Learning Disability Psychiatry

Question 1

What is the definition of a learning disability?

Answer 1

‘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 2

What is the criteria for a learning disability?

Answer 2

1) Intellectual impairment (IQ < 70) (Wechsler)

2) 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

3) Onset in the developmental period (age 18)

Question 3

What is the prevalence of intellectual disability?

Answer 3

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%, because of:
1) Differential mortality (the more severe the degree of learning disability, the higher the mortality c.f. general population)

2) The role of functioning - those with IQ<70 but no problems functioning within their environment would not be defined as having a learning disability

Question 4

IQ is used to classify the level of learning disability what is consider a mild learning disability?

Answer 4

IQ of 50 to 69

Question 5

IQ is used to classify the level of learning disability what is consider a moderate learning disability?

Answer 5

IQ of 35 to 39

Question 6

IQ is used to classify the level of learning disability what is consider a severe learning disability?

Answer 6

IQ of 20 to 34

Question 7

IQ is used to classify the level of learning disability what is consider a profound learning disability?

Answer 7

IQ of <20

Question 8

Aetiology of learning disabilities?

Answer 8

1) Genetic
2) Infective
3) Toxic
4) Trauma
5) Unknown

Question 9

Aetiology of learning disabilities - Genetic?

Answer 9

Genetic: e.g.
> Single gene: Fragile X, PKU, Retts Syndrome

> Microdeletion/duplication: DiGeorge Syndrome, Prader-Willi, Angelman syndrome

> Chromosomal abnormality: Down Syndrome

Question 10

Aetiology of learning disabilities - Infective?

Answer 10

ante-natal e.g. rubella;

post-natal e.g. meningitis, encephalitis

Question 11

Aetiology of learning disabilities - Toxic?

Answer 11

foetal alcohol syndrome

Question 12

Aetiology of learning disabilities - Trauma?

Answer 12

birth asphyxia, head injury

Question 13

What common conditions are associated with learning disabilities?

Answer 13

Epilepsy – increased incidence and complexity with severity of learning disability (10-50%)

Sensory impairments – hearing (40 %) and vision (20%), earwax

Obesity – predisposes to other health problems

Gastrointestinal – swallowing problems, reflux oesophagitis, Helicobacter pylorii, constipation

Respiratory problems – chest infections, aspiration pneumonia

Cerebral palsy – especially with severe learning disability

Orthopaedic problems – joint contractures, osteoporosis

Dermatological and Dental problems- 33% unhealthy gums, for Down’s Syndrome, 80%

Question 14

Assessment areas of learning disabilities?

Answer 14

Aetiology of LD

Associated biomedical conditions

Severity of LD

Psychiatric Disorders, their cause and consequences

Question 15

Which mental health problems are associated with learning difficulties?

Answer 15

1) Schizophrenia / Psychosis
2) Mood Disorders
3) OCD
4) Autism
5) Over-activity syndromes
6) Challenging Behaviour and Self Injury
7) Forensic

Question 16

Which mental health problems are associated with learning difficulties - Schizophrenia / Psychosis?

Answer 16

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 17

Which mental health problems are associated with learning difficulties - Mood Disorders?

Answer 17

Increased incidence

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

Question 18

Which mental health problems are associated with learning difficulties - OCD?

Answer 18

Ritualistic behaviour and obsessional themes significantly increased in LD

Obsessions hard to describe by people with LD but compulsions more readily observed

Question 19

Which mental health problems are associated with learning difficulties - Autism?

Answer 19

2/3 of persons with Autism have a LD

Question 20

Which mental health problems are associated with learning difficulties - Over-activity syndromes?

Answer 20

ADHD much higher incidence

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

Question 21

Which mental health problems are associated with learning difficulties - Challenging Behaviour and Self Injury?

Answer 21

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 22

Which mental health problems are associated with learning difficulties - Forensic?

Answer 22

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

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

Question 23

What is diagnostic overshadowing?

Answer 23

Presenting symptoms are put down to their learning disability, rather than seeking another, potentially treatable cause

E.G: when a person presents with a new behaviour or existing ones escalate, consider:
1) Social cause - change in carers, lack of support, lack of social activities

2) Psychological issues - bereavement, abuse
3) Physical problems - pain or discomfort, e.g. from ear infection, toothache, constipation, reflux oesophagitis, deterioration in vision or hearing.
4) Psychiatric cause - depression, anxiety, psychosis, dementia