Intellectual Disability

Question 0

Diagnosis of intellectual disability

Answer 0

1: significant intellectual difficulties (IQ < 70)
2. Impairment in functional abilities
3. Presence <18 yo

Impairment of adaptive/social functioning
-the individual requires significant assistance to provide for his/her own survival (eating & drinking as well as keeping clean, warm and clothed) and/or with his/her social/community adaptation

Question 1

Learning disability include

Answer 1

• A significantly reduced ability to understand new or complex information or to learn new skills (impaired intelligence) with
• a reduced ability to cope independently (impaired social function)
• which started before adulthood with a lasting effect on development

Question 2

Mental capacity acts

Answer 2

• define the criteria that someone must fulfil to be deemed capable of making an informed decision

Capacity not equal to making wise choice

Understand, retain, and weight up the information to make decision and then communicate the decision made

Question 3

Intellectual disability in DSM5 (3domains)

Answer 3

The conceptual domain (skills in language, math, reading, memory, etc)

The social domain (empathy, social judgment, interpersonal communication skills)

The practical domain (self management)

Question 4

Common comorbid physical problem

Answer 4

Sensory impairment (hearing, vision) 
Epilepsy 
Physical disability 
Feeding, swallowing and nutrition problem
Obesity is common with ID
Endocrine disorder

Question 5

Cause of ID

Answer 5

Aetiology unknown: 20-40% (severe) and 38-55% (mild)

Around 80% of them are not known to service

Complex interaction: biological, social, behavioural and educational factor

Severe ID= generic/environmental cause

• trisomy21 (Down syndrome)
• fragile X syndrome(absence of expression of theFMR-1)

Question 6

Autism spectrum disorder in Dsm 4

Answer 6

1. Imagination
2. communication
3. social interaction

Impairment in all 3 + <3 yrs old

Question 7

Autism spectrum disorder - DSM5

Answer 7

1. Restricted, repetitive patterns of behaviour, interests, or activities
2. &3 = social communication & interaction

Question 8

Valuing people (2001) 
Valuing people now (2007)

Answer 8

Better Heath; health action planning (access to housing)

Independence; individual budget & direct payment (choice of daily life)

Personalization; person centred planning (right as citizens )

Question 9

Social theories driving changes

1) Normalization
2) Social role valorisation

Answer 9

social deviation due to societal rejection and labelling rather than individual pathology

socially valued roles in society challenges negative stereotypes

Question 10

People with Down syndrome are high risk of developing -

Autism are risk of developing-

Answer 10

Dementia and depression

Anxiety disorder

Question 11

Challenging behaviour

Answer 11

Behaviour that ;

• arise due to lack of impulse control
• arise from difficulties communicating needs/pain/worry
• not associated with a co-existing mental disorder
• is managed by specialist psychological and environmental treatment

Question 12

Who has an ID?

Answer 12

1% of population meet criteria for intellectual disability >1 million people

The majority (around 80%) are not known to statutory service

Causes might be

• idiopathic (inc extreme lower end of normal)
• genetic/chromosomal (eg Down’s syndrome, Fragile X)
• problems during pregnancy and birth (eg hypoxia, infection, maternal substance misuse)
• problems in childhood (eg trauma, infection, extreme neglect)

Question 13

Associated physicals problems are common

Answer 13

Sensory impairments (hearing, vision)
Epilepsy (roughly 1/3)
Physical disabilities
Feeding, swallowing and nutrition problems
Obesity is more prevalent in people with ID
Endocrine disorders (eg hypothyroidism)

Question 14

Premature death of people with ID

Answer 14

Men with LD die 13 years younger than men without LD
Women with LD die 20 years younger than women without LD
37% deaths investigated were deemed “avoidable” ie preventable by the provision of good quality health care
Barriers and delays in treatment are a problem
Lower uptake of screening and preventative medicine
Communication between professionals need to be improved
Staff knowledge of LD and services should be better

Question 15

Diagnostic overshadowing

Answer 15

Occurs when a presentation is attributed to intellectual disability rather than a potentially treatable cause

-the person might not be communicating well not due to the ID but due to physical problem

Question 16

Mental illness in ID

Answer 16

The presentation of mental illness can be different in people with ID

• difficult in communication or lack of verbal communication
• classical symptoms may be complex subjective experience.
• poor insight and “health literacy”
• differentiation from other conditions ie autism
• misinterpretation of developmentally-appropriate behaviours

Question 17

Psychosis and ID -risk factor

Answer 17

• genetic (heritability >80% but small effect of individual genes)
• pregnancy and birth complications
• urbanicity , ethnic minority status
• cannabis use
• negative life events
• possibly effect of early and severe form of schizophrenia

•affective psychosis highly prevalent in Prader William syndrome, particularly in the subtype caused by maternal disomy

Question 18

Dementia presentation in ID and Down Syndrome

Answer 18

General deterioration in functioning
Behavioural or emotional change
Depression

Irritability, loss of interest, apathy, emotional instability
Non-cognitive symptoms
-difficulty in walking
Behavioural symptoms
-aggression
-uncooperative
Psychiatric symptoms
-lack of energy, low mood, disturbed sleep
-delusion, auditory hallucination
Decline in social abilities
Fewer delusions and problem behaviour overall
Low mood, restlessness, disturbed sleep, being uncooperative, auditory hallucination

Question 19

Comorbid condition with ID

Answer 19

Epilepsy (prevalence ranges from 6-26%)
Autism (approximately 115000 children and adults with autism also have ID)
ADHD (approximately 25%-40% of children with ID also have ADHD)

*its getting a problem to distinguish autism from ID and ADHD comorbid is getting more noticed

Question 20

Assessment and treatment of challenging behaviour

Answer 20

Functional analysis (behavioural triggers and consequence)
Implement behavioural plans or combined interventions
Multidisciplinary focus
Improve environment
Work with parents or paid carers and the person with ID

Question 21

Risk factor for challenging behaviour

Answer 21

Autism 
Male gender 
Severity of ID 
Younger age 
Visual impairment 
Communication difficulties 
Abusive care inc restrictive practice 
Poor stimulation/day care 
Lack of appropriate communication strategies

Question 22

Assessment tools

Answer 22

Scales for behaviour assessment (ABC)
Mental status
Can be used for treatment monitoring

Question 23

Interventions-psychosocial

Answer 23

For younger people with ID, parent training in groups may be helpful
Usually manualised treatment
Support at school too
For adults, behavioural interventions in the main
CBT for anger management
Sleep hygiene

Question 24

Interventions-medications

Answer 24

``` Antipsychotic Alone or in combination with psychosocial treatment Melatonin Monitor response Consider discontinuation Off-label mood stabilizer Monitor side-effects (ie blood glucose) ```

Question 25

Facts about ASD

Answer 25

Genetic (MZ twins) Increased risk in siblings Rare genetic abnormalities Specific syndrome (fragile X, tuberous sclerosis) Role of epigenetics (impact of environment on gene expression) Prevalence of 1% Risk 4 times higher in boys than girls --but more girls are getting diagnosed Now ASD is considered to be a genetic disorder Some children with Fragile X also have ASD -similar symptoms (ie gaze avoidance)

Question 26

Assessment (NICE )

Answer 26

Adult Asperger Assessment Autism Diagnostic Interview -Revised -you have to be trained to use this assessment ``` Autism Diagnostic Observation Schedule -Genetic Asperger Syndrome (and high-functioning autism) Diagnostic Interview ```

Question 27

ASD and comorbidities

Answer 27

``` Sensory problem Sleep difficulties ID Seizure Gastrointestinal problem Mood disorder ADHD ```

Question 28

Treatment

Answer 28

Early intervention aiming at social and self management skill acquisition with parent training components May prevent later behavioural difficulties, improve cognitive ability and promote independence Usually resource intensive (>15 hours a week) x years Structure and visual cues Impact on family life and social environment

Question 29

Seeing people with ID

Answer 29

Ensure sufficient time Gather collateral information if possible Establish a baseline - change is important Don't forget possible physical causes for presentation Observable psychopathology and behavioural correlates of mental illness - anxiety: physical arousal (ie tremor, hyperventilation, increased drinking), anger, self-injury, compulsive behaviour - depression:tearfulness, withdrawal, irritability, altered biological function (sleep, appetite), diurnal variation, motor retardation - mania: hyperactivity, fear, responding to unseen/unheard stimuli

Question 30

Mental health in people with ID

Answer 30

Under-diagnosis - diagnostic overshadowing - differentiation between MH problems & challenging behaviours Prevalence (widely spread) 10-80%

Question 31

Epidemiology of ASD

Answer 31

1% of children 1% adult (they won't decrease as age) Men (2:1)

Question 32

Mental health in people with autism

Answer 32

16% adults with ASD diagnosed with new MH proven in 20s High IQ=high risk of mental health problem High level of anxiety, delusion, social anxiety, depression. Regression; stressful life event, lack of structure , change in family structure

Question 33

Mental capacity act

Answer 33

Defines criteria for capacity for decision making Capacity is not making wise decision Capacity relates to specific decision only Criteria= •Understand •retain • weight up information to make decision And communicate the decision made

Question 34

Triad of impairment

Answer 34

1) impairment of social interaction - an impaired ability to engage in reciprocal social interactions 2) impairment of social communication - the whole range of communicative skill may be affected (eye gaze, speech, non verbal cues) 3) impairment of social imagination - difficulty thinking imaginatively (pretend play)

Question 35

The red flag for autism

Answer 35

No babbling by 12 month No gesture (pointing, waving) by 12 month No single words by 16 month No two-word phrase by 24 month Any loss of any language or social skills at any age

Question 36

Mood in people with ID

Answer 36

Can be difficult to describe their mood Asking them to draw their feeling might be helpful Negative view of self is common Ask suicide thought it self harm

Question 37

Cognition in people with LD

Answer 37

Any assessment of cognition should take into account their premorbid level of functioning Tools such as MMSE might not be useful for people with LD

Question 38

Structure assessment should include

Answer 38

``` Presenting complaints Psychiatric history Medical history and medication history Family history Personal and social history -to include developmental, educational, employment, interest, relationship, substance use, current level of support and activity Forensic history ``` Physical examination to rule out any underlying physical health issue (ie pain)

Question 39

Who does this exclude?

Answer 39

People with poor educational attainment due to lack of opportunity Traumatic brain injury sustained in adulthood Progressive neurological disease Age-related neurodegeneration (dementia) Long term serious mental illness that can result in cognitive deficit (ie schizophrenia)

Question 40

Adaption communication techniques with people with ID

Answer 40

``` Use simple language Easy read information (using picture, large font) Visual timetable Talking mats Social stories ```

Question 41

Stepped care -guildline

Answer 41

Require that the person has the best chance of a positive outcome with the least burden, but that a system of review should be in place to detect and act on non-improvement and to enable stepping up to more intensive treatment if necessary * treatment should always have the best chance of delivering positive outcome while burdening the patient as little as possible * a system of scheduled review to detect and act on non-improvement must be in place to enable stepping up to more intensive treatments, stepping down where a less intensive treatment becomes appropriate and stepping out when an alternative treatment or no treatment become appropriate The least intensive intervention that is appropriate for a person is typically provided first, people can step up or down according to their needs If less intensive intervention is able to deliver the desired positive outcome, this limits the burden of disease and cost associated with more intensive treatment

Question 42

IAPT

Answer 42

The development of IAPT service represent the largest scale development by a government into mental health service worldwide It has seen a 100% increase in spending on mental health from 0.3-0.6% of the annual NHS budget. Many argue that this is still a very small investment given the burden of mental health problem ok society and the economy

Question 43

Steps of stepped care

Answer 43

1) Prevention and promotion - support that can be utilized before approaching health or social service: friends and family; self-help,occupational advice 2) Recognition in Primary Care - "Watchful waiting" with further assessment; self-help, guided self-help, short term intervention 3) Assessment/Primary Care Interventions - MH Assessment;short term psychological intervention, physical health check; medicine review; computerized CBT; case worker support 4) Secondary/Specialist Service - Comprehensive specialist assessment, specialist service (crisis/home treatment, early intervention, assertive outreach, Mental Health Act assessment, specialist medical and paychosocial intervention, care coordination, risk/relapse plan, crisis accommodation

Question 44

IAPT

Answer 44

Improving Access for Psychological Therapy (IAPT) is the first ever provision of talking therapy on a mass scale by a government Before IAPT, the NHS spent just 3% of its mental health budget on talking therapy. IAPT has doubled that budget The biggest expansion of mental health service anywhere in the world ever