overview of learning disability in children. a population of 250, 000 – would be expected to...
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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)
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 MRF79 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
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
Characteristics of children with severe LD:Marked social impairment Organic pathology prominentDysmorphology, physical handicap, major health issuesFairly equal distribution across socio economic groupsHigher 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
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
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
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
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
Sleep Disorders
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
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
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
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
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
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
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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