1. Recognition Diagnosis and Treatment of Mental Health Problems in Children and Young People with Learning Disabilities Dr Lucy Grafen Consultant Child and Adolescent Psychiatrist Chantal Homan Clinical Nurse Specialist (Learning Disability Mental Health)

2. Types of Problems Conduct disorder, anxiety disorders, ADHD and ASD are higher among children with ld. No significant difference between children with and without ld with regards to depressive disorders, eating disorders or psychosis.Emerson, E. (2003) In many cases however the difficulties experienced by young people with ld cannot be adequately described by diagnostic systems. Behaviour indicating emotional distress can include aggression, SIB, destruction of property and sexualised behaviours.

3. Prevalence Rates  Approx 10% of children and young people without learning disabilities suffer from mental health difficulties (ONS, 2000).  Up to 50% of children and young people with learning disabilities suffer from mental health difficulties (Rutter 1976, Cormack et al 2000)

4. Risk Factors BiologicalPsychologicalSocial Physical illness Physical disability Sensory impairments Brain damage Behavioural phenotypes Few coping strategies Low self esteem Awareness of difference Developing identity Abuse Isolation Poverty Bullying Disabling society

5. Risk Factors  55% of families of children with disabilities have a low income (30% in non-ld population) AND the costs of bringing up a child with a disability is three times greater (Dept for Education and Skills 2004).  44% of children with ld are cared for by a mother who has mental health difficulties, compared to 24% of non-ld population.  34% of children with ld are living in ‘unhealthily’ functioning families, (18% of non ld).  92% of children with ld face at least one social adversity, (65% on non ld population). Emerson and Hatton 2007

6. Behavioural Phenotypes “The behavioural phenotype is a characteristic pattern of motor, cognitive, linguistic and social abnormalities which is consistently associated with a biological disorder. In some cases, the behavioural phenotype may constitute a psychiatric disorder; in others, behaviours which are not normally regarded as symptoms of psychiatric diagnosis may occur.” Flint and Yule 1993

7. ‘Psychiatric’ Phenotypes  Fragile X: autism, anxiety, ADHD, depression  Rett: anxiety, self harm  Velo Cardio Facial: attention deficit disorders, psychotic episodes  Down: Inattention, over activity, non- compliance, stubbornness, argumentative (depression and dementia in adults)  Williams: Anxiety, fears, phobias, inattention, hyperactivity, social disinhibition, overly friendly

8. Diagnostic Challenges  Diagnostic Overshadowing.  Verbal communication limitations in young person.  Physical Disabilities  Complex health conditions  Difficulty in interpreting signs and symptoms, e.g. when anxiety becomes overwhelming it can present as bizarre behaviour and symptoms which can be mistaken for psychotic symptoms.  Possible change in presentation in different environments as LD environments often provide perfect intervention environment.  Seeking help relies on third person identifying need, child/young person on their own not likely to seek help.

9. Co-Morbidity (associated conditions) Increased severity of challenging behaviour has been found to be associated with increased prevalence of psychiatric symptoms.  Depression; 4 times more prevalent in individuals with challenging behaviour. (Moss et al 1998, N.B. research concerns adults)  ADHD; more common in children and young people with learning disabilities but very often overlooked.  Anxiety Disorders; anxiety reactions frequently underlie the challenging behaviour.  Psychosis; emergence of in young people with learning disabilities nearly always associated with a change in personality and a reduction in functional abilities which may be mistaken as challenging behaviour alone.

10. Consider Mental Health Needs if…  Biological changes such as in sleep pattern, appetite and weight  Reduction or loss in skills  Onset or increase in challenging behaviour  Increase in stereotypical movements  Increase in minor physical complaints  Change in communication levels  Social withdrawal or disinhibition  Change in energy and activity levels  Difficulties with memory and adaptation to new environments and situations  Reduced concentration span  Conflict in relationships Hardy and Bouras (2002)

11. Mental illness?  Think also: Pain? – ears, teeth, constipation, UTI Distress? – loss, change, trauma, abuse Frustration? – communication, sibs too Developmental stage? – realisation, sexuality Sensory integration? Physical reason? – medication, thyroid

12. Multi-axial Diagnosis  Level of learning disability  Medical Conds/Physical Illness  Mental Illness/Disorder  Developmental disorder  Psychosocial concerns

13. Intervention  There is no significant body of evidence relating to the effectiveness of interventions for children and young people with learning disability and mental health difficulties.  However, there is no reason to suggest that children with learning disabilities will respond any differently to biological, psychological, educational & social interventions currently employed for children and young people without learning disabilities.

14. Perspectives  Disease – physical or mental Treat it  Dimension – autism, ADHD Psycho-education, support  Behaviour – self-injury, etc Behavioural/choice based 1:1 work  Life story – experiences, developmental stage 1:1, family/carer support

15. Intervention ConditionInterventions Considered Effective Considerations for children with ld Depressive DisordersBrief supportive therapy first choice, CBT or psychotherapy can be considered, life style alterations, last resort – medication. Communication level may make the talking therapies difficult, creative therapies could be the preferred alternative. No evidence to suggest that response to medication is any different for children with ld. ADHDBehaviourally based parent management training, behavioural interventions across settings, alterations to environment, medication, teach coping strategies to the child Dependant upon engagement of parents (as with non ld peers), no evidence to suggest response to medication is any different, behavioural interventions are often interventions of choice for children with ld.

16. Medications  Clear indication, use usual meds ADHD, Depression, Psychosis, low and slow to same doses  Severe persistent challenging behaviour, Differing advice from experts, All say, last resort Low dose risperidone, poor evidence, used a lot Valproate/Carbamazepine/Lithium, ditto, used less SSRIs, ditto Melatonin, ditto, seems to work, maybe low doses? Mostly agree NOT Benzodiazepines, or Zopiclone etc

17. Before medicating for behaviour,  Think: Social help Behavioural interventions Family support Individual intervention Pros and cons of meds

18. References Cormack, K. et al (2000) Behavioural and emotional difficulties in students attending schools for children and adolescents with severe learning disability Journal of Intellectual Disability Research 44(2) pp 124-129 Emerson, E. (2003) Prevalence of psychiatric disorders in children and adolescents with and without intellectual disability Journal of Intellectual Disability Research 47(1) pp 51-58 Emerson, E. and Hatton, C. (2007) The Mental Health of Children and Adolescents with Learning Disabilities in Britain Lancaster University: Foundation for People with Learning Disabilities Flint, J. and Yule, W. (1993) Behavioural Phenotypes In Rutter, M. and Hersov, L. (eds) Recent Advances in Child and Adolescent Psychiatry 3 rd ed Oxford: Blackwell Scientific Gale, I. (2003) Is there a general evidence base for child and adolescent mental health problems applicable to children and young people who have learning disabilities? Northgate and Prudhoe NHS Trust Hardy, S. and Bouras, N. (2002) The presentation and assessment of mental health problems in people with learning disabilities Learning Disability Practice 5(3) pp 33-38 Mental Health Foundation (1999) Bright Futures: Promoting Children and Young People’s Mental Health London: Mental Health Foundation Turk, J. (2008) Assessment, Diagnosis & Service Provision for Children & Young People who have Intellectual Disability & Mental Health Problems Conference Presentation