Define Learning Disability?
A state of arrested or incomplete development of the mind. Characterised by impairment of skills manifested during the developmental period and skills that contribute to the overall level of intelligence.
What are the main groups of factors influencing the development of LDs?
- Genetic
- Antenatal
- Perinatal
- Neonatal
- Postnatal
- Environmental
- Psychiatric
What are the main Genetic causes of learning difficulties?
Trisomy 21 (Down’s), Trisomy 13 (Patau’s), Trisomy 18 (Edward’s), 45XO (Turner’s syndrome), Fragile X, PKU, Tay Sachs disease, Tuberous sclerosis
What are the main Antenatal causes of learning difficulties?
Teratogens: alcohol, cocaine, prescribed drugs e.g. sodium valproate
Infections (TORCH): Toxoplasmosis, Other, Rubella, Cytomegalovirus, HSV)
What are the main Perinatal causes of learning difficulties?
Extreme prematurity, Intraventricular haemorrhage, Hypoxic-ischaemic injury, neonatal hyperglycaemia, neonatal hyperbilirubinemia
What are the main Neonatal causes of learning difficulties?
Traumatic brain injury, Anoxia (e.g. suffocation, near drowning), Toxin exposure (heavy metals), Infections (meningitis, encephalitis), Abuse, Neglect
What are the main Postnatal causes of learning difficulties?
Traumatic brain injury, Shaken baby syndrome, Malnutrition, Lead poisoning, Abuse, Neglect, Seizure disorders, Rett syndrome, CNS haemorrhage, Acquired hypothyroidism, Hearing or visual impairment
What are the main Environmental causes of learning difficulties?
Lead exposure, Allergies, Substance abuse, Accidents, Impoverished living conditions
What are the main Psychiatric causes of learning difficulties?
Psychological stress, Abuse, Depression, Anxiety, Eating disorders
How are learning difficulties categorised?
Mild: IQ between 50-69
Moderate: IQ between 35-49
Severe: IQ of less than 35
What are the 4 key features which distinguish mild, moderate and severe LD (apart from IQ)?
- Ability to Self Care
- Reading and Writing
- Social Skills
- Physical Issues
What are the features of mild LD?
- Independent self care
- Reasonable reading and writing skills
- Normal social skills
- Rarely see physical issues
What are the features of moderate LD?
- Need some assistance with self-care
- Only basic reading and writing skills
- Only moderate social skills
- Some occasional physical issues are seen
What are the features of severe LD?
- Basic to zero self caring
- Minimal reading and writing ability
- Few social skills
- Physical issues are common
What are some common psychiatric co-morbidities seen in patients with LD?
- Adjustment disorders
- Anxiety
- ADD/ADHD
- Depression
- Substance abuse
Why might people with LDs have worse health than people without LDs.
- Difficulty accessing healthcare
- Communication difficulties (both from the patient and the doctor)
- Shrouding effect of other issues (doctors only seeing the LD)
- Higher rates of co-morbidity
- Lower SES
- Difficulty engaging in certain interventions (complexity, pain, therapy)
- Differences in drug metabolism and the failure of modern medicine to work around this
- Vulnerability to neglect or abuse
- Social stigma
What are some common physical co-morbidities of LDs?
- Epilepsy
- Hearing issues
- Visual issues
- CVD
- Hypothyroidism and Leukaemia in Down’s syndrome
What is it important to bare in mind when taking a history from someone with LD?
- CONDITIONS; is this environment suitable for them? is it causing unnecessary anxiety
- COMMUNICATION; ask the carer what the patient’s preferred mode of communication is, and if you could switch to that
- CONSET and CAPACITY; is this person capable of giving a medical history and do you have their consent
- CARER; establish relationship, start by talking to patient, involve carer at an appropriate point
- CO-MORBIDITIES; make sure to ask about the common co-morbidities suffered by LD patients. both physical and psychiatric.
- Drug history and COMPLIANCE; have their been any issue taking medication
- CARING; social situation and home setup
What is ‘challenging behaviour’? Why is it more common in individuals with LDs?
CB = any behaviour that puts them or those around them (such as their carer) at risk, or leads to a poorer quality of life. Examples include; hurting themselves or others, destroying things, spitting, smearing, stripping off, running away, eating inedible things.
More common in people with LD as they might lack the communication and social skills to understand what is acceptable behaviour, may have underlying issues which they can’t verbalise which manifests as CB.
What are some causes of CB in people with LD (things to look for when investigating LD)?
- Pain or other heal issues (e.g. banging head due to ear ache)
- Social attention (everyone needs attention and kids with LDs are often neglected, may resort to CB).
- Mental health issues
- To get something (some people with LDs learn CB as a means of getting something specific)
- Escape (e.g. from a doctor or dentist)
- Sensory stimulation (they may just enjoy the feeling of whatever they’re doing)
What are ‘psychotropic medications’?
anti-anxiety agents. antidepressants. antipsychotics. mood stabilizers. stimulants.
Why is psychotropic medication use in people with learning difficulties complex?
Often require them due to increased risk of mental health issues BUT, there is a suggestion that often they are given inappropriately in order to curb challenging behaviour which could be best managed conservatively.
STOMP is a project aiming at monitoring psychotropic medication use in these groups and reducing it as much as possible.
When should psychotropic medicine be used in a patient with LD?
If…
- There is a clear indication (in the form of a diagnosis/symptom) AND other options have been trialled first AND use fits in with BNF regulations
- Consent to treatment OR best interest rationale has been met
- Regular monitoring of treatment and side effects
- Continuation /Discontinuation is discusses
What are the most common causes of LD?
- Down’s
- Fragile X
- Worldwide; Malnutrition
