Learning disabilities

Question 1

1) What are learning disabilities characterised by?
2) Why can the management of patients with learning disabilities be challenging?
3) Why do patients with learning disabilities have frequent contact with doctors?
4) Describe the male: female ratio for learning disabilities.
5) Why is it estimated that the number of people with severe learning disabilities is increasing?

Answer 1

1) A developmental condition characterised by global impairment of intelligence and significant difficulties in socially adaptive functioning.
2) Due to impairments in language and communication.
3) Because they are at increased risk of physical and mental illness.
4) 3:2.
5) Because of the increased survival of very premature babies.

Question 2

1) What might multifactorial causes of learning disabilities represent?
2) When do learning disabilities usually present?
3) Behavioural difficulties may arise secondary to a combination of what 4 factors?
4) What are behavioural phenotypes?

Answer 2

1) Environmental factors combined with polygenic inheritance.
2) Usually present in childhood, but may be missed if mild.
3) communication problems, psychiatric or physical illness, epilepsy or suboptimal support for individual needs.
4) They are behaviours which are commonly recognised in particular syndromes. For example, self-harm in Lesch-Nyhan syndrome.

Question 3

Name 7 potential antenatal causes of learning disabilities.

Answer 3

1) Genetic (e.g. phenylketonuria).
2) Activities during pregnancy:
a) Alcohol (FAS)
b) Drugs
c) Medications
d) Smoking
e) Infection (e.g. rubella)

Question 4

Name 4 potential perinatal causes of learning disabilities.

Answer 4

1) Neonatal hypoxia
2) Birth trauma
3) Hypoglycaemia
4) Prematurity

Question 5

Name 5 potential postnatal causes of learning disabilities.

Answer 5

1) Social deprivation
2) Malnutrition
3) Lead
4) Infections (e.g. meningitis)
5) Head injury

Question 6

In people with learning disabilities, abilities can be delayed, reduced or absent in what 6 areas?

Answer 6

1) Language
2) Schooling
3) Motor ability
4) Independent living
5) Employment
6) Social ability

Question 7

Describe the 3 areas concerned with a mild learning disability.

Answer 7

1) Language is usually reasonably good, although development may be delayed.
2) Problems may go undiagnosed, but individuals may struggle through school or may be labelled with behavioural problems.
3) With appropriate support, many people live and work independently.

Question 8

Describe the 4 areas concerned with a moderate learning disability.

Answer 8

1) Language and cognitive abilities are less developed.
2) Reduced self-care abilities and limited motor skills may necessitate support.
3) May need long-term accommodation with their family or in a staff-supported group home.
4) Simple practical work should be achievable in supported settings.

Question 9

Describe the 4 areas concerned with a severe learning disability.

Answer 9

1) Marked impairment of motor function.
2) Little/ no speech during early childhood (some may develop during school years).
3) Simple tasks can be performed with assistance.
4) Likely to require their family home or a 24-hour staffed home.

Question 10

Describe the 3 areas concerned with a profound learning disability.

Answer 10

1) Severely limited language, communication, self-care and mobility.
2) Significant associated medical problems.
3) Usually require higher levels of support.

Question 11

1) Describe the morbidity and mortality rates in people with learning disabilities.
2) Why might medical problems be more common in people with learning disabilities.
3) What percentage of people with learning disabilities have additional mental health problems or associated Autism spectrum disorder?
4) State 3 psychiatric problems which are commonly comorbid in patients with a learning disability.

Answer 11

1) People with learning disabilities have increased physical mortality and morbidity, including higher rates of epilepsy.
2) Problems are compounded by less frequent involvement in health screening and preventative interventions (respiratory infections are a leading cause of death and there are lower uptakes of flu vaccines amongst the learning disability population).
3) 30-50%
4) Mood and anxiety disorders are more common across the spectrum of learning disability. There is an increased risk of schizophrenia in those with a mild learning disability.

Question 12

1) Describe diagnostic overshadowing.
2) Changes in what are usually dismissed, despite indicating physical or mental illness in a patient that does not have a learning disability?

Answer 12

1) The tendency to attribute everything to the learning disability itself.
2) Changes in behaviour, mental state or ability are often dismissed.

Question 13

State and describe 5 possible differential diagnoses for learning disabilities.

Answer 13

1) Autism spectrum disorders: people with Asperger’s syndrome may have significant social deficits, communication difficulties and difficulties in living independently.
2) Epilepsy: may cause transient cognitive impairment. Very frequent uncontrolled seizures can mimic persistent cognitive impairment.
3) Adult brain injury or progressive neurological conditions: if patients present late, it is important to determine if impaired intellect was present before any adult illness.
4) Psychiatric: severe and enduring mental illness such as schizophrenia can lead to chronic cognitive impairment, reduced social functioning and associated speech disorders. Exclude intellectual impairment prior to the onset of psychiatric symptoms.
5) Educational disadvantage/ neglect: lacking the opportunity to learn must be distinguished from a learning disability.

Question 14

Describe 7 investigations you might carry out in patients with learning disabilities.

Answer 14

1) IQ testing: is there global intellectual impairment?
2) Functional assessment of skills, strengths and weaknesses.
3) Detailed developmental history from parents.
4) FBC, U&E, LFT, TFT, bone profile - to exclude reversible disturbances.
5) Additional blood tests for known causes of LD.
6) Investigations for associated physical illness: for example, EEG for epilepsy.
7) Genetic testing if appropriate.

Question 15

What 5 pieces of information might you want to know when asking about the patients developmental history?

Answer 15

1) Details of pregnancy and birth
2) Language and motor skills development
3) Schooling
4) Emotional development
5) Relationships.

NB: school reports can be helpful.

Question 16

1) What might more complex cases of learning disabilities require with regards to treatment?
2) What professions are involved in a specialist learning disability team?

Answer 16

1) They may involve specialist learning disability teams.

2) Psychologists, OTs, nurses, psychiatrists and speech and language therapists.

Question 17

State the 6 areas of management for learning disabilities.

Answer 17

1) Prevention
2) Treat physical comorbidity
3) Treat psychiatric comorbidity.
4) Educational support
5) Psychological therapy.
6) Other support.

Question 18

Describe the 4 factors involved in prevention in management of learning disabilities.

Answer 18

1) Education (for example, on the risks of alcohol during pregnancy)
2) Improved antenatal/ perinatal care
3) Genetic counselling
4) Early detection and treatment of reversible causes.

Question 19

1) Why might the presentation of mental health problems in the LD population be different?
2) How might diagnostic accuracy of psychiatric conditions be improved in patients with LDs?
3) Why might slower dose titration and careful monitoring of medications be essential in people with LDs?
4) In the UK, what might allow appropriate support in mainstream/ specialised schools to maximise a child’s potential?
5) What might psychological therapy include?

Answer 19

1) Because of cognitive, language and communication difficulties.
2) Through the use of specialist guidelines, for example, DC-LD.
3) Because LD patients can be particularly sensitive to medications.
4) Early detection and a statement of special educational needs allow appropriate support.
5) counselling, group therapy and modified CBT.

Question 20

1) What can behavioural therapy help to do in patients with LDs?
2) What appproach is taken in psychological therapy in patients with LDs?
3) Addressing problems in what areas might be of help to a patient with LDs?
4) Change in behaviour in a patient with LDs may mean what?
5) What determines the degree of limitation in a patient with LDs?

Answer 20

1) Can often help to improve unhelpful behaviour patterns.
2) The ABC approach (antecedents, behaviour and consequences of behaviour).
3) Daily living, housing, employment and finances as well as enabling integration into the local community.
4) May communicate any number of emotional or physical problems which cannot be verbalised.
5) The extent of effective support determines the degree of limitation.

Question 21

What 4 things might a psychological management plan for patients with LDs include?

Answer 21

1) Avoiding antecedants.
2) Reinforcing positive behaviours.
3) Preventing reinforcement of negative behaviours (e.g. by using distraction techniques)
4) Helping people understand the consequence of their actions.

Question 22

1) Why is life expectancy decreased in patients with LDs?
2) People with learning disabilities can be very vulnerable to what 3 things?
3) How might their problems then be further compounded?

Answer 22

1) Because of comorbid physical illness and unmet health needs.
2) Neglect, abuse and exploitation.
3) By communication difficulties, so behavioural change may again be the only way of communicating distress.