Learning disability, ASD and ADHD

Question 1

What is included in the subsets of mental disorder according to legislation?

Answer 1

• Mental illness
• Personality disorder
• Learning disability

Question 2

What is the ICD-10 definition of learning disability?

Answer 2

A condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence i.e. cognitive, language, motor and social abilities

Question 3

Learning disability criteria

Answer 3

• Intellectual impairment (IQ < 70) (Wechsler)
• Social or adaptive dysfunction (Vineland Scale)
  
  • Deficits/Impairments in 2 or more of following adaptive skills: communication, self-care, home living, social skills, community use, self direction, health and safety, functional academics, leisure & work
• Onset in the developmental period (< age 18)

Question 4

Statistically the prevalence of people with IQ<70 should be 2.5% (2SD from mean).

Actually the prevalence of people with LD is 1-2%, why is this?

Answer 4

• Differential mortality (the more severe the degree of learning disability, the higher the mortality c.f. general population)
• Adaptive functioning included in diagnosis - those with IQ<70 but no problems functioning within their environment would not be defined as having a learning disability

Question 5

How is learning disability classified?

Answer 5

IQ is used to classify level of LD

• Mild learning disability 50 to 69 (85%)
• Moderate learning disability 35 to 49 (10%)
• Severe learning disability 20 to 34 (3-4%)
• Profound learning disability <20 (1-2%)

Question 6

A person with a milder learning disability may only need support in some areas. Name some common areas of difficulty.

Answer 6

• Budgeting
• Making plans
• Managing time

Question 7

Classes of causes of learning disability

Answer 7

• Genetics
• Pre-natal
• At birth
• In childhood

Question 8

Genetic causes of learning disability

Answer 8

• Single gene disorders
  
  • Fragile X syndrome
  • Phenylketonuria
• Copy number variants/microdeletion/duplication
  
  • DiGeorge
  • Prader-Willi
  • Angelman
• Chromosomal disorders
  
  • Down syndrome
  • Klinefelter syndrome
  • Turner (most commonly “learning difficulty”

Question 9

Prenatal causes of learning disability

Answer 9

In-utero exposure to

• alcohol - foetal alcohol syndrome
• tobaco smoke
• prescried and illicit drugs (eg sodium valproate)
• infections - TORCH
  
  • toxoplasmosis
  • others (hep B, syphillis)
  • rubella
  • cytomegalovirus
  • herpes simplex, herpes zoster

Question 10

Causes of learning disability at birth

Answer 10

• Prematurity
• Late delivery
• Hypoxic brain injury

Question 11

Early childhood causes of learning disability

Answer 11

• Head injuries in childhood
• Pesticide and heavy metal exposure
• Untreated congenital conditions
  
  • eg PKU, hypothyroidism
• Malnutrition, iodine deficiency

Question 12

Schizophrenia / Psychosis in learning disability

Answer 12

• 3% Point Prevalence compared to 1% in general population
• Associated with change in personality and reduction in functional abilities
• ‘Self-Talk’ common in LD, particularly Downs Syndrome

Question 13

Mood Disorders in learning diability

Answer 13

• Increased incidence
• Less likely to complain of mood changes and noted by change in behaviour ie biological symptoms

Question 14

OCD in learning disability

Answer 14

• Ritualistic behaviour and obsessional themes significantly increased in LD
• Obsessions hard to describe by people with LD but compulsions more readily observed

Question 15

Autism in learning disability

Answer 15

• 2/3 of persons with Autism have a LD

Question 16

Over activity syndrome in learning diability

Answer 16

• ADHD much higher incidence
• Many severe LD children are overactive, distractible and impulsive but NOT to extent that would indicate diagnosis of ADHD

Question 17

Challenging Behaviour and Self Injury in Learning Disability

Answer 17

• Mannerisms, head banging and rocking common with severe LD
• General trend is towards greater prevalence of problem behaviour with increasing severity of LD (but people with profound LD exhibit less outwardly)

Question 18

Forensic in learning disability

Answer 18

Mild LD have similar rates of offending to the general population but different profile of offending.

IQ below 70 over-represented for arson and sexual (usually exhibitionism) in prison population.

Question 19

Contributors to health inequalities

Answer 19

• Social exclusion
• Socio-economic deprivation
• Inaccessible services
• Discrimination
• Lack of appropriate knowledge and skills in professionals
• Minimal evidence base from research

Question 20

Features of autistic spectrum disorder

Answer 20

• Social interaction
• Communication
• Behaviour

Question 21

Social interaction in autistic spectrum disorder

Answer 21

• Lack of eye contact
• Delay in smiling
• Avoids physical contact
• Unable to read non-verbal cues
• Difficulty establishing friendships
• Not displaying a desire to share attention (ie not playing with others)

Question 22

Communication in autistic spectrum disorder

Answer 22

• Delay, absence or regression in language development
• Lack of appropriate non-verbal communications such as smiling, eye contact, responding to others and sharing interest
• Difficulty with imaginative or imitative behaviour
• Repetitive use of words or phrases

Question 23

Behaviour in patients with autistic spectrum disorder

Answer 23

• Greater interest in objects, numbers or patterns than people
• Stereotypical repetitive movements (may be self stimulating movements to comfort themselves, such as hand flapping or rocking)
• Intensive and deep interests that are persistent and rigid
• Repetitive behaviour and fixed routines
• Anxiety and distress with experiences outside their normal routine
• Extremely restricted food preferences

Question 24

ICD 10 criteria for attention deficit hyperactivity disorder (ADHD)

Answer 24

• The main symptoms of HKD are impaired attention and overactivity. Both are necessary for diagnosis.
  
  • Impaired attention – manifested by a lack of persistent task involvement and a tendency to move from one activity to another without completion.
  • Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting, particularly in situations requiring calm.
• Early onset – behavioural symptoms present prior to 6 years of age, and of long duration.
• Impairment must be present in two or more settings (e.g. home, classroom, clinic).
• Diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia must be excluded.

Question 25

Managment of ADHD

Answer 25

• Parental and child education
• Healthy diet and exercise
• Medication - Central nervous system stimulants
  
  • Methylphenidate