9. Learning Disabilities

Question 1

Define intellectual disability.

Answer 1

• significant impairment of intelligence (IQ ≤ 70)
• significant impairment of ADLs
• both impairments evidence before adulthood*

*Note if these impairments develop in adulthood, the correct term is acquired brain injury.

Question 2

What is adaptive functioning?

Answer 2

A persons ability to manage activities of daily living.

Significant impairment in this area suggests LD pts need considerable support in navigating ADLs.

Question 3

What is a learning difficulty?

Answer 3

A person who experiences isolated problems with specific skills only (e.g. reading, writing, numeracy).

Question 4

What is Fragile X syndrome?

Answer 4

A genetic condition that causes a range of developmental problems, including learning disabilities and cognitive impairments.

Question 5

Why are males more severely affected by Fragile X syndrome, than females?

Answer 5

X-linked dominant disease.

Since males only have one X chromosome, it’s phenotypic expression is more apparent than in females with two X chromosomes.

Question 6

Give some pre-natal causes of learning disability.

Answer 6

• Down syndrome
• Fragile X syndrome
• Spinal bifda
• malnutrition
• alcohol

Question 7

What is the most frequently known cause of LD?

Answer 7

Down syndrome

Question 8

What is the aetiology of Down syndrome?

Answer 8

Trisomy 21 - it is a genetic condition but cases are sporadic, not inherent.

Question 9

Presentation of Down syndrome.

Answer 9

Physical signs (see image)

Cognitive signs:
- learning disability
- gross and fine motor skills affected
- depression

Behavioural symptoms of Down syndrome:
- stubbornness
- difficulty paying attention
- obsessive or compulsive behaviours

Question 10

Give some perinatal causes of LD.

Answer 10

• intrauterine infections (e.g. toxoplasmosis)
• asphyxia
• premature birth

Question 11

Give some postnatal causes of LD.

Answer 11

• epilepsy
• meningitis
• measles
• head injury
• malnutrition

Question 12

What are the IQ ranges for

a) mild LD

b) moderate LD

c) severe LD

Answer 12

a) IQ ≤70

b) IQ ≤49

c) IQ ≤34

Question 13

What are the features of borderline LD (IQ ≤85)?

Answer 13

• living independently
• subtle communication difficulties
• high school drop out / in special education
• difficulty keeping a job
• risk of abusive relationships

Question 14

What are the features of mild LD (IQ ≤70)?

Answer 14

• relative independence in self-care and ADLs
• can hold conversation and engage in clinical interview
• abstract concepts (e.g. time) are difficult
• requires service support
• may engage in paid employment

Question 15

What are the features of moderate LD (IQ ≤49)

Answer 15

• basic communication skills
• requires supervision with self-care
• living in supported accommodation
• engage in structures day programmes
• community access with staff

Question 16

What are the features of severe LD (IQ≤34)?

Answer 16

• limited communication
• motor impairment
• needs supervision in ADLs
• living in 24-hour staffed home

Question 17

What LD is not

Answer 17

• specific learning difficulty (e.g. dyslexia, dyspraxia)
• emotional or behavioural problems
• ADHD or ASD
• acquired brain injury

Question 18

What are the physical associations of LD?

Answer 18

• epilepsy
• hypothyroidism
• obesity
• sensory impairments
• recurrent respiratory tract and ear infection

Question 19

What are the psychiatric associations of LD?

Answer 19

• dementia
• depression
• hyperactivity
• OCD
• ASD

Question 20

Issues with communication in people with LD:

Answer 20

• mask comprehension difficulties
• difficulty understanding medical terms
• will say ‘yes’ to appease
• suggestible
• sensory issues

Question 21

Issues with expression in people with LD:

Answer 21

• content of conversation can be superficial
• articulation may be difficult
• may speak too slowly or loudly

Question 22

What are some factors that can affect communication in LD?

Answer 22

Sensory function:
- hearing impairment
- visual impairment

Cognitive function:
- attention difficulties
- retention difficulties

Environment:
- too many people in room
- temperature
- lighting
- sound

Question 23

What is a communication passport?

Answer 23

Allows patients with LD and their carers to agree and record all the ways a person communicates, and the best ways you can communicate with the person.

https://www.leicestershospitals.nhs.uk/aboutus/our-hospitals/childrens-hospital/children-and-young-people-with-autism/patientpassport/

Question 24

Tips for effective consultations for patients with LD.

Answer 24

• minimise waiting time
• double consultation time
• explain basics
• speak to patient before speaking to carer
• offer breaks

Question 25

What are independent mental capacity advocates?

Answer 25

Independent persons appointed to represent the interests of people who lack capacity, and have no-one else to speak other than paid carers. Must be involved for decisions about serious medical treatment.

Question 26

What is the prevalence of ASD?

Answer 26

1%

Question 27

What is the triad of impairments in ASD?

Answer 27

1. Social spectrum (passive, overformal, sociable with one person) 2. Restricted activities / Imagination spectrum (handles objects for sensations, repetitive movement, special skills) 3. Communication spectrum

Question 28

Define challenging behaviour.

Answer 28

Culturally abnormal behaviour of intensity, frequency or duration that the physical safety of the person or others is placed in jeopardy.

Question 29

What kind of behaviour might be considered challenging?

Answer 29

- aggressive behaviour - self-injury - destructive behaviour - inappropriate sexual behaviour

Question 30

What is NICE guidance on use of antipsychotics to manage challenging behaviour?

Answer 30

Other interventions should be tried first - only specialists should initiate antipsychotics. Monitor response and adverse effects.

Question 31

What are the four key principles of improving the health of people with LD?

Answer 31

- inclusion - choice - independence - rights

Question 32

What is diagnostic overshadowing?

Answer 32

When a HCP makes assumptions that the behaviour of a person with LDs is part of their disability, without exploring other factors such as biological determinants.

Question 33

What are some reasonable adjustments for consultations with LD patients?

Answer 33

- double consultation time - talk to informants - reduce stress* See at home if appropriate; avoid long waits; see at quiet time; seek help for difficult communication.