Transcript overview of learning disability in children

OVERVIEW OF
LEARNING
DISABILITY IN
CHILDREN
A population of 250, 000 –
would be expected to include 200 children with a
severe LD
( British Paediatric Association, 1994)
Would be expected to include 25 children with
challenging behaviour
Psychiatry , Paediatrics or Neurology ?
Mind – Brain Dichotomy is less evident in current
practice of CAMHS Psychiatrists
Paediatricians and Neurologists appreciate the
impact of emotional and environmental factors
Push towards Bio Psychosocial Formulations and
Evolution of Developmental Psychiatry within
CAMHS
Application of psychotherapuetic principles
ICD 10 Diagnostic category for condition s
associated with IQ under 70 and deficits in
social adaptation is Mental Retardation
 But the OFFICIAL TERM is LEARNING
DISABILITY (LD)
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ICD- 10 Categories from F70- F79
Mild MR ( IQ 50-69), in adults mental age from 9
to under 12 years
 Moderate LD ( IQ 35-49) , in adults mental age
from 6 to under 9 years
 Severe LD ( IQ 20-34) , in adults mental age
from 3 to 6 years
 Profound LD ( IQ BELOW 20), in adults mental
age below three years
F78 Other MR
F79 Unspecified

Multi –Axial Framework
ICD 10 has Multi axial framework for psychiatric
disorders in childhood and adolescence ( WHO,
1996)
Axis 1 Clinical Psychiatric Syndromes
Axis 2 specific Disorders of Development
Speech ,language, reading, spelling, motor
development
Axis 3 Intellectual Level , IQ below 50, have
around 40-50% incidence of psychiatric disorder
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Multi Axial Framework
Axis 4 associated medical conditions
including genetic syndrome
Axis 5 associated abnormal psychosocial
conditions - parental mental illness, child
abuse and neglect, other adversities
Axis 6 Global social functioning
Be ware of uneven cognitive profiles
 Areas of relative strength and weaknesses
 A child with mild LD in health terms would
be sometimes described as having a
moderate learning disability in educational
terms
 Children with borderline learning disability
show more prominent specific educational
impairments
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Characteristics of children with severe LD:
Marked social impairment
Organic pathology prominent
Dysmorphology, physical handicap, major health issues
Fairly equal distribution across socio economic groups
Higher incidence of hyperactivity, autism , self injury ,
psychiatric & behavioural disorder ( rate of 47% ,
Corbett 1979)
Presentation of disorders often altered , mental state may
be difficult to determine

Isle of Wight , 10 year research project by
Prof Rutter and colleagues- 10-12 yr olds
Increased incidence of psychiatric disorder
in children with learning disability, epilepsy,
cerebral palsy
Predisposing Factors to Mental
Health Issues
Poor Communication
 Sensory deficits
 Sensory processing difficulties
 Epilepsy
 Physical illness
 Behavioural Phenotype
 Side effects to medication

Predisposing Factors
Adverse life events and circumstances
including abuse and neglect
 Attachment issues
 Limited range of coping strategies
 Lack of appropriate educational provision

Predisposing factors
Lack of adequate support for psychosexual
issues
Lack of exploration of life limiting conditions,
parental health and mortality
Lack of space to explore YP’s vulnerabilities
and ongoing need to rely on parents /
carers
Role of CAMHs LD Psychiatrists
Diagnostic assessments for
developmental disorders,( e.g. Autism,
ADHD)
 Assessments of behavioural difficulties,
challenging behaviour, psychiatric illness
and various comorbidities
 Crisis management
 Multiagency working

Developmental assessment
Developmental history inc family history,
Functioning at 4-5 years
Language development
Social skills and play skills development
Current function
Observational assessments at school,
home, with peer group

Developmental assessment
Review medical file and identify current
medical issues
 Note physical anomalies, musculoskeletal
conditions
 Height, weight , sexual maturation
 Neurocutaneous markers
 Sensory deficits

Diagnostic assessments
Developmental behaviour checklist(DCBL)
 WISC, WAIS
 ADOS, ADI
 Medical: karyotyping, molecular
cytogenetics- CGH,
Metabolic screening
MRI, EEG

Behavioural Phenotype
Non progressive syndromes
Fragile X S
Angelman S
Prader willi S
TSC
Williams Syndrome

Progressive Syndromes
Mucoploysaccharidoses
Trisomies such as Trisomy 18 (
Edwards),Trisomy 13( Patau)
Lesch Nyhan syndrome
Rett Syndrome
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Down ‘s Syndrome
1 in 600 live born
 One third of cases with significant LD
 1 IN 3 can have a psychiatric disorder
 A large proportion develop clinical features
of Alzheimer’s in their mid 40s

22q 11 deletion Syndrome
Cardiac problems
 Anomalous facies
 Thymus hypoplasia
 Cleft palate
 Hypocalcemia
 Higher incidence of psychosis
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Fragile X syndrome
Atyical ASD, theory of mind often less
impaired than in classical autism
 Overactivity
 Social anxiety, repetitive behaviour
 FMR-1 gene is located on the distal arm of
x chromosome
 Direct correlation between length of CGG
repeat sequence and severity

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Failure of inhibition of arborisation of
neurons

Brain 10% heavier

Females have a milder phenotype
Prader willi syndrome – loss of paternal
contribution on proximal part of long arm
of chromosome 15 ( q 11-13) variable LD,
insatiable eating from mid childhood,
anxiety, mood disorders, paranoid
psychosis
 Angelman syndrome – loss of maternal
contribution on the same portion of
Chromosome 15
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Angelman’s- severe to profound LD, lack
of speech, autism, ataxia, motor
difficulties, sleep problems, epilepsy , half
the cases, inappropriate laughter
Tuberous sclerosis complex
Autosomal dominant, ch 9q, 16 p
 Neuro cutaneous, multisystem
 Seizures, LD, hamartoms, neoplasms,
subependymal giant cell astrocytomas
 Specific guidelines established for life time
management

William’s syndrome
Microdeletion on chromosome 7,
disruption of elastin gene
 Moderate LD

Superior verbal abilities
 Visuospatial processing difficulties

Rett Syndrome
Mutation on MECP2 gene, distal arm of ch
Xq 28
 Normal development until 6-18 months
 Marked global developmental regression
 Severe to profound LD
 Loss of purposeful hand movements
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Sleep Disorders
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Poor sleep pattern
Sleep cycle disorders
Catastrophic sleep pattern in smith Magenis
Syndrome
Deletion chromosome 17 ( 17p 11.2)
Inverted circadian rhythm of melatonin
secretion
Behavioural difficulties including self injury
Smith Magenis Syndrome
Epilepsy
Childhood absence
 Complex partial epilepsy
 Non convulsive convulsive Status
epilepticus
 Interictal phenomena
 Landau-kleffner syndrome

Psychiatric Disorders
Depressive episodes
 Anxiety Disorders
 OCD
 Episodic psychiatric disorders
 Paediatric Bipolar, Bipolar nos
 Bipolar 1& 2
 Psychosis

Aspects of Legal Framework
Children Acts 1989 &2004
 Mental Health Act 1983, amendments in
2007, introduced Nov 2008
 Mental Capacity Act 2005
 Human Rights Act 1998
 Family Reform act 1969

The Children act generally applies to
young people under 18
 MCA 2005 applies to young people aged
16 and 17 ( and adults over 18)
 Even if detained under MHA, treatment for
ab physical disorder is under MCA
 Disputes regarding placement for YP aged
16 and 17 may be transferred from Family
Court to Court of Protection

Human Rights Act
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HRA 1998 became the law within the UK in Oct
2000
Before the HRA was passed, UK had been
bound by the 1950 ECHR
Incompatibility with HRA may apply to both
omissions and actual acts
UK citizens can bring a stand- alone legal action
if they believe their convention rights have been
breached or about to be breached
Main Articles of HRA -1
2.Right to Life
 3.Prohibition of torture or inhuman or
degrading treatment/punishment
 5.Right to liberty and security
 6.Right to a fair trial
 7.No punishment without law
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Main Articles of HRA-2
Right to respect for private and family life
 Freedom of thought, conscience and
religion
 Freedom of expression
 Freedom of assembly and association
 Right to marry
 Prohibition of discrimination
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Detention under MHA is recognised as a lawful
option within Article 5 of HRA
There is broad compatibility between MHA and
HRA
Ways in which MHA can be scrutinised by a
court of law
Seclusion whilst detained under MHA is lawful ,
but the way in which it is used might breach a
person’s human rights
Hence the reasons for use of seclusion and
conditions of seclusion must follow guidelines
MCA 2005
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Fully implemented in 2007
Provides a statutory framework for making
decisions for people over the age of 16 who lack
the capacity to make a decision/decisions for
themselves
It is particularly important in client groups with
learning disability , dementia and brain injuries
It defines capacity in relationship to particular
decisions
MCA 2005
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A person must be presumed to have capacity unless it is
established that he is lacking in capacity
Any one working with service users should do as much
as they can to assist them in making any decision for
themselves
a. simplify information
b. presenting in non verbal form
c. giving the service user time to
understand
MCA 2005
A person should not be treated as unable
to make a decision merely because the
decision is considered to be unwise
 Any decision made on behalf of someone
who lacks capacity should be an option
that is least restrictive and is in their best
interests
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Lack of capacity
Two stage test
1. Person must be unable to make a
decision for himself in relation to the
matter because of an impairment or , or a
disturbance in the functioning of , the mind
or brain
It does not matter if the impairment is
permanent or temporary

Lack of capacity
2. Person is unable to
to understand information relevant to the
decision
to retain that information
to use or weigh the information as part of the
process of making the decision
to communicate his decision
If the person is unable to any one of the four above
then they are deemed to lack capacity
Decisions and choices are made after
establishing what is in their best interests
 Use of restraint in certain situations must
be proportionate to the risk of harm
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