1. Learning Disability December 3/12/15

2. Learning Disability Definition Disability vs. Difficulty vs. Mental Health Causes Diagnosis Management GP challenges

3. Definition A learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life. People with a learning disability tend to take longer to learn and may need support to develop new skills, understand complex information and interact with other people. (Mencap website) A learning disability is defined by 3 core criteria: lower intellectual ability (usually an IQ of less than 70), significant impairment of social or adaptive functioning, and onset in childhood. (NICE 2015) Mild, moderate or severe (profound). Behaviour issues.

4. Disability vs. Difficulty vs. Mental Health Learning disability is often confused with dyslexia and mental health problems. Mencap describes dyslexia as a “ learning difficulty ” because, unlike learning disability, it does not affect intellect. Mental health problems can affect anyone at any time and may be overcome with treatment, which is not true of learning disability.

5. Learning Disability Definition Disability vs. Difficulty vs. Mental Health Causes Diagnosis Management GP challenges

6. Causes Prenatal Perinatal Postnatal Others

7. Pre-natal causes Maternal illness Maternal injury Maternal stress Genetic Foetal Alcohol Syndrome

8. Prenatal Stress Subjects were eighty-nine 5½-year-old children whose mothers were pregnant during a natural disaster: the January 1998 ice storm crisis in the Canadian province of Québec that resulted in power losses for 3 million people for as long as 40 days. In June 1998, women completed several questionnaires including those about the extent of objective stress (Storm32) and subjective distress (Impact of Events Scale-Revised) experienced due to the storm. Their children were assessed with the Wechsler Preschool and Primary Scale of Intelligence-Revised (IQ) and Peabody Picture Vocabulary Test-Revised (language) at 5½ years of age, and mothers completed assessments of recent life events and psychological functioning. Children exposed in utero to high levels of objective stress had lower Full Scale IQs, Verbal IQs, and language abilities compared to children exposed to low or moderate levels of objective prenatal maternal stress; there were no effects of subjective stress or objective stress on Performance Iqs. Conclusions Prenatal exposure to a moderately severe natural disaster is associated with lower cognitive and language abilities at 5½ years of age. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47:(9):1063–1072.

9. Prenatal genetic causes Angleman Syndrome / Klinefelter’s Cri du chat Syndrome /Lennox Gastaut Syndrome Downs Syndrome /Prader-Willi Syndrome Fragile X / Rett Syndrome Smith Magenis Syndrome/ William’s syndrome and many more…. Consanguinity

10. Peri-natal causes Prolonged labour Anoxic brain damage Prematurity

11. Postnatal causes Childhood illness Trauma Brain damage (NOT vaccination)

12. Other causes Autism Asperger’s ADHD / ADD Global developmental delay

13. Learning Disability Definition Disability vs. Difficulty vs. Mental Health Causes Diagnosis Management GP challenges

14. Learning Disability - Diagnosis Concern raised: Health visitor, family, school etc. Referral to see GP. Referral to Secondary Care (LD team/ Community Paeds). Assessment tools : home and at school. Review of assessments. Recommendations and Diagnosis

15. Learning Disability Definition Disability vs. Difficulty vs. Mental Health Causes Diagnosis Management GP challenges

16. Management General principles of care: NICE May 2015 Support and interventions for family members or carers Early identification of the emergence of behaviour that challenges Assessment of behaviour that challenges Psychological and environmental interventions Medication

17. Management Person-centred care : Care Act 2014 Aged less than 16, parents usually decide. Mental Capacity Act 2005 D eprivation o f L iberty S afeguards 2005 Safeguarding issues.

18. Management - Medication Evidence is not really all that good. http://www.bmj.com/content/351/bmj.h5203 Always started by Secondary Care. Issues re who does the scripts. Medication is ‘off licence’. Are we medicalising/medicating ‘bad behaviour’?

19. Learning Disability Definition Disability vs. Difficulty vs. Mental Health Causes Diagnosis Management GP challenges

20. Capacity A presumption of capacity : unless it is proved otherwise. The right for individuals to be supported to make their own decisions : all appropriate help before anyone concludes that they cannot make their own decisions. That individuals must retain the right to make what might be seen as eccentric or unwise decisions. Best interests : anything done for or on behalf of people without capacity must be in their best interests. Least restrictive intervention : anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedoms. Understand, Retain and Weigh the information provided and Communicate their decision. Decision -specific

21. Restraint or deprivation of liberty Section 5: If judged by MCA to lack capacity then care/ treatment can be given without the risk of legal liability – ill treatment in these circs liable to 5 years imprisonment Section 6 : Use or threat of force where an incapacitated person resists, and any restriction of liberty or movement whether or not the person resists. Permitted if the person using it reasonably believes it is necessary to prevent harm to the incapacitated person, and if the restraint used is proportionate to the likelihood and seriousness of the harm. Section 6(5) makes it clear that an act depriving a person of his or her liberty cannot be an act to which section 5 provides any protection.

22. GP Challenges When is it more than just ‘bad behaviour’? Who, when and where to refer? Communication issues. Dealing with the whole family/care unit. Becoming the coordinator of care. Medication

23. Communication Exercise In pairs one person be the doctor one be the patient. Patient choose a relatively common complaint to have. Patient you have moderately severe learning difficulties. Doctor you can ask any questions to get a diagnosis. Patient you can only nod or shake your head to answer. Patient look blank if the question is too complicated. Doctor once you have the diagnosis put your hand up.

24. Useful Resources Mencap web site Mental Capacity Act 2005 Deprivation of Liberties Safeguards 2005 The Care Act 2014 Challenging behaviour and learning disabilities : NICE May 2015. B’ham City Council Web site – ‘Learning Disability’

25. Any questions?