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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 ?

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OVERVIEW OF LEARNING DISABILITY IN CHILDREN

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  1. OVERVIEW OF LEARNING DISABILITY IN CHILDREN

  2. 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

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Predisposing Factors to Mental Health Issues • Poor Communication • Sensory deficits • Sensory processing difficulties • Epilepsy • Physical illness • Behavioural Phenotype • Side effects to medication

  12. Predisposing Factors • Adverse life events and circumstances including abuse and neglect • Attachment issues • Limited range of coping strategies • Lack of appropriate educational provision

  13. 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

  14. 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

  15. 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

  16. Developmental assessment • Review medical file and identify current medical issues • Note physical anomalies, musculoskeletal conditions • Height, weight , sexual maturation • Neurocutaneous markers • Sensory deficits

  17. Diagnostic assessments • Developmental behaviour checklist(DCBL) • WISC, WAIS • ADOS, ADI • Medical: karyotyping, molecular cytogenetics- CGH, Metabolic screening MRI, EEG

  18. Behavioural Phenotype • Non progressive syndromes Fragile X S Angelman S Prader willi S TSC Williams Syndrome

  19. Progressive Syndromes Mucoploysaccharidoses Trisomies such as Trisomy 18 ( Edwards),Trisomy 13( Patau) Lesch Nyhan syndrome Rett Syndrome

  20. 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

  21. 22q 11 deletion Syndrome • Cardiac problems • Anomalous facies • Thymus hypoplasia • Cleft palate • Hypocalcemia • Higher incidence of psychosis

  22. 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

  23. Failure of inhibition of arborisation of neurons • Brain 10% heavier • Females have a milder phenotype

  24. 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

  25. Angelman’s- severe to profound LD, lack of speech, autism, ataxia, motor difficulties, sleep problems, epilepsy , half the cases, inappropriate laughter

  26. 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

  27. William’s syndrome • Microdeletion on chromosome 7, disruption of elastin gene • Moderate LD • Superior verbal abilities • Visuospatial processing difficulties

  28. 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

  29. 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

  30. Smith Magenis Syndrome

  31. Epilepsy • Childhood absence • Complex partial epilepsy • Non convulsive convulsive Status epilepticus • Interictal phenomena • Landau-kleffner syndrome

  32. Psychiatric Disorders • Depressive episodes • Anxiety Disorders • OCD • Episodic psychiatric disorders • Paediatric Bipolar, Bipolar nos • Bipolar 1& 2 • Psychosis

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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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