• Psycho-social assessment
• Psychiatric Disorders, their cause and consequences

consider how much mental health problem might be contributing to the difficulties that this person with an intellectual disabilities having

Question 17

Overview of Mental Health Problems in LD - what is Schizophrenia / Psychosis like in LD?

Answer 17

• 3% Point Prevalence compared to 1% in general population
• Associated with change in personality and reduction in functional abilities
• ‘Self-Talk’ common in LD

Often people with intellectual disability struggle to describe some of the more complex symptoms that we see in in in psychosis

So those kind of elaborate delusional systems or complex auditory hallucinations, we tend to see more change in personality and in particular a reduction in functional abilities

The negative symptoms of schizophrenia can have a really significant impact.

Question 18

Overview of Mental Health Problems in LD - what are mood disorders like in LD?

Answer 18

• Increased incidence
• Less likely to complain of mood changes and noted by change in behaviour ie biological symptoms

Question 19

Overview of Mental Health Problems in LD - what are Anxiety Disorders like in LD?

Answer 19

• Ritualistic behaviour and obsessional themes significantly increased in LD
• Obsessions hard to describe by people with LD but compulsions more readily observed

Question 20

Overview of Mental Health Problems in LD - what is autism like in LD?

Answer 20

•Half of persons with Autism have a LD

Question 21

Overview of Mental Health Problems in LD - what are Over-activity syndromes like in LD?

Answer 21

• ADHD much higher incidence
• Many severe LD children are overactive, distractible and impulsive but NOT to extent that would indicate diagnosis of ADHD (appropriate given their significant level of intellectual impairment)

Question 22

Overview of Mental Health Problems in LD - what is Challenging Behaviour and Self Injury like in LD?

Answer 22

• Wide range of behaviours – socially constructed rather than diagnostic term.
• Frequent end point for wide range of conditions
• General trend is towards greater prevalence of problem behaviour with increasing severity of LD (but people with profound LD exhibit less outwardly)

Question 23

Overview of Mental Health Problems in LD - what is Forensic like in LD?

Answer 23

• Mild LD have similar rates of offending to the general population but diff profile of offending
• IQ below 70 over-represented for arson and sexual (usually exhibitionism) in prison population

Question 24

And the role of the team involved in supporting someone with an intellectual disability, the psychiatrist as part of that, is to try and identify what it is that’s causing this ______ rather than to treat the _________ itself

Answer 24

stress

behaviour

Question 25

Beware Of: “Diagnostic Overshadowing”: Reiss what is it?

Answer 25

Presenting symptoms are put down to their learning disability, rather than seeking another, potentially treatable cause ## Footnote often when we see someone with a challenging behaviour, such as self injury or aggression, breaking things around the house And the assumption is that this behaviour is due to the learning disability and that therefore it is not something that anything can be done about it And it is just part of who they are, rather than considering what it is that might have been causing this behaviour E.G: when a person presents with a new behaviour or existing ones escalate, consider: * Social cause - change in carers, lack of support, lack of social activities * Psychological issues - bereavement, abuse * Physical problems - pain or discomfort, e.g. from ear infection, toothache, constipation, reflux oesophagitis, deterioration in vision or hearing. * Psychiatric cause - depression, anxiety, psychosis, dementia

Question 26

Health professionals need to do what when dealing with someone with a LD?

Answer 26

* Take time and have patience. * Value what is being communicated. * Recognise non-verbal cues. * Find out about the person's alternative communication strategies if verbal communication is difficult (e.g. their typical non-verbal cues, use symbols, sign language). * Explain things clearly in an appropriate way (verbally & with pictures etc). Simple, short, jargon free language * Be prepared to meet the person several times to build up rapport & trust. * Use the knowledge and support of people's carers

Question 27

case on powerpoint