Learning Disabilities Flashcards
What are the criteria for learning disability?
- Sub average intellectual functioning - IQ of 70 or below.
- At least two limited areas of adaptive functioning exist concurrently (but tend to have more) e.g….
- Comunication
- Self-care
- Home living
- Social Skills
- Community Use
- Health and Safety
- Functional academics
- The disability occured before the age of 18 years
All these criteria must be present concrrently
It is not a specific LD
- Dyslexia, dyspraxia (difficulty with complex movements), dyscalculia as they are specific areas
- However, specific learning difficulties and intellectual disability can coexist
It is not emotional or behavioural problems
These can disrupt schooling, thus impacting on subsequent achievement in later life
ADHD or ASD
Though these conditions are more prevalent in the LD population
Describe borderline intellectual functioning
- Not classified as LD but still vulnerable due to cognitive status 70-100 IQ
- 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
Describe mild LD
IQ 55-70 - 2% population, 75% of LD
- 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 support service
- Mat be employed
Describe moderate LD
IQ 40-55 - 20% of LD
Basic communication skills
Requires supervision with self-care
Living in supported accommodation
Can engage in a structures day programme or workshop activities
Community access with staff
Describe severe LD
IQ 20-40 - 5% of LD
Limited communication
Motor impairment
Needs supervision in daily activities
Living in 24-hour staffed home
In alterative day programmes with a combination of skills-based and recreational activities
Describe profound LD
IQ <20. <1% of LD
Requires 24-hour supervised care
Living either with family or in group home / nursing home
Multiple medical problems
Inner world largely unavailable to others because of communication difficulty
Describe the genetic aetiology of LD
• Cause Unknown in majority of cases, cspccially in those with a mild to borderline LD
- Most common inherited cause of LD: — Fragile X Syndrome
- Most common known genetic cause of LD: — Down’s syndrome
- Most common cause of LD world wide: — Malnutrition
Autosomal abnormalities
Downs syndrome - Trisomy 21
Edwards syndrome - Trisomy 18
Pataus syndrome - Trisomy 13
Di George syndrome - Micro deletion of 22
AD:
Tuberous Sclerosis
Neurofibromatosis
AR:
Disorders of protein metabolism - PKU
Disorders of carbohydrate metabolism - galactosaemia
Disorders of fat metabolism - Cerebromacular degeneration
Sex chromodomal abnormalities
Fragile X syndrome - X q 27-28
Klinefelters syndrome - 47 XXY
Turners Syndrome - 45 XO
Lesch–Nyhan syndrome
Describe the perinatal and postnatal causes of LD
Perinatal - first trimester
Iatrogenic - radiation chemotherapy, medication
Infections - Toxoplasmosis, rubella, cytomegalovirus, herpes, syphillis
Delivery - anoxic brain damage, prematurity
Others - hyperbilirubinaemia, FAS
Postnatal causes
• Infections - Encephalitis
• Metabolic - Hypoglycaemia
• Endocrine - Hypothyroidism
• Cerebro-vascular - Thrombo-embolism
• Toxins - Lead poisoning
• Trauma - head injury
• Neoplasms - Meningioma
• Psychosocial - Low socio-economical background, malnutrition, deprivation
Describe Down’s syndrome
The most frequent know cause of LD
- 1 in 660 live births
Caused by a microscopically demonstratable chromosomal aberration - trisomy 21
Moderate to mild LD
Behavioural Phenotype: Humorous, good natured, sociable, affectionate, stubborn
Multisystem disorder
• Epilepsy Infantile spasms — Tonic (Ionic Seizure, in middle age
• Hypothyrodism
• Obesity
• Sensory impairments
• C-spine abnormalities 7-40% Atlanto Axial Instability
• Recurrent Respiratory Tract and car infection
• Obstructive sleep apnoea
Psychiatric Associations
Dementia - 2-3% <40, 55% <60
Depression
Hyperactivity
OCD
Autism
What are the issues involved in communicating with people with LD
Expression
Content of conversation can be superficial
Likely to contain fillers such as ‘you know’
Articulation may be difficult
May speak too slowly or loudly, find it difficult to use conventional syntax or grammar
Pragmatics
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
Environmental problems - too many people, noise, lights
Organic Function
Attention and retention difficultes
Hearing and visual impairment
What is the best way to communicate with people with LD
- 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, eavdrink, favourite book/object, offer reassurance, one person takes lead
- Continuity of care particularly important
- Use simple language that avoids ambiguity. Check if they have understood
- Write down and draw things to aid understanding
- Don’t ask yes/no questions. Will usually be yes.
Describe the similarities and differences in psychiatric disorder in LD
Same disoders seen but prevalence is higher - from 14% to 67%
1. Presentation of symptoms can be different
- Limited communication skills
- Difficult to assess thought disorder & hallucinations esp. in IQ<50
- Diagnostic overshadowing ( automatically attributed the symptoms or disturbance to LD)
- Change in behaviour e.g. self harm
- loss of skills e.g. incontinence
- Withdrawal / isolatoin
- Not doing things they used to enjoy
- Biological Symptoms such as sleep disturbance or weight change
2. Increased vulnerability/stressors
• Limited coping strategies
• Limited choices and opportunities
• Limited social networks
• Limited or adverse life experiences including discrimination, victimisation, multiple moves
What are the principles of treatment of psychiatric illness in people with LD
Same options as general population Bio-psycho-social but:
Capacity / best interests
Extra support
- Accessible information
- Psychotherapies may need adapting
- Community learning disability team involvement
Go low and slow with medication
Describe autism
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. Symptoms may be part of an underlying syndrome e.g. TS, fragile X.
Triad of impairments: Within each is a range of presentations
Social spectrum:
- *Aloof**: most impaired, in own bubble
- *Passive**: Don’t know how to interact, sit back and wait
- *Active but odd:** one sided interational style - in your face
- *Overformal, stilted**: learned a social style and will apply it regardless of circumstance
Communication spectrum:
None
Needs-based: communicate when want something
Repetative, one-sided: telling you things but no recriprocal interest
Formal, long-winded, literal, unsual: Esoteric
Restricted activities / imagination spectrum
- *Handles objects for sensations**: most impaired, interested in sound and smell
- *Handles objects for practical purposes only**
- *Limited, repetitive, isolated pretend play**
- *Rigid, stereotyped imaginary world**: but don’t have a social imagination
- *Special skills:** can be useful but not if it takes over their world
Also sensory Sensitivities
- Hyper/hypo to stimuli (hypo more common in LD)
- Sound most common sense affeced
- Also vision, touch, smell and taste
- Propnsity to sensory overload
- Sensory blocking or tuneouts like humming
Describe mental heath and autism
Anxiety is core. Virtually everyone with autism has it.
Challenging behaviour can be underlying anxiety because they are always on the edge.
Depression is a major issue especially with better insight. Most want friends and relationships and get it wrong. Also very vunerable because they take everything at face value.
Difficult to dissociate psychosis vs. a complicated fantasy world
OCD lots of rituals in both but in OCD egodystonic - in autism they are around anxiety reduction and enjoyment
How can you manage autism
- 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 MTI issues
Describe challenging behaviour
‘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’.
- Aggressive behaviour
- Self-injury
- Stereotypic behaviour (repetitive with no function)
- Destructive or dangerous behaviour
- Loud or other behaviour that makes others frightened
- “Absconding”, or behaviour making the individual vulnerable
- Inappropriate sexual behaviour which may be related to misunderstanding
- Spitting, smearing
- Sexist, racist or other upsetting behaviours
• Relatively common
— Increases with severity of ID
— 5-15% in educational, health or social care services
— 30-40% in hospital
— Current “problem behaviour” in 22.5% in a community sample
• Depends on what is considered to he challenging
— May sometimes reflect more on service/carers/care than the individual
Causes and reasons
• Physical illness and pain
• Mental disorders — Mental illness, PD, dementia, autism etc
• Communication of need or distress
• Learnt behaviour - gets them what they want
• Sensory impairment
• Communication difficulties
• “Behavioural phenotypes”
• Medications or substances
• Developmentally normal
• Environment or abuse
What are the physical health issues in people with Learning Disability?
Describe epilepsy in people with LD
• Primary (associated) : — Hypothyroidism, Epilepsy, Visual/Hearing impairment, Cerebral palsy, motor problems,
• Secondary: — Fracture, Obesity, Gastro-esophageal reflux, Caries, Edentulus, Incontinence, Infection, Constipation
Epilepsy
- 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
What is a behavioural phenotype?
Behavioural phenotypes are patterns of behaviour that present in syndromes caused by chromosomal or genetic abnormalities.
They have both physiological and behavioural manifestations with distinctive social, linguistic, cognitive and motor profiles. Their course is not static.
The study of behavioural phenotypes aims to identify bona fide links between genotype and phenotype.
Started with Down who thought trisomy 21 kids had “a lively sense of the ridiculous”
Opinions are divided, between those who regard the study of behavioural phenotypes as being worthwhile and those who have their doubts
Describe fragile X syndrome
Most common inherited cause of LD
Affected male patients typically have moderate mental retardation; female patients can have milder learning difficulties
Autism spectrum disorders are common in about 30% and hyperactivity in 10%
Common physical features include long face, large ears, prominent jaw, and macro-orchidism in postpubertal male patients
An expansion of the trinucleotide repeat region in the FMR1 gene on the X chromosome can be detected in affected individuals. This results in not enough fragile X mental retardation protein (FMRP), which is required for normal development of the connection between neurons.
Affected children should receive early behavior, speech, and cognitive interventions
Families may benefit from genetic counseling because of the range of features seen in both affected individuals and carriers, as well as for future reproductive planning
