Intellectual Disability Flashcards
Diagnosis of intellectual disability
1: significant intellectual difficulties (IQ < 70)
2. Impairment in functional abilities
3. Presence <18 yo
Impairment of adaptive/social functioning
-the individual requires significant assistance to provide for his/her own survival (eating & drinking as well as keeping clean, warm and clothed) and/or with his/her social/community adaptation
Learning disability include
- A significantly reduced ability to understand new or complex information or to learn new skills (impaired intelligence) with
- a reduced ability to cope independently (impaired social function)
- which started before adulthood with a lasting effect on development
Mental capacity acts
- define the criteria that someone must fulfil to be deemed capable of making an informed decision
Capacity not equal to making wise choice
Understand, retain, and weight up the information to make decision and then communicate the decision made
Intellectual disability in DSM5 (3domains)
The conceptual domain (skills in language, math, reading, memory, etc)
The social domain (empathy, social judgment, interpersonal communication skills)
The practical domain (self management)
Common comorbid physical problem
Sensory impairment (hearing, vision) Epilepsy Physical disability Feeding, swallowing and nutrition problem Obesity is common with ID Endocrine disorder
Cause of ID
Aetiology unknown: 20-40% (severe) and 38-55% (mild)
Around 80% of them are not known to service
Complex interaction: biological, social, behavioural and educational factor
Severe ID= generic/environmental cause
- trisomy21 (Down syndrome)
- fragile X syndrome(absence of expression of theFMR-1)
Autism spectrum disorder in Dsm 4
- Imagination
- communication
- social interaction
Impairment in all 3 + <3 yrs old
Autism spectrum disorder - DSM5
- Restricted, repetitive patterns of behaviour, interests, or activities
- &3 = social communication & interaction
Valuing people (2001) Valuing people now (2007)
Better Heath; health action planning (access to housing)
Independence; individual budget & direct payment (choice of daily life)
Personalization; person centred planning (right as citizens )
Social theories driving changes
1) Normalization
2) Social role valorisation
social deviation due to societal rejection and labelling rather than individual pathology
socially valued roles in society challenges negative stereotypes
People with Down syndrome are high risk of developing -
Autism are risk of developing-
Dementia and depression
Anxiety disorder
Challenging behaviour
Behaviour that ;
- arise due to lack of impulse control
- arise from difficulties communicating needs/pain/worry
- not associated with a co-existing mental disorder
- is managed by specialist psychological and environmental treatment
Who has an ID?
1% of population meet criteria for intellectual disability >1 million people
The majority (around 80%) are not known to statutory service
Causes might be
- idiopathic (inc extreme lower end of normal)
- genetic/chromosomal (eg Down’s syndrome, Fragile X)
- problems during pregnancy and birth (eg hypoxia, infection, maternal substance misuse)
- problems in childhood (eg trauma, infection, extreme neglect)
Associated physicals problems are common
Sensory impairments (hearing, vision)
Epilepsy (roughly 1/3)
Physical disabilities
Feeding, swallowing and nutrition problems
Obesity is more prevalent in people with ID
Endocrine disorders (eg hypothyroidism)
Premature death of people with ID
Men with LD die 13 years younger than men without LD
Women with LD die 20 years younger than women without LD
37% deaths investigated were deemed “avoidable” ie preventable by the provision of good quality health care
Barriers and delays in treatment are a problem
Lower uptake of screening and preventative medicine
Communication between professionals need to be improved
Staff knowledge of LD and services should be better
Diagnostic overshadowing
Occurs when a presentation is attributed to intellectual disability rather than a potentially treatable cause
-the person might not be communicating well not due to the ID but due to physical problem
Mental illness in ID
The presentation of mental illness can be different in people with ID
- difficult in communication or lack of verbal communication
- classical symptoms may be complex subjective experience.
- poor insight and “health literacy”
- differentiation from other conditions ie autism
- misinterpretation of developmentally-appropriate behaviours
Psychosis and ID -risk factor
- genetic (heritability >80% but small effect of individual genes)
- pregnancy and birth complications
- urbanicity , ethnic minority status
- cannabis use
- negative life events
- possibly effect of early and severe form of schizophrenia
•affective psychosis highly prevalent in Prader William syndrome, particularly in the subtype caused by maternal disomy
Dementia presentation in ID and Down Syndrome
General deterioration in functioning
Behavioural or emotional change
Depression
Irritability, loss of interest, apathy, emotional instability
Non-cognitive symptoms
-difficulty in walking
Behavioural symptoms
-aggression
-uncooperative
Psychiatric symptoms
-lack of energy, low mood, disturbed sleep
-delusion, auditory hallucination
Decline in social abilities
Fewer delusions and problem behaviour overall
Low mood, restlessness, disturbed sleep, being uncooperative, auditory hallucination
Comorbid condition with ID
Epilepsy (prevalence ranges from 6-26%)
Autism (approximately 115000 children and adults with autism also have ID)
ADHD (approximately 25%-40% of children with ID also have ADHD)
*its getting a problem to distinguish autism from ID and ADHD comorbid is getting more noticed
Assessment and treatment of challenging behaviour
Functional analysis (behavioural triggers and consequence)
Implement behavioural plans or combined interventions
Multidisciplinary focus
Improve environment
Work with parents or paid carers and the person with ID
Risk factor for challenging behaviour
Autism Male gender Severity of ID Younger age Visual impairment Communication difficulties Abusive care inc restrictive practice Poor stimulation/day care Lack of appropriate communication strategies
Assessment tools
Scales for behaviour assessment (ABC)
Mental status
Can be used for treatment monitoring
Interventions-psychosocial
For younger people with ID, parent training in groups may be helpful
Usually manualised treatment
Support at school too
For adults, behavioural interventions in the main
CBT for anger management
Sleep hygiene
Interventions-medications
Antipsychotic Alone or in combination with psychosocial treatment Melatonin Monitor response Consider discontinuation Off-label mood stabilizer Monitor side-effects (ie blood glucose)
Facts about ASD
Genetic (MZ twins)
Increased risk in siblings
Rare genetic abnormalities
Specific syndrome (fragile X, tuberous sclerosis)
Role of epigenetics (impact of environment on gene expression)
Prevalence of 1%
Risk 4 times higher in boys than girls –but more girls are getting diagnosed
Now ASD is considered to be a genetic disorder
Some children with Fragile X also have ASD -similar symptoms (ie gaze avoidance)
Assessment (NICE )
Adult Asperger Assessment
Autism Diagnostic Interview -Revised -you have to be trained to use this assessment
Autism Diagnostic Observation Schedule -Genetic Asperger Syndrome (and high-functioning autism) Diagnostic Interview
ASD and comorbidities
Sensory problem Sleep difficulties ID Seizure Gastrointestinal problem Mood disorder ADHD
Treatment
Early intervention aiming at social and self management skill acquisition with parent training components
May prevent later behavioural difficulties, improve cognitive ability and promote independence
Usually resource intensive (>15 hours a week) x years
Structure and visual cues
Impact on family life and social environment
Seeing people with ID
Ensure sufficient time
Gather collateral information if possible
Establish a baseline - change is important
Don’t forget possible physical causes for presentation
Observable psychopathology and behavioural correlates of mental illness
- anxiety: physical arousal (ie tremor, hyperventilation, increased drinking), anger, self-injury, compulsive behaviour
- depression:tearfulness, withdrawal, irritability, altered biological function (sleep, appetite), diurnal variation, motor retardation
- mania: hyperactivity, fear, responding to unseen/unheard stimuli
Mental health in people with ID
Under-diagnosis
- diagnostic overshadowing
- differentiation between MH problems & challenging behaviours
Prevalence (widely spread)
10-80%
Epidemiology of ASD
1% of children
1% adult (they won’t decrease as age)
Men (2:1)
Mental health in people with autism
16% adults with ASD diagnosed with new MH proven in 20s
High IQ=high risk of mental health problem
High level of anxiety, delusion, social anxiety, depression.
Regression; stressful life event, lack of structure , change in family structure
Mental capacity act
Defines criteria for capacity for decision making
Capacity is not making wise decision
Capacity relates to specific decision only
Criteria=
•Understand
•retain
• weight up information to make decision
And communicate the decision made
Triad of impairment
1) impairment of social interaction
- an impaired ability to engage in reciprocal social interactions
2) impairment of social communication
- the whole range of communicative skill may be affected (eye gaze, speech, non verbal cues)
3) impairment of social imagination
- difficulty thinking imaginatively (pretend play)
The red flag for autism
No babbling by 12 month
No gesture (pointing, waving) by 12 month
No single words by 16 month
No two-word phrase by 24 month
Any loss of any language or social skills at any age
Mood in people with ID
Can be difficult to describe their mood
Asking them to draw their feeling might be helpful
Negative view of self is common
Ask suicide thought it self harm
Cognition in people with LD
Any assessment of cognition should take into account their premorbid level of functioning
Tools such as MMSE might not be useful for people with LD
Structure assessment should include
Presenting complaints Psychiatric history Medical history and medication history Family history Personal and social history -to include developmental, educational, employment, interest, relationship, substance use, current level of support and activity Forensic history
Physical examination to rule out any underlying physical health issue (ie pain)
Who does this exclude?
People with poor educational attainment due to lack of opportunity
Traumatic brain injury sustained in adulthood
Progressive neurological disease
Age-related neurodegeneration (dementia)
Long term serious mental illness that can result in cognitive deficit (ie schizophrenia)
Adaption communication techniques with people with ID
Use simple language Easy read information (using picture, large font) Visual timetable Talking mats Social stories
Stepped care -guildline
Require that the person has the best chance of a positive outcome with the least burden, but that a system of review should be in place to detect and act on non-improvement and to enable stepping up to more intensive treatment if necessary
- treatment should always have the best chance of delivering positive outcome while burdening the patient as little as possible
- a system of scheduled review to detect and act on non-improvement must be in place to enable stepping up to more intensive treatments, stepping down where a less intensive treatment becomes appropriate and stepping out when an alternative treatment or no treatment become appropriate
The least intensive intervention that is appropriate for a person is typically provided first, people can step up or down according to their needs
If less intensive intervention is able to deliver the desired positive outcome, this limits the burden of disease and cost associated with more intensive treatment
IAPT
The development of IAPT service represent the largest scale development by a government into mental health service worldwide
It has seen a 100% increase in spending on mental health from 0.3-0.6% of the annual NHS budget.
Many argue that this is still a very small investment given the burden of mental health problem ok society and the economy
Steps of stepped care
1) Prevention and promotion
- support that can be utilized before approaching health or social service: friends and family; self-help,occupational advice
2) Recognition in Primary Care
- “Watchful waiting” with further assessment; self-help, guided self-help, short term intervention
3) Assessment/Primary Care Interventions
- MH Assessment;short term psychological intervention, physical health check; medicine review; computerized CBT; case worker support
4) Secondary/Specialist Service
- Comprehensive specialist assessment, specialist service (crisis/home treatment, early intervention, assertive outreach, Mental Health Act assessment, specialist medical and paychosocial intervention, care coordination, risk/relapse plan, crisis accommodation
IAPT
Improving Access for Psychological Therapy (IAPT) is the first ever provision of talking therapy on a mass scale by a government
Before IAPT, the NHS spent just 3% of its mental health budget on talking therapy. IAPT has doubled that budget
The biggest expansion of mental health service anywhere in the world ever
