Learning disability

Question 1

Define intellectual disability.

Answer 1

A developmental condition characterised by global impariment of intelligence and significant difficulties in socially adaptive functioning.

E.g. The presence of:

• reduced ability to understand new or complex information or to learn new skills;
• less able to cope independently;
• impairment that started before adulthood, with a lasting effect on development.

Question 2

How common is ID?

Answer 2

• 2-3% prevalence
• Many never formally diagnosed
• F>M (3:2)

Question 3

What is the aetiology of ID? List 2 antenatal, perinatal and postnatal causes of learning disability.

Answer 3

Usually no specific cause e.g. brain damage, genetic abnormalities, hypothyroidism. Multifactorial causes are common.

Question 4

Name 3 syndromes associated with learning disability.

Answer 4

• Down syndrome
• Fragile X
• Fetal alcohol syndrome

Question 5

List 5 clinical features of learning disability.

Answer 5

Presents in childhood but can be missed if mild

Abilities in … are delayed /reduced /absent:

• language
• schooling
• motor ability
• independent living
• social ability
• employment

Behavioural difficulties - 2^o to combination of

• communication problems
• psychiatric illness
• physical illness
• epilepsy
• suboptimal support

Question 6

What are the levels of ID?

Answer 6

• Profound: <20
• Severe: 20-35
• Moderate: 35-50
• Mild: 50-69

Question 7

List 2 features of each level of ID.

Answer 7

1. Mild
   
   • Language: usually good, but its development may be delayed
   • Cognitive, motor, social: many live and work independently.
2. Moderate
   
   • Language and cognitive abilities: less developed.
   • Motor and social: Reduced self-care abilities and limited motor skills +/- long-term supported accomodation. Simple practical work should be achievable in supported settings.
3. Severe
   
   • Motor: Marked impairment of motor function.
   • Language: Little/no speech in early childhood
   • Cognitive and social: Simple tasks performed with assistance. Likely to require their family home or 24-hourstaffed home.
4. Profound learning disability
   
   • Language, cognitive, social, motor: Severely limited language, communication, self-care, and mobility. Usually require higher levels of support.
   • Significant associated medical problems.

Question 8

What are the components of the Wechsler Adult Intelligence Scale?

Answer 8

2 main components:

Verbal scales: general knowledge, digit span, vocabulary, simple arithmetic, comprehension, similarities

Performance scale: picture completion, arrangement, block design, digit symbol, object assembly.

Question 9

What are the differential diagnoses in ID?

Answer 9

ASD - in Asperger’s there may be significant social deficits, communication difficulties and daily living issues

Epilepsy - frequent uncontrolled seizures can mimic persistent cognitive impairment

Brain injury or progressive neurological conditions*

Psychiatric - schizophrenia if severe and persistent, can lead to chronic impairment across many domains

Educational disadvantage/neglect - lacking opportunity to learn must be distinguished from LD.

*learning disabilities are neurodevelopmental disorders, occurring while the brain is still developing. If the patient presents late, it is important to decide whether or not impaired intellect was present before any adult illness.

Question 10

What psychiatric comorbidities are common in those with ID?

Answer 10

~30–50% of people with LD have additional mental health problems and associated autistic spectrum disorders.

• Schizophrenia (3%)
• Mood disorders (x4)
• Autism (75% of those diagnosed have ID)

Question 11

What are the physical comorbidities commonly present in ID?

Answer 11

• Obesity and poor diet
• Epilepsy
• Sensory impairment e.g. hearing loss, poor visual acuity
• Infections - less likely to be screened or have vaccinations

Question 12

How do you assess for ID?

Answer 12

1. Intellectual impairment - assessed using the WAIS IV: 11 subtests to derive Verbal IQ + Performance IQ = Full Scale IQ
2. Adaptive/Social functioning - established via clinical interview and ABAS II (Adaptive Behaviour Assessment System)

Presence in childhood established using clinical interview and school reports

Question 13

What is the average score for the WAIS scale?

Answer 13

• Average Range: 70-130.
• Average score: 100

Question 14

What additional investigations should be done for ID?

Answer 14

1. IQ testing: is there global intellectual impairment?
2. Functional assessment of skills, strengths and weaknesses.
3. Detailed developmental history from parents, e.g. details of pregnancy and birth, language and motor skills development, schooling, emotional development, and relationships. School reports are helpful.
4. FBC, U&E, LFT, TFT, bone profile—to exclude reversible disturbances.
5. Additional blood tests for known causes of learning disability.
6. Investigations for associated physical illnesses, e.g. EEG for epilepsy.
7. Genetic testing if appropriate.

Question 15

What condition causing ID do these patients have?

Answer 15

Fragile X

Question 16

What are 3 steps taken to prevent learning disability?

Answer 16

1. Parental Education (e.g. risks of alcohol during pregnancy)
2. Improved antenatal/perinatal care
3. Genetic counselling
4. Early detection and treatment of reversible causes (e.g. excluding phenylalanine in babies with PKU)

Question 17

What is the management of ID?

Answer 17

Biopsychosocial approach

Biological:

• Treat physical comorbidity
• Patients may be particularly sensitive to medications so slower dose titration and careful monitoring maybe required

Psychological:

• Treat psychiatric comorbidity - mental health problems can be difficult to diagnose because of cognitive, language and communication difficulties
• May include counselling, group therapy and modified CBT
• Behavioural therapy - helps improve unhelpful behaviour patterns + ABC approach

Social:

• Educational Support
• Statement of Special Educational Needs allow appropriate support
• This may be in mainstream or specialised schools
• The aim is to maximise the child’s potential
• Support network is needed to provide specific help with daily living, housing, employment and finances
• Assess carers’ needs

Question 18

Describe the ABC approach used in behavioural therapy in ID.

Answer 18

ABC:

• Antecedents –> avoiding antecedents
• Behaviour –> reinforcing positive behaviours and preventing reinforcement of negative behaviours (e.g. using distraction techniques)
• Consequences –> helping people understand the consequences of their actions

Question 19

What is the importance of the Equality Act (2010) in treatment of patients with ID?

Answer 19

People with learning disabilities to utilise mainstream services as much as is possible

Ensuring equity of access to health care for people with a learning disability is every health professional’s business.

Question 20

Who is included in the community learning disability teams?

Answer 20

• Community learning disability nurses
• Psychiatrists
• Psychologists
• OT
• SALT
• Physiotherapists
• Dieticians
• Care managers

Question 21

What tool can be used to promote normal daily living e.g. choice-making, in ID?

Answer 21

Choice board - with pictures; fosters sense of control and independance

Self-help board - helps service users learn new skills or activities; each picture is in order of the task

Schedule board calendar - provides structure to person’s day /life

Communication board - with emojis or emotions

Question 22

Define adaptive functioning.

Answer 22

Performance in coping on a day-to-day basis with the demands of the environment and is related to age and socio-cultural expectancies.

Question 23

What is diagnostic overshadowing?

Answer 23

The tendency to attribute everything to the learning disability itself

e.g. dismissing someone with LD who is crying and stops eating because ‘that’s the way these people are sometimes’—when appendicitis is the problem

Question 24

What is challenging behaviour?

Answer 24

Culturally abnormal behaviour

Often persistent

Not a diagnosis

Question 25

What should you do to communicate effectively with someone with ID? What if they are visually or hearing impaired?

Answer 25

Allow time in relaxed environment Use open questions - be careful not to ask leading questions Pictorial and symbolised material may be useful **If visually impaired**, touch hand before speaking and start sentence with name **If hearing impaired**, check that they can see your mouth and face and place yourself on side of best hearing

Question 26

What is the prognosis with LD?

Answer 26

**Lifelong condition** **Life expectancy is reduced** because of comorbid physical illness and unmet health needs **_Important_: people with learning disabilities are very vulnerable to neglect, abuse and exploitation** * This may be compounded by communication difficulties * Behavioural change may be their way of communicating distress