7- Learning disability Flashcards
1
Q
Definition of LD (American psychiatric association (APA))
A
- Sub average intellectual functioning
- At least two limited areas of adaptive functioning exist concurrently
- The disability occurred before the age of 18 years
- All three criteria need to be satisfied
2
Q
IQ distribution
A
3
Q
Classification of intellectual function based on IQ score
A
mild LD = below 70
4
Q
borderline intellectual functioning
A
- Not classified as LD but still vulnerable due to cognitive status
- Living independently
- Subtle communication difficulties
- High-school ‘drop-out’ or in special education
- Difficulty keeping a job, receiving government assistance
- At risk of abusive relationships, challenges rearing children
5
Q
adaptive skills
A
Communication
Self-care
Homeliving
Socialskills
Communityuse
Self-direction
Health and safety
Functionalacademics
Leisure
Work
6
Q
mild learning disability
A
- Relative independence in self-care and daily living skills
- Can hold a conversation and engage in the clinical interview
- Abstract concepts e.g. time are difficult
- Requires varying levels of service support
- May have paid employment
7
Q
moderate learning disability
A
- basic comm skills
- requires supervision with self-care
- living in supported accom
- can engage in a structured day programme or workshop activities
- community access with staff
8
Q
severe learning disability
A
- limited communication
- motor impairment
- needs supervision in daily activities
- living in 24-hour staffed home
- in alternative day programmes with a combination of skills- based and recreational activities
9
Q
-profound learning disability
A
- requires 24-h supervised care
- living either with family or in group home/nursing home
- multiple medical problems
- inner world largely unavailable to other because of communication difficulty
10
Q
what LD is NOT
A
- specific learning difficulty
- dyslexia
- dyspraxia
- dyscalculia
- emotional or behavioural problems
- ADHD or ASD
- acquired brain injury in adult life
11
Q
aetiology of LD
A
- inherited
- genetic
- malnutrition
- perinatal
- postnatal
12
Q
genetic causes of LD
A
13
Q
perinatal causes
A
14
Q
postnatal causes
A
15
Q
down syndrome and LD
A
16
Q
LD is associated with
A
- physical problems
- psychiatric associations
17
Q
LD and physical associations
A
- Epilepsy
- Infantile spasms
- Tonic Clonic Seizure in middle age
- Hypothyrodism
- Obesity
- Sensory impairments
- C-spine abnormalities
- Recurrent Respiratory Tract and ear infection
- Obstructive sleep apnoea
18
Q
LD and psychiatric associations
A
- dementia
- depression
- hyperactivity
- conduct disorder
- OCD
- autism
19
Q
issues with communication in people with LD
A
20
Q
examples of how people with LD may find expression difficult
A
- Content of conversation can be superficial
- Likely to contain ‘fillers’ such as ‘as you know’.
- Articulation may be difficult
- May speak too slowly or loudly, find it difficult to use conventional syntax or grammar
21
Q
examples of how people with LD may find pragmatics difficult
A
- Problems understanding and applying social conventions in conversations
- Difficulty waiting their turn
- Communication style may seem self-centred
- Sensitive to criticism or negative approach in conversation
22
Q
other factors which impact on communication
A
Sensory function
- Hearing impairment
- Visual impairment
- Other physical disabilities
Cognitive function
• Attention difficulties
• Retention difficulties
Environment
• Too many people in room
- Temperature
- Lighting
- Sound
• Other environmental triggers
23
Q
how to communicate
A
- Look at the Communication Passport
- Environmental alterations
- Use simple language, check if they have understood, clarify
- Phrase questions carefully in order to avoid interrogative suggestibility
- Give enough time for responses
- Write things down / draw pictures to aid understanding
24
Q
how not to communicate
A
- Ask yes/no questions
- Most people with learning disability will say yes even if they do not understand what is being asked/said.
- Feel offended if the patient seems disinterested
- This could be due to a less well developed social communication style.
- Pretend to understand what the patient has said if you have not.
25
Tips for Effective Consultations
* Minimise waiting time
* Double the consultation time
* Make them comfortable
* Explain the basics
* Who you are, why you are seeing them, how long it will take
* Speak to patient before speaking to carer
* Get supporting information from carer
* If anxious consider a short break, eat/drink, favourite
* book/object, offer reassurance, one person takes lead
* Continuity of care particularly important
* Remember the communication strategies!
26
which mental health conditions are the most prevalent within LD pops
higher prevalence in LD pop
* Anxiety (16%)
* mood disorder (6&)
* schizophrenia (1.3-3.7%)
27
mental health problems in LD compared to general population
28
atypical presentations of mental health problems in LD pop
* Change in behaviour e.g. self harm
* Loss of skills e.g. incontinence
* Withdrawal/isolating self
* Not doing things they used to enjoy doing
* Biological symptoms:
* Sleep disturbance
* Weight change
29
Principles of treatment of psychiatric illness in people with Learning Disability
* Same options as general population, but:
* MCA- Capacity/best interests
* Extra support
* Accessible information
* Psychotherapies may need adapting
* Community learning disability team involvement
* **Go ‘low and slow’ with medication**
30
Autism Spectrum Disorder in people with Learning Disability - define
“Autism is a lifelong neurodevelopmental condition, the core features of which are persistent difficulties in social interaction and communication and the presence of stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests.”
* 20-33% of those with LD have ASD
* often part of an underlying syndrome e.g. Fragile X, tuberous sclerosis, Retts syndrome
31
autism: triad of impairments
**Wing and Goulds triad**
1. social spectrum
2. restricted activities/imagination spectrum
3. communication spectrum
32
mental health and autism
* Anxiety = core
* Challenging behaviour – Underlying anxiety
* Other mental disorders
* Depression
• Insight in more able
* Psychosis vs fantasy world
* OCD
• Obsessions vs rituals
33
sensory sensitivities and autism
* Hyper / hypo sensitivity to sensory stimuli
* Hyposensitivity morecommon in LD
* Sound most common sense affected
* Also vision, touch, smell and taste
* Propensity to sensory overload
* Sensory blocking or ‘tune outs’ e.g. humming
* Now part of core diagnostic features in DSM 5
34
management of autism in LD
* Communication support
* Structure & routine, passage of time
* Managing transitions and change
* Environment
* Vulnerabilities & risk
– Inability to generalise
– Taking things at ‘face value’
* Medication
– Only for associated MH issues
35
ways to help LD pop with understanding structure, routine and transitions
36
define challenging behavioir
* ‘culturally abnormal behaviour of*
* such an intensity, frequency or*
* duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities’.*
* a bit vague
* numerous meanings in society
* not a diagnosis
* encourages consideration of cause rather than reason
37
What kind of behaviour might be considered challenging?
* Aggressive behaviour
* Self-injury
* Stereotypic behaviour
* Destructive or dangerous behaviour
* Loud or other behaviour that makes others frightened
* “Absconding”, or behaviour making the individual vulnerable
* Inappropriate sexual behaviour
* Spitting,smearing
* Sexist, racist or other upsetting behaviours
38
challenging behaviour increases with
severity of ID
39
causes of challenging behaviour
* Physical illness and pain
* Mental disorders
* Mental illness, PD, dementia, autism etc
* Communication of need or distress
* Learnt behaviour
* Sensory impairment
* Communication difficulties
* “Behavioural phenotypes”
* Medications or substances
* Developmentally normal
* Environment or abuse
40
Antipsychotics and challenging behaviour...
• NICE recommends
– Other interventions should be tried first – That it is only initiated by specialists
– Monitor response and adverse effects, stop if not working and use lowest dose possible
41
Common Physical Health Problems in people with Learning Disability
**Primary** (associated) :
* Hypothyroidism, Epilepsy, Visual/Hearing impairment, Cerebral palsy, motor problems,
**Secondary**:
* Fracture, Obesity, Gastro-esophageal reflux, Caries, Edentulus, Incontinence,
Infection, Constipation
42
Epilepsy in people with learning disability
More common than the general population (20-30% in comparison to 1%).
Multiple types exist in one person at the same time
More chance of being treatment resistant
Rate of polypharmacy is higher
Mortality rate is high especially because of SUDEP
43
Improving the health of people with Learning Disability
Valuing People (a new strategy for learning disability for the 21st Century, 2001):
* They no longer should be marginalized, abused or excluded
* Community integration and access to generic health services
* 4 key principles:
* Inclusion
* Choice
* Independence
* Rights
44
History taking for patient with challenging behaviour
45
Examination and investigations for challenging behaviour
46
Mental state examination
47
How can doctors help in the treatment of LD
48
Diagnostic overshadowing
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
49
reasonable adjustment/ adaptations for consultations with LD patients
* allocate more time
* talk to informants
* reduce stress
* see at home if appropriate
* avoid long waits
* see at quiet time e.g. first or last appointment
* if communication difficult get help- LD teams have SLT
