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