Learning Disability

Question 1

Define learning disability

Answer 1

Learning disability is a developmental condition characterised by global impairment of intelligence and significant difficulties in socially adaptive functioning

DSM-5: limited functioning in three areas:
• Social skills (e.g. communicating with others)
• Conceptual skills (e.g. reading and writing ability)
• Practical ability (e.g. clothing/bathing one’s self)

Question 2

Define the 4 degrees of learning disability in terms of IQ

Answer 2

Mild intellectual disability
o IQ: 50-69 (in adults, mental age from 9 to under 12 years)

Moderate intellectual disability
o IQ: 35-49 (in adults, mental age from 6 to under 9 years).

Severe intellectual disability
o IQ: 20-34 (in adults, mental age from 3 to under 6 years)

Profound intellectual disability
o IQ: <20 (in adults, mental age below 3 years)

Question 3

Outline the aetiology of LD using a bio-psycho-social model

Answer 3

Biological:
- Genetics e.g. phenylketonuria
- During pregnancy: Alcohol (foetal alcohol syndrome),drugs, medications, smoking, infection (e.g. rubella)
Prematurity
- Hypoglycaemia
- Birth trauma, Neonatal Hypoxia
- Malnutrition
- Infections e.g. meningitis
- Mental health disorders

Psychological:

• Poor parenting
• Poor schooling
• Poor education

Social:

• Social deprivation
• Poor support

Question 4

Give the main domains in which abilities may be; delayed, reduced or absent in LD

Answer 4

o	Language  
o	Schooling  
o	Motor ability  
o	Independent living  
o	Employment  
o	Social ability  

Behavioural difficulties may arise due to a combination of communication problems, psychiatric or physical illness, epilepsy or suboptimal support for individual needs

Question 5

Outline the different levels of functional impairment for each degree of LD

Answer 5

Mild Learning Disability
o Language is usually good (development may be delayed)
o Problems may go undiagnosed, may be labelled as behavioural problems
o Individuals struggle through school
o May live and work independently with appropriate support

Moderate Learning Disability
o Language and cognitive abilities are less developed
o Reduced self-care abilities and limited motor skills may need support
o May need long-term accommodation with their family or in a staff-supported group home
o Simple practical work should be achievable in supported settings

Severe Learning Disability
o Marked impairment of motor function
o Little/no speech during early childhood (may develop during school years)
o Simple tasks can be performed without assistance
o Likely to require their family home or 24-hour staffed home

Profound Learning Disability
o Severely limited language, communication, self-care and mobility
o Significant associated medical problems
o Usually require higher levels of support

Question 6

Give 3 examples of specific syndromes associated with learning difficulties

Answer 6

• Down syndrome
• Fragile X (elongated face, prominent ears, high arched palate, large tastes)
• Fetal alcohol syndrome (wide palpebral fissure, smooth philtrum, thin top lip)

Question 7

Give some differentials for learning disability

Answer 7

Autism spectrum disorder
o People with Asperger’s syndrome (autism with normal intelligence) may have social deficits, communication problems and difficulties living independently

Epilepsy
o Causes transient cognitive impairment

Adult brain injury or progressive neurological conditions
o Learning disabilities occur while the brain is still developing
o With patients presenting late, decide whether the impaired intellect was present before any adult illness

Psychiatric
o Severe and enduring mental illness (e.g. schizophrenia) can lead to chronic cognitive impairment and reduced social functioning

Educational Disadvantage/Neglect
o Lacking opportunity to learn must be distinguished from learning disability

Question 8

Give some investigations for learning disability

Answer 8

• IQ testing- is there global intellectual impairment?
  WAIS III (Wechsler adult intelligence scale)- 11 subsets to derive verbal IQ and performance IQ to give full scale
  IQ.
  Adaptive and social functioning established via clinical interview and Adaptive Behaviour Assessment system
  (ABAS II)
• Functional assessment of skills, strengths and weaknesses
• Detailed developmental history from parents e.g. details of pregnancy, birth, language and motor skills
  development, schooling, emotional development and relationships. School reports helpful.
• FBC, U&Es, LFT, TFT, bone profile- exclude reversible disturbances.
• Additional blood tests for known causes of LD e.g. PKU
• Investigations for associated physical illness e.g. EEG for epilepsy.
• Genetic testing if appropriate

Question 9

Generate a management plan for learning disability using a bio-psycho-social model

Answer 9

Biological
- Prevention
• Education e.g. risks of alcohol during pregnancy
- Treat physical comorbidity
- Treat psychiatric comorbidity
• Improve diagnostic accuracy with specialist guidelines e.g. DC-LD

Psychological

• Counselling, group therapy, and modified CBT
• Behavioural therapy can improve unhelpful behaviour patterns: ABC approach
  i. Antecedents (avoid)
  ii. Behaviours (reinforce positive)
  iii. Consequences (help people understand the consequences of their action)
• Psychodynamic therapies
• Creative/complimentary therapies
  i. Art therapy, drama therapy, aromatherapy

Social:
- Educational support
- Other support
• Personalised help with daily living, employment, finances
• Integration into local community
• Carer’s needs
• Environmental change including under/over stimulation and address abuse or neglect
- Community inclusion
- Skill’s training – develop independent living

Question 10

Identify some complications of learning disability

Answer 10

Mental illness (particularly):

• Schizophrenia
• Mood disorders
• Autism

Question 11

Summarise the prognosis for patients with learning disability

Answer 11

• LD is a life-long condition.
• Extent of effective support determines degree of limitation
• Life expectancy is reduced: comorbid physical illness and unmet health needs.