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clinical mental health > Intellectual Disability > Flashcards

Intellectual Disability Flashcards

0
Q

Diagnosis of intellectual disability

A

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

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1
Q

Learning disability include

A
  • 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
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2
Q

Mental capacity acts

A
  • 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

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3
Q

Intellectual disability in DSM5 (3domains)

A

The conceptual domain (skills in language, math, reading, memory, etc)

The social domain (empathy, social judgment, interpersonal communication skills)

The practical domain (self management)

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4
Q

Common comorbid physical problem

A 
Sensory impairment (hearing, vision) 
Epilepsy 
Physical disability 
Feeding, swallowing and nutrition problem
Obesity is common with ID
Endocrine disorder
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5
Q

Cause of ID

A

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)
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6
Q

Autism spectrum disorder in Dsm 4

A
  1. Imagination
  2. communication
  3. social interaction

Impairment in all 3 + <3 yrs old

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7
Q

Autism spectrum disorder - DSM5

A
  1. Restricted, repetitive patterns of behaviour, interests, or activities
  2. &3 = social communication & interaction
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8
Q 
Valuing people (2001) 
Valuing people now (2007)
A

Better Heath; health action planning (access to housing)

Independence; individual budget & direct payment (choice of daily life)

Personalization; person centred planning (right as citizens )

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9
Q

Social theories driving changes

1) Normalization
2) Social role valorisation

A

social deviation due to societal rejection and labelling rather than individual pathology

socially valued roles in society challenges negative stereotypes

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10
Q

People with Down syndrome are high risk of developing -

Autism are risk of developing-

A

Dementia and depression

Anxiety disorder

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11
Q

Challenging behaviour

A

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
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12
Q

Who has an ID?

A

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)
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13
Q

Associated physicals problems are common

A

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)

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14
Q

Premature death of people with ID

A

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

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15
Q

Diagnostic overshadowing

A

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

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16
Q

Mental illness in ID

A

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
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17
Q

Psychosis and ID -risk factor

A
  • 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

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18
Q

Dementia presentation in ID and Down Syndrome

A

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

19
Q

Comorbid condition with ID

A

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

20
Q

Assessment and treatment of challenging behaviour

A

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

21
Q

Risk factor for challenging behaviour

A 
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
22
Q

Assessment tools

A

Scales for behaviour assessment (ABC)
Mental status
Can be used for treatment monitoring

23
Q

Interventions-psychosocial

A

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

24
Q

Interventions-medications

A 
Antipsychotic 
Alone or in combination with psychosocial treatment 
Melatonin 
Monitor response 
Consider discontinuation 
Off-label mood stabilizer 
Monitor side-effects (ie blood glucose)
25
Q

Facts about ASD

A

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)

26
Q

Assessment (NICE )

A

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
27
Q

ASD and comorbidities

A 
Sensory problem 
Sleep difficulties 
ID 
Seizure 
Gastrointestinal problem
Mood disorder 
ADHD
28
Q

Treatment

A

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

29
Q

Seeing people with ID

A

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
30
Q

Mental health in people with ID

A

Under-diagnosis

  • diagnostic overshadowing
  • differentiation between MH problems & challenging behaviours

Prevalence (widely spread)
10-80%

31
Q

Epidemiology of ASD

A

1% of children
1% adult (they won’t decrease as age)

Men (2:1)

32
Q

Mental health in people with autism

A

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

33
Q

Mental capacity act

A

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

34
Q

Triad of impairment

A

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)

35
Q

The red flag for autism

A

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

36
Q

Mood in people with ID

A

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

37
Q

Cognition in people with LD

A

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

38
Q

Structure assessment should include

A 
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)

39
Q

Who does this exclude?

A

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)

40
Q

Adaption communication techniques with people with ID

A 
Use simple language
Easy read information (using picture, large font) 
Visual timetable 
Talking mats
Social stories
41
Q

Stepped care -guildline

A

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

42
Q

IAPT

A

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

43
Q

Steps of stepped care

A

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

44
Q

IAPT

A

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

clinical mental health (12 decks)

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