W2 - Learning disabilities, autism, ADHD Flashcards
1
Q
What is a LD?
A
- Impaired intellectual function
- Impaired adaptive function
- Arising in developmental period
2
Q
What is the average IQ?
A
100
3
Q
How can you classify LDs?
A
By IQ intellectual level Mild 50-69 Moderate 35-49 Severe 20-34 Profound <20
4
Q
What are the 3 domains of adaptive functioning?
A
- Conceptual o IQ, learning, academic, language - Social o Empathy, social judgment, make friends - Practical o Personal care, job, money, organise
5
Q
What causes LDs?
A
- Pre-natal o Genetics syndrome o Infection – rubella o Maternal alcohol - During birth o Trauma – cerebral palsy - After birth o Environmental factors o Inf – meningitis o Traumatic brain injury - Most – no established cause, reflection of normal distribution
6
Q
define autism
A
- Pervasive developmental disorder
- Qualitative impairment in social interaction
- Impairment in verbal and non-verbal communication
- Restricted, repetitive, stereotyped patterns of behaviour, interests and activities.
- Associated sensory difficulties
7
Q
What is the 2 stage test of capacity?
A
- MUST be an impairment or disturbance in the functioning of mind and brain
- MUST be sufficient that the person lacks capacity to make a particular decision
8
Q
What BIOLOGICAL factors could be associated with a rise of mental illness in LD?
A
- Medical Factors
o Hypothyroidism associated Depression in Down Syndrome
o Sensory impairment - Associations with specific syndromes and genetic loci
o Prader-Willi, Down Syndrome have an association with Depression
o Autism is associated with Anxiety
o Smith Magenis Syndrome associated with self injurious behaviours - Diet and lifestyle
o increased rates of inactivity and poor nutrition - Neuroanatomical changes
o Frontal lobe disorder may increase frequency of behaviours which challenge
9
Q
What psychological factors could be associated with a rise of mental illness in LD?
A
- Reduced Adaptive functioning skills
- Reduced problem solving ability
- Poor help seeking behaviours
- Cognitive Deficits eg temporal memory and reduced understanding of time can impact on how life events are experienced
10
Q
What social factors could be associated with a rise of mental illness in LD?
A
What social factors could be associated with a rise of mental illness in LD?
- Increased prevalence of Trauma and Abuse
- Increased number of significant life events:
o Eg Moving placement, support worker moving jobs, loss of contact with family
- Less control over decisions in their life eg moving hom
11
Q
Signs and symptoms people with LD suffering from a mental disorder
A
- Non specific behavioural disturbances
o Aggression, self injury, withdrawal
o Repetitive movements out of keeping of person’s usual presentation - Biological symptoms prominent
o Not sleeping, poor appetite, weight loss
o Tearfulness - Change in functioning is highly significant
o No longer going to work, day centre, neglecting self care/hygiene - Simple and fleeting psychotic symptoms
o Hearing single voices, isolated false beliefs
12
Q
Define challenging behaviour
A
When it is of such an intensity, frequency or duration as to threaten the QOL and/or physical safety of the individual or others and it is likely to lead to responses that are restrictive, aversive or result in exclusion
13
Q
3 core features of ASD
A
- Language – delayed development
- Social Interaction – impaired reciprocal interactions
- Behaviours – Restricted Repetitive behaviours and interests (RRBIs)
14
Q
What psychiatric co-morbidities are common with ASD?
A
What psychiatric co-morbidities are common with ASD?
• 70% have 1 co-morbid condition 40% 2 or more
o ADHD
o Anxiety
o Affective Disorders
o OCD
o Disruptive behaviour disorders
15
Q
What NON-psychiatric co-morbidities are common with ASD?
A
- Epilepsy
- Intellectual disability
- Sleep disturbance
16
Q
Current theories for development of ASD
A
- Strong genetic component
o Twin studies
o GWAS studies
o Rett’s syndrome - Several environmental factors
o Valproate usage by mother during pregnancy*
o Case-Control studies suggest infection or fever during pregnancy - Debunked theories
o “Refrigerator mother”
o MMR – somehow still a concern
o It’s Schizophrenia
17
Q
risk factors for ASD
A
RF for ASD
- Autism in siblings
- Any CNS birth defect
- Prematurity (<35/40)
- Parental psychosis or affective disorder (Schizophrenia++)
- Valproate usage during pregnancy
- Other genetic conditions affecting brain (Fragile X++)
18
Q
Proposed pathophysiology of ASD
A
- 1985 Mind-blindenss theory of autism
- 2002 E-S theory empathising-systemising theory
- 2002 extreme male brain theory
o Females better empathies, males better systemisers
19
Q
When would you assess for ASD?
A
When would you assess for ASD?
One of
- persistent difficulties in social interaction
- persistent difficulties in social communication
- stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests
And
- problems in obtaining or sustaining employment or education
- difficulties in initiating or sustaining social relationships
- previous or current contact with mental health or learning disability services
- a history of a neurodevelopmental condition (including learning disabilities and attention deficit hyperactivity disorder) or mental disorder.
20
Q
What is the scoring chart used to refer patients for a specialist diagnosis assessment?
A
- AQ-10
- For adults with suspected autism without severe or moderate LD
- If score >6/10 –> consider referral
21
Q
What is core autism treatment?
A
- For patients social context increase understanding and sensitivity
o Psychoeducation of family, carers, school workers and students (adults colleagues etc) - For patient increase social skills, attention and reciprocal social skills
o Interactive play
o Increasing social skills
o Adults – group based social learning programmes with peer feedback, explicit rules
- Do not use: o Medications (antipsychotics, antidepressants, mood stabilizers) or diets
22
Q
What medication is best for challenging behaviour?
A
Best evidence for risperidone and aripiprazole
Benzodiazepines not recommended
23
Q
is autism a mental disorder?
A
yes
24
Q
What is the triad of impairment in ASD?
A
- Communication
- Social interaction
- Flexible thinking
- …and often sensory processing difficulties
25
DSM-5 Autism Diagnostic criteria
DSM-5 Autism Diagnostic criteria
- A: persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
- B: restricted, repetitive patterns of behaviour, interests or activities as manifested by at least 2 of the following, currently or by history
- C: symptoms in early developmental period – may not fully manifest until social demands exceed limited capacities or may be masked
- D: symptoms cause clinically significant impairment in functioning
- E: disturbances not better explained by intellectual disability or global developmental delay
26
Define ADHD
* Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with daily functioning
* Neurodevelopmental disorder
* 3-5% of children have ADHD
27
What can Increase the prevalence of ADHD?
```
People born pre-term
Epilepsy
Other neurodevelopmental disorders
History of substance misuse
People known to criminal justice system
Acquire brain injury
Look-after children/young people
Oppositional defiant disorder or conduct disorder (types of personality disorders)
Mood disorders
```
28
What causes ADHD?
• Neurobiological disorder involving aberrant dopamine and noradrenaline
Genetic link
• Link with smoking and alcohol in pregnancy
• Link with prematurity
• Upbringing may increase the symptoms or functional impairment, but do not cause ADHD
29
What are the symptoms of ADHD?
What are the symptoms of ADHD?
Inattention
o Trouble holding attention on tasks
o Does not seem to listen when spoken to
o Difficulties following instructions or finishing schoolwork/tasks
o Difficulty organising tasks and activities
o Difficulty doing tasks that require prolonged mental effort
o Often lose objects
o Easily distracted
o Forgetful
Hyperactivity and impulsivity
- Fidgety
• Often leaves seat when expected to stay in seat
• Runs/climbs in situations where it is not appropriate (in children)
• Restlessness
• Unable to take part in activities quietly
• “On the go” acting as if “driven by a motor”
• Excessive talking
• Blurts out answers before a question has been finished
• Difficulty waiting their turn
• Interrupts others
```
Functional impairments
Academic:
- Difficulty sitting through lectures
- Difficulty revising
- Forgetting meetings and tutorials
- Poor performance during exams
Social
- Friends becoming annoyed at interrupting
- Being late to events
Emotional
- Exhausted due to over-compensation
- Exacerbation of co-morbidities (anxiety, depression, OCD etc.)
Substance misuse
- Cigarettes
- Alcohol
- Illicit substances
```
30
what are the domains of ADHD?
inattention
hyperactivity and impulsiveness
functional impairment
31
How do you diagnose ADHD?
- Persistent pattern of inattention and/or hyperactivity-impulsivity
o ≥6 symptoms of inattention and/or hyperactivity-impulsivity
- Symptoms present in two or more settings (e.g. home, school/work, with friends/family, other activities)
- Negatively impacts directly on social, academic or occupational functioning
- Symptoms present before 12 years old
32
Why do we care to diagnose ADHD?
* x2 more likely to be arrested
* x2 more likely to be divorced
* 50% more likely to be in a serious accident
* 27% less likely to graduate from college
* x4 more likely to lose their job
* x8.5 more likely to abuse alcohol
* x4 more likely to die prematurely
33
How do you manage ADHD?
- MDT approach: psychiatrist, GP, paediatrician, school, parents, patient
- Psychoeducation
o Understand ADHD
o Goal setting
o Healthy lifestyle and exercise
o Parent-training programme
- Psychological therapies
o CBT
- Pharmacological therapies
o Stimulants = methylphenidate, dexamphetamine
o Non-stimulants = atomoxetine, clonidine, guanfacine
34
How do you manage children <5 with ADHD?
- Psychoeducation
- Parent-training programme
- Only consider meds with advice of 2nd specialist
35
How do you manage children >5 with ADHD?
- Psychoeducation
- Lifestyle modifications
- Parent-training programme
- Meds if:
o ADHD symptoms still causing persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed
o Parents/carers have discussed risks and benefits
o Baseline assessment has been carried out
• CBT if
- Symptoms still causing significant impairment despite medication
36
How do you manage ADHD in adults?
```
How do you manage ADHD in adults?
Psychoeducation
Lifestyle modifications
Medication 1st line
Non-pharmacological treatment can be used in conjunction with medication if impairment remains despite medication
```
37
how do ADHD meds work?
Inc availability of neurotransmitters (NA, DA)
38
2 stimulant ADHD drugs
Methylphenidate (short and long acting)
Dexamphetamine (short and long-acting)
39
3 non-stim ADHD drugs
Atomoxetine
Clonidine
Guanfacine
40
side effects of stimualnt ADHD drugs
```
Sleep disturbance
• Loss of appetite
• Increased BP
• Rebound irritability
• Headaches
• Increased anxiety
• Reduced growth in children
```
41
contra-indications to stimulant ADHD drugs
```
Cardiac problems
• Hypertension (untreated)
• Hyperthyroidism (untreated)
• Tics/Tourette’s
• Active psychotic symptoms
```
42
what do you monitor for ADHD drugs?
Adults
- Every 6 months
- HR, BP, weight
- Check for SEs
Children
- Height every 6months
- Weight every 3 months
- HR, BP every 6 m
- If concern about growth, planned break considered for ‘catch-up’
43
Around 3-6 in every 100 school-aged children have ADHD. For about 1 in 7 children with ADHD, their ADHD will continue into adulthood. Stimulant medications can be effective in treating ADHD. Which of the following is not a possible side effects of stimulant preparation (methylphenidate, dexamphetamine and lisdexamfetamine).
```
Weight loss
Insomnia
Hypotension
Psychosis
Headache
```
Stimulant preparations may cause hypertension, not hypotension. Other listed side effects are possible with stimulants.
44
According to ICD10, which of the following is not a diagnostic feature of Autistic Disorder?
The presence of abnormal or impaired development that is manifest before the age of six years.
A type of pervasive developmental disorder.
Abnormal functioning in reciprocal social interaction
Difficulty in communication
Restricted, stereotyped, repetitive behaviour
The presence of abnormal or impaired development that is manifest before the age of three years, not six years.
45
A 13-year-old boy’s mother is concerned that he has no friends and she brings him to the GP surgery. He does not play with other children. He likes model cars and has 1,000 cars in his collection. He is indifferent to either praise or criticism from his mother or teachers. Which is the most likely diagnosis?
```
Attachment disorder
Attention deficit hyperactivity disorder
Autistic spectrum disorder
Obsessive compulsive disorder
Schizoid personality disorder
```
Autistic spectrum disorder
46
Diagnostic overshadowing is an often-debated issue in the psychiatry of intellectual disabilities. This concept refers to
Providing an insufficient diagnostic explanation for genetically determined Syndromes
Making more than one diagnosis for a behavioural problem
Making more than one diagnoses for a physical health problem
Attributing a psychiatric symptom to a behavioural phenotype
Attributing a health issue to an already existing health issue
Attributing a health issue to an already existing health issue
47
Which of these are part of the definition of a learning disability?
```
Difficulty with daily living skills
Restrictive repetitive behaviour
Behaviour that challenges
Memory problems
Increased IQ
```
Learning disabilities are heterogeneous conditions, but are defined by 3 core criteria: lower intellectual ability (usually defined as an IQ of less than 70), significant impairment of social or adaptive functioning and onset in childhood. (NICE)
