Introduction – Learning Disability Psychiatry

1. Introduction – Learning DisabilityPsychiatry Dr Michelle Beaumont SPR to Professor Read

2. Aims • Introduction • Assessment • LD specific issues • Psychiatric Disorders • Legal issues • Physical issues

3. Introduction • History • Epidemiology • Aetiology

4. Picture 1

5. History

6. From this…

7. To this….

8. Valuing People 2001 • Principles • Rights - equal • Independent living • Control • Inclusion • Practice • LD register • Health Education factor • Health Action Plans • Housing • Employment

9. Epidemiology

10. Epidemiology • 210,000 Severe & Profound LD • 65,000 children & young people • 120,000 working age • 25,000 older people • 1.2 million Mild / Moderate LD Valuing People 2001

11. Epidemiology continued… • Institute for Health Research at Lancaster University 2004 • 985,000 with LD • 224,000 known to social services • 761,000 mild / moderate LD maybe unknown • Emerson & Hatton total adults with LD • increase by 8 % - 868,000 by 2011 • Increase by 14 % - 908,000 by 2021

12. Epidemiology continued... • 5% live home of own • 30% residential care home • Significant proportion miles away from family • 1 in 10 (known to SS) employment • Significant number live with elderly carers Valuing People Now: A New 3 year strategy for people with LD

13. Picture 2

14. Aetiology

15. IQ Distribution Curve

16. Aetiology

17. Aetiology • Primary disorders with direct effects • Syndromes • Primary disorders with secondary effects • Inborn error metabolism • PKU • TS • Secondary disorders • Antenatal • Neural tube defects • Infection – syphillis, CMV, rubella • Perinatal • Hypoxia • Infection • Trauma • Abuse / accident • Postnatal • Nutrition • Trauma • Infection • Encephalopathies • Metabolic

18. LD levels

19. Picture 3

20. Assessment

21. Assessment considerations • LD criteria • Informants / Carers • Communication • Assessment • Risks

22. Learning Disability Definition • Global impairment of intellectual functioning > diminished ability to adapt to daily demands. (IQ below 70). • Significant deficits / impairments in adaptive behaviours & social functioning. • Onset in development period (<18) ICD - 10

23. LD - Indicators • Special school • Statement (can be behavioural) • Educational support NOT • Asperger’s • Dyslexia / Specific learning difficulty • Normal education • GCSEs • Drive car

24. AssessmentInformants / Carers • Key worker / family • Key knowledge • Aid to compliance • Stress

26. Communication • Simple language with short sentences • Avoid jargon and negatives • Give concrete examples and avoid abstract ideas • Be aware literal meanings & use humour cautiously • Sign language /pictures. Consider interpreter • Check comprehension

27. Accessible information

28. Consideration • Compliance • System • Capacity / Best interests

29. Picture 5

30. Psychiatric Assessment

31. Assessment • Psychiatric Assessment with carer (known x years) • Presenting Compliant • History of presenting compliant • Change • Illness / pain • Developmental history • Skills • Social history • Support • Day care • Benefits • Other peers • Forensic • Forensic issues • Past Psychiatric History • Past Medical History • Medications / Allergies

32. AssessmentMSE • Appearance & behaviour • Agitation • Eye contact • Mood • Speech • Understanding • Thoughts. • Less guilt / suicidal ideas – cognitive level • Delusions. Basic • Hallucinations • Suicidal ideation • Harm to others • Insight • Illness / not • Medication • Capacity • Best interests

33. Assessment • Day care reports • Family • Monitoring charts • Other assessments • Social issues • Safeguarding issues

34. Risks • Aggression / violence • Neglect • Abuse from others • Abuse to others • DSH • Suicide • Domestic

35. Assessment • Multi Professional Team working • CMN • SALT • OT • Physiotherapy • Psychology • Care managers • Teachers

36. Treatment • Medication • Research/ evidence poor • Extrapolated from general adult psychiatry • If use off license medication should indicate • Reduced doses & slow titration

37. Treatment • Side effects • Reduced ability to communicate • Reduced ability to not comply • Increased risk of • Neuroleptic Malignant Syndrome • Tardive Dyskinesia • Other • Confusion • Constipation • Weight gain • Medication interactions,

38. Treatment • Review effect • Side effects

39. Picture 4

40. LD Specific issues • Challenging Behaviour • Behavioural phenotypes • Autism

41. Challenging Behaviour

42. Challenging behaviour • 10-15 % of LD use services • Most common reason for referral to psychiatrist • Behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities. • Emerson et al (1988)

43. Challenging behaviour • Can present as part of specific psychiatric disorder or independently • Need to exclude mental / physical illness • May be due to lack of appreciation of social norms. • Serious impact on accessing services / quality of life • Carers

44. Challenging behaviour • Management • monitoring, • boundary setting, • evaluation of environment, • medication may be indicated • MDT

45. Picture 6

46. Behavioural Phenotypes

47. Behavioral Phenotypes • Known (usually genetic) disorder is associated • Pattern behaviour • Personality characteristics • Psychiatric symptoms • Eg

48. Fragile X • Testicular enlargement • Large head circumference • Long & prominent ears • High arched palate • Connective tissue disorder • Lax joints • flat feet • Mitral valve prolapse

49. Fragile X cont.. • Mild - moderate LD • Flattening trajectory learning over childhood • Abstract reasoning • Visuo-motor & spatial deficits • Strengths verbal & adaptive behaviour • 5 - 46 % have autism

50. Fragile X characteristics • Social avoidance • Gaze aversion • Shy rather than autistic indifference • Fast garbled speech • Litanic pitch • Anxious interest in speech • Hyperactivity • Impulsiveness • Distractible • Wrist biting