Learning Disabilities Flashcards
ICD-10 definition of learning disability
Diagnostic criteria emphasises need for deficits in :
- Intellectual functioning (IQ)
+ - Adaptive functioning
+ - Onset must be before adulthood
how is severity of learning disability determined
by adaptive functioning instead of IQ
what is adaptive functioning
how well a person handles common demands in life
how independent they are compared to others of a similar age and background.
what is DSM-5 definition of learning disability
Limited functioning in 3 areas
- Social skills (communicating with others)
- Conceptual skills (reading & writing)
- Practical ability (bathing one’s self)
what is the general definition of learning disability
A significantly reduced ability to understand new or complex information and in learning new skills (impaired intelligence) with a reduced ability to cope independently (impaired social functioning), which started before adulthood, with a lasting effect on development
what are the different terminology for this disabilty
ICD 10 and DSM 4: mental retardation
ICD 11 and DSM 5: intellectual disability
DoH: learning disabilty
factors of Learning Difficulty
Onset during infancy / childhood
Impairment / delay in functions related to maturation of nervous system
Steady course, without remission / relapse (usually diminishes progressively with age)
How does learning disability differ from a learning difficulty
a learning difficulty does not affect general intellect
examples of learning difficulty
Dyslexia, attention deficit-hyperactivity disorder (ADHD), dyspraxia and dyscalculia
classes of the Disorders of Psychological Development
F80 Specific developmental disorders of speech & Language
F81 Specific developmental disorders of scholastic skills e.g. dyslexia
F82 Specific developmental disorder of motor function
F83 Mixed specific developmental disorders
F84 Pervasive developmental disorders e.g. Autism, Atypical Autism, Rett Syndrome
average IQ stats
95% of the population have an IQ between 70 & 130
68% of the population have an IQ between 85 and 115
expected IQ at AGES depending on severity of disability
IQ
AGE
Mild (85%)
50-69
9 – 12 y
Moderate
35-49
6-9y
Severe
20-34
3-6y
Profound
< 20
<3y
Criticism of IQ
IQ scores are not fixed throughout life
Difficult to measure in more severe learning disability
No formal measure of adaptive / social function
Subdivisions vary within and between countries
DSM-5 does NOT rely on IQ score
what is the average intelligence
According to the Wechsler Adult Intelligence Scale, an averageIQ scoreis between 90-109.
what is Borderline Intelligence
Not coded in ICD
Generally understood as IQ 71 – 84
1 SD below mean IQ & 1 SD above LD cut off
Associated with higher rates of mental illness
Other comorbidities e.g. ADHD, autism because they are higher functioning than LD
Forensic issues, substance misuse
Gap in clinical service
what are some e.g., of IQ tests
Weschler Adult Intelligence Scale (WAIS)
Weschler Intelligence Scale for Children (WISC)
prevalence in the UK for learning disabilty
Approx 1.5 million people in the UK have a learning disability (Mencap)
england employment facts
7907 ages 18-64 in paid employmet in 2017/18 where a higher proportion is men
the history of learning disabilities- 17th century
Social mobility a significant feature of society as people travelled in search of employment
Elizabethan Poor Law Act (1601): Restricted the movement of beggars, invalids, people with LD
Segregation by creating ‘workhouses’ as they were considered to be social and economic burden
the history of learning disabilities- the industrial revoulution
Demand for new technical skills amongst workforces
People with LD were singled out - perceived as having neither social or practical competencies - hence regarded as financial burden
the history of learning disabilities- what is Eugenics: GALTON 1883
Improving inborn human qualities through selective breeding (Galton 1883)
Western countries competed to become the most powerful and industrial nations globally.
Galton set out to consciously “improve the race.”
He coined the word eugenics to describe efforts at “race betterment.”
Imperialism served to strengthen the belief of ‘survival of the fittest state’ termed as Social Darwinism Bowler 1990
“..the danger lies in the fact that these
degenerates mate with healthy members of
the community and thereby constantly drag
fresh blood into the vortex of disease and
lower the general vigour of the nation.”
what was The Mental Deficiency Act: 1913
defining disabilities into 4 categories
- idiots
- imbeciles
- feeble
- moral defectives
what were the idiots
persons so deeply affected in mind from birth or from an early age as to be unable to guard themselves against common
dangers.
what were the imbeciles
persons who whilst not being as defective as idiots were still incapable of managing their own affairs
what were the feeble
Feeble-minded persons - persons who whilst not being as defective
as imbeciles still required care, supervision and control for their own protection or for the protection of others.
who were the moral defects
persons who from an early age display some permanent mental defect coupled with vicious or criminal propensities on which punishment has had little or no effect.
the development of institutes
Dr John Langdon Down (1828-1896) founded Normansfield hospital, Richmond, in 1868, for people with mental handicap (LD)
By end of 19th century – 120 asylums in England & Wales housing more than 100,000
Concept of community care in 1950s led to closure of institutions
what factors contributed to the worldwide movement of deinstitutionalisation
- Cost
- Emerging treatments
- Scandals
- Civil rights philosophy
- Antipsychiatry movement
- Normalisation concept
what stages in life is the brain vulnrabe to development
Main growth is prenatal & first few years of life
Most vulnerable to damage during this growth period
Adolescence:
Myelination proceeds from back to front, with continued development
Periods of intense restructuring of synaptic networks occur
which 3 environmental factors can contribute to the afeected brain development
- intra-uterine
- prenatal complications
- early infancey
what are some of the associated implications of damage to the brain
Damage to the brain very early in life is more likely to have a global rather than specific impact
* Undamaged areas can take over functions
* However repair processes may result in misconnections
A brain area may have different functions at different ages, so damage may be silent initially
Sensory input has a driving role in development
Development is affected by hormonal and other external influences
the 3 types of aietologic causes and e.g.,
Prenatal causes- chromosomal dsorders, inborn errors of metabolism, developmental disorders of brain formation and environmental influences
perinatal causes- anoxia, low birth weight and syphillis and herpes complex
postnatal- biological, psychosocial, child abuse and neglect
some prenatal/ intrauterine causes
Nutritional deficiencies – folic acid
Toxin exposure – alcohol, drugs
Genetic mutations (autosomal dominant / recessive
Chromosomal (trisomy, deletion, sex chromosome abnormality)
some perinatal causes
Prematurity
Congenital infection (TORCH, HIV)
Hypoxic-ischaemic encephalopathy (intrapartum asphyxia)
some postnatal causes
Infection
Traumatic brain injury
Severe neglect and abuse
what is the most common inherited cause of learning disability
FRAGILE X SYNDROME
what is the most common chromosomal abnormality causing learning disability
Down’s syndrome
what couls be the genetic causes
Trisomy – Down’s syndrome
Deletion – Cri du chat, Angelman’s, Prada-Willi, Rubinstein-Taybi, Smith-Magenis
Sex chromosome anomaly – Fragile X syndrome, Klinefelter’s, Turner, Lesch-Nyhan
what are the metabolic causes
CALM
Carbohydrate – galactosaemia
Amino acid – phenylketonuria
Lipids – Tay-Sachs, Gaucher’s, Niemann-Pick
Muccopolysaccharidosis – Hurler’s
what are some of the structural causes of LD
Spina bifida (Neural tube defect)
Tuberous sclerosis
Anencephaly
Neurofibromatosis
Corpus callosum agenesis
why may you suspect a child has a learning disability
● The child is not being able to turn to a sound by 6 months
● The child is not being able to start babbling by 9 months
● Failure to understand a simple command without a gesture by 18 months
● The child can’t use approximately 10 to 25 single words by 2 years
● Failure to speak two-word phrases by 26 months
● Failure to speak in three-word sentences by 3 years
● Unintelligible speech in a child more than 3 years
● Regression in language skills at any age
what are some of the clinical presentations
Delay in reaching developmental milestones: Fine and gross motor, language, social
Mild deficits may not be picked up until school
Genetic and chromosomal disorders tend to be associated with additional features which may be diagnostic
Increased incidence of:
Hearing impairment (40%)
Epilepsy (22% v 1%)
Dementia
what are some of the differential diagnosis of leraning disabilities
Autism
Specific Learning Disorders
Cerebral Palsy (without extensive cognitive impairment)
Global Developmental Delay
what is diagnostic overshadowing
Presence of a diagnosis creates a bias or prejudice in the interpretation of symptoms
Also issues of discrimination: worse or less treatment offered
Tendency for clinicians to attribute symptoms or behaviours of a person with LD to their underlying cognitive deficits and under-diagnose the presence of co-morbid psychopathology
Why someone with an intellectual disability may be more likely to suffer with their mental health?
Biological factors
* Pain, physical ill health, polypharmacy
* Some genetic conditions associated with specific mental health problems
Negative life events: More likely to have experiences abuse, poverty etc
Fewer resources
* Lack of social support
* Reduced coping skills
Other people’s attitudes: Stigma and discrimination
what are some psychiatric co-morbidity of LD
More common
* ASD
* ADHD
* Anxiety
* OCD
* Repetitive self-injury
* Disruptive behaviour
Less common
* Substance misuse
* Conduct disorder
what are some of the challenging behaviours that present with LD
- Aggression (e.g. hitting, kicking, biting)
- Destruction (e.g. ripping clothes, breaking windows, throwing objects)
- Self-injury (e.g. head banging, self-biting, skin picking)
- Tantrums (e.g. running away, eating inedible objects, Other (rocking / stereotyped movements)
- Prevalence 10-15%
- More common in males
- Most prevalent 15-34 years
- Have greater prevalence with increasing severity of learning disability
- More than one type of problem behaviour may occur
why might one show repetitive self-injurious behaviour
- Institutionalisation
- Low stimulation
- Abuse
- Neglect
- Bereavement
what are some of the syndromes showing self-injurious behaviour
Lesch-Nyhan
De Lange
Smith-Magenis
Prader-Willi
Fragile X
what is the Relationship between learning disability and offending behaviour
it is complex
Evidence that increasing offending is seen in mild LD & borderline intelligence
Rare in moderate to severe LD
what is ASD
Autistic spectrum disorder
- Lifelong condition 1 percent
- Restricted, repetitive patterns of behaviour, interests or other activities
- Persistent deficits in communication & social interaction across contexts
Symptoms must be present in early childhood
Symptoms limit and impair everyday functioning.
what are some communication problems that can be presented in LD
Language understanding limitations and range of
vocabulary – may be good at masking their understanding
Attention & concentration difficulties
Memory problems
Being complicit - “yes” to everything
Shyness & low self esteem, feeling ‘different’, not used to having a chance to express their view
what are some tips to help communicate with those with LD better
- Use simple and familiar key words
- Keep sentences short and give one idea at a time
- Use concrete rather than abstract ideas
- Write things down, perhaps in colour, use worksheets
- Give accessible information – pictures, leaflets
- Perhaps do shorter (concentration) or longer (to aid understanding) sessions
- Check to ensure you have explained clearly and they have understood
- Involve and listen to family / carers / GP
what is Makaton
Makaton is a communication tool together with speech and symbols, to enable people with disabilities or learning disabilities to communicate. It is not a British Sign Language or any form of Sign Language in its own right
what does makaton aim to help people with
Makaton can help children and adults who have difficulty with:
Communicating what they want, think or how they feel
Making themselves understood
Paying attention
Listening to and understanding speech
Remembering sequencing
what are the typical features of Down’s syndrome
Protruding tongue
Flat nasal bridge
Upward slanted eyes
Single palmar crease
AVSD
Dementia
what are the typical features of Prader-Willi
- Autosomal Dominant
- Deletion of Paternal 15q
- M = F
- Infancy – hyptonia, floppy baby, poor feeding (sucking reflex poor), developmental delay
- Childhood – increased appetite, obesity
- Compulsive behaviours – skin picking, tantrums
- Hypogonadism – delayed / incomplete puberty
- Strabismus ?
what are the typical features of Angelman
- Maternal chromosome 15
- Global developmental delay evident by 6 months
- sitting at 12 months; walking at 3-4 years
- ‘Happy puppet syndrome’ – wide mouth, wide-spaced teeth
- hand flapping – uplifted flexed arms when walking
- fascination with water
- Speech impairment, non-verbal
- Ataxia
- Wide spaced legs, flat feet, toe walking / prancing gait
what are the typical features of Fragile x Syndrome
- > 200 CGG repeats in FMR1 gene on X chromosome
- commonest inherited cause of LD
- 1 / 4000 males
- M:F 2:1
- commonest single gene cause of autism
- stereotypical movements, hyperactivity
- facial features – protruding ears, elongated face, high arched palate
- large testes
- 10% seizures
common features of foetal alcohol syndrom
a characteristic pattern of facial anomalies (smooth philtrum, thin vermilion border of the upper lip)
evidence of growth retardation (pre-and/or postnatal)
evidence of central nervous system abnormalities (e.g. Microcephaly, LD, irritability)
what are some social outcomes for those with learning disabilities
Social exclusion
Bullying
Poor access to education & training
< 1 in 5 adults with LD are in employment
> 50% continue to live with their birth family
what are some of the impacts on families of those with LDs
Emotional or behavioural problems have a greater impact than LD
Families that cope have managed 4 main tasks:
* Adjustment to a child with developmental differences
* Acceptance that the burden of increased care persists
* Understanding emotional and behavioural disturbance and seeking appropriate help
* Dealing with the cumulative effects of other 3 factors on family wellbeing and relationships
what is down’s syndrome
Deficits: language, long-term memory and motor function
Strengths: visuo-spatial
what is William’s syndrome
Deficits: attention, visuo-spatial, short term memory and planning
Strengths: auditory processing, music and concrete language
development of mental competencies such as.,
- Identification of self and non-self
- Motor regulation and coordination, sensory modulation
- Selective attention and attention-switching - this develops as children mature
- Communication skills and theory of the mind - as children grow older, they gradually are able to understand that other people are agents who similar ideas of the world but can be different (Sally-Anne Test)
- Emotion recognition, regulation and empathy - to understand emotions in yourself and other people - whether the child can recognise that they are/ another person is distressed
- Self-concept and self-esteem - when do you start having a sense of self?
- Reciprocal social interaction and relationship building
- Reality testing, perspective-taking and other executive function skills - if you don’t have theory of mind, it is hard to develop these skills - cannot understand other people’s reality and perspective.
