Learning Disability

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’

ICD 10

Question 2

What is the criteria for learning disability?

Answer 2

1. Intellectual impairment (IQ < 70) (Wechsler)
2. Social or adaptive dysfunction (Vineland Scale)
   
   1. 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 general prevalence of learning disability?

Answer 3

• The prevalence of people with LD is 1-2%, because of:
  
  • Differential mortality (the more severe the degree of learning disability, the higher the mortality c.f. general population)
  • 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

What are the classifications of learning disability using IQ?

Answer 4

• Mild learning disability 50 to 69
• Moderate learning disability 35 to 49
• Severe learning disability 20 to 34
• Profound learning disability <20

Question 5

What are the options for aetiology of LD?

Answer 5

• Genetic: e.g.
  
  • Single gene: Fragile X, PKU, Retts Syndrome
  • Microdeletion/duplication: DiGeorge Syndrome, Prader-Willi, Angelman syndrome
  • Chromosomal abnormality: Down Syndrome
• Infective :
  
  • ante-natal e.g. rubella;
  • post-natal e.g. meningitis, encephalitis
• Toxic: e.g. foetal alcohol syndrome
• Trauma: e.g. birth asphyxia, head injury
• Unknown: for most individuals, the cause of their LD is unknown

Question 6

Which physical conditions can be affected by someone having a LD?

Answer 6

• 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 7

Why do we need a speciality of psych for LD specifically?

Answer 7

• Higher incidence of psychiatric disorders in those with LD
• More severe the LD - higher prevalence of psychiatric disorder
• People with mild learning disability may present in broadly similar way to the general population
• Where there is less verbal communication, observable signs are relied on more in making the diagnosis
  • e.g. weight loss, withdrawal, agitation, tearfulness in depression
  • behavioural disturbance in psychotic disorder

Question 8

Which areas do we need to assess in the psychiatry of LD?

Answer 8

• Aetiology of LD
• Associated biomedical conditions
• Severity of LD
• Psychiatric Disorders, their cause and consequences

Question 9

Notable features of schizo in LD?

Answer 9

• 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 Syndromea

Question 10

Notable features of mood disorders in LD?

Answer 10

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

Question 11

Notable features of OCD in LD?

Answer 11

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

Question 12

Notable features of autism in LD?

Answer 12

• 2/3 of persons with Autism have a LD

Question 13

Notable features of over-activity syndromes in LD?

Answer 13

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

Question 14

How can challenging behaviour and self harm present in someone with LD?

Answer 14

• 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 15

Do people with LD have a differing forensic history?

Answer 15

• 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 16

What should health professionals do when treating people with LD?

Answer 16

• Take time and have patience.
• Value what is being communicated.
• Recognise non-verbal cues.
• Find out about the person’s alternative communication strategies if verbal communication is difficult (e.g. their typical non-verbal cues, use symbols, sign language).
• Explain things clearly in an appropriate way (verbally & with pictures etc). Simple, short, jargon free language
• Be prepared to meet the person several times to build up rapport & trust.
• Use the knowledge and support of people’s carers

Question 17

How can we be aware of diagnostic overshadowing?

Answer 17

THINK: SOCIO-PSYCHO-BIOLOGICALLY

• 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:
  
  • Social cause - change in carers, lack of support, lack of social activities
  • Psychological issues - bereavement, abuse
  • Physical problems - pain or discomfort, e.g. from ear infection, toothache, constipation, reflux oesophagitis, deterioration in vision or hearing.
  • Psychiatric cause - depression, anxiety, psychosis, dementia