Beruflich Dokumente
Kultur Dokumente
Overview of learning
disability in children
History
This group was originally the remit of learning disability psychia
try at a time when it had a much wider role which included, for
example, physical and genetic investigation. About 15 years ago
it was proposed that all children, irrespective of ability, should
be dealt with by child psychiatry; a move consistent with other
policies such as Children First and Inclusion, although, lacking
resources, this aspiration has remained unfulfilled. However,
many learning disability psychiatrists restricted themselves to
adult practice and it was left to community paediatrics to fill
the gap. Recently, there has been a resurgence of interest in this
group, with the establishment of specialist posts and the develop
ment of a professional network that meets regularly and encour
ages informal contact.
Tom Berney
Abstract
The child/adolescent is set in a complex framework of relationships and
services for the psychiatrist to work with. The medical disorders that
accompany learning disability, as well as the disability itself, complicate
the psychopathology so that the risk of misdiagnosis increases with the
degree of disability. To be effective the psychiatrist has to work well with
other disciplines and agencies, being open to their perspectives, as well
as being familiar with the subculture and dynamics of disability. The
work requires expertise in a variety of neurodevelopmental conditions,
particularly autism and epilepsy, as well as in psychopharmacology.
The setting
Children with learning disabilities and their families
The child and his family are at the centre of a complex of ser
vices and professionals which has the potential to become so
extensive as to lose them in the gaps (learning disabilities and
other developmental disorders affect males more frequently than
females, therefore he and his are used throughout this contri
bution). For these children and their families, diagnosis is not
just some academic exercise or even a working hypothesis but a
passport to a different life, determining the way they see them
selves, the solutions they select and the kind of service they get.
Diagnosis comes at different times depending on the basis
of the disability. For example, while the childs physical charac
teristics can lead to Down syndrome being recognized at birth
or the genetic history may be a prenatal pointer to Fragile-X, it
may need the childs introduction to nursery or even to school to
highlight the symptoms of autism. The parents then face a process
of adjustment that has parallels with the process of bereavement
but with the essential difference that, rather than adjusting to a
single event, they find themselves in a drawn-out process.In this
they develop a progressively better-defined appreciation of the
nature and degree of their childs disability as he moves through
his developmental stages, each point a potential crisis for them
to deal with. One example is the start of education, when the
child has to cope with and be compared against other children.
Another is puberty, which brings with it not only the immedi
ate issues around sexual expression but is also a reminder of
the childs potential (or not) to have children of his own.3 The
process is spread over years and many families benefit from the
support provided by the community learning disability teams.
Services need to be flexible, adapting to the wide diversity of
ethnic and cultural backgrounds in which families are rooted.
Families also require practical help as they bring up a child
whose responses may make their job far from intuitive. For exam
ple, a recurrent theme is the family whose feelings (whether of
empathy, pity, guilt or protectiveness) have led them to give their
child whatever he wants. As he grows up and becomes physi
cally stronger, he becomes a tyrant used to having his wishes
granted (if only for the sake of parental peace), uncertain where
the limits are and, not only enforcing his demands with disrup
tive or even violent behaviour but also continually testing to
find out at what point rules will be imposed. All this in a child
whose emotional needs may be no different from others at the
The population
Disability can take many forms, selectively affecting various
functions such as cognition, language or emotional development;
its nature and degree the result of infinite permutation. It takes
the child and family into its own network of relationships and
care, amounting to a subculture, which the psychiatrist has to
understand both to make sense of their problems as well as to
enlist its help in their management. The focus is not simply about
working with individuals and their families but is also about the
development and use of services that will prevent as well as treat
the problems that go with disability.1
This complex system can involve a large variety of disciplines
and agencies, targeting populations that, although overlapping,
are not identical. For example, while legislation pivots around
the age of 18 as the time of transition to adulthood, various ser
vices stop short of this. Similarly, although learning disability is
defined by an intellectual ability more than two standard devia
tions below the norm (i.e. an IQ of less than 70), services vary in
their chosen remit with some excluding mild learning disability.
All this is blurred by the needs of people, such as those with
autism spectrum disorder (ASD), whose functional ability may
fall far short of their intellectual potential.2
PSYCHIATRY 5:10
346
ASSESSMENT
same developmental stage but who, less able to learn from his
peer group and environment, requires more formal teaching and
support.
On the other hand, for many families such difficulties are off
set by a great sense of achievement in the extent to which their
children overcome their disability, enjoy their childhood and
grow up with good self-esteem to make their own contribution
to society.
Health
Education
learning disabilities
learning difficulties
6950
4935
3420
< 20
Mild
Moderate
Severe
Profound
Moderate
Severe
Table 1
Educational services
From the start, the child, less able to learn for himself, will
need formal teaching and pre-school programmes which work
intensively with both parents and child (such as Hanen, Por
tage and Sure Start). While these can produce substantial shortterm improvements in the childs attainments and adjustment,
more sustained change is likely to need further intervention (e.g.
through booster programmes).
The child then moves into the educational system and its
assortment of provision. The policy of inclusion encourages his
needs to be met within the mainstream school but the addition
of psychiatric disturbance often tips the balance towards a spe
cial school. These schools, smaller and with more structure and
supervision, may be divided by age (into primary and secondary)
or by ability; the labelling of the latter causing confusion. In the
UK, the adoption of the term learning disabilities by the Depart
ment of Health was confusingly similar to the term learning dif
ficulties used in Education the distinction is an important one
as the two systems attach different meanings to mild and mod
erate4 (Table 1) confusion that is compounded by the tendency
to use disabilities and difficulties interchangeably. Schools may
also specialize in particular forms of disability including autism,
epilepsy, cerebral palsy and visual or auditory impairment. The
more specialist the school, the more likely it is that children will
be disturbed and also that they will not be local.
Depending on the nature and degree of disability, the child
may need to be taught a wide variety of skills in areas as diverse
as self-help, language and social and sexual relationships. Classes
PSYCHIATRY 5:10
IQ*
Psychiatric disturbance
How prevalent is psychiatric disturbance?
Disturbance is more common than in the general population and is
more prevalent the greater the degree of disability. The actual figures
depend on the definition of disturbance so that rates such as 40%
tend to include autism as one of the diagnoses, whether or not there
are any additional problems. Even allowing for this, the rates of anxi
ety, conduct and neuropsychiatric disorder are much higher than in
the normal population.6,7 About 10% of the population with learning
disability will have challenging behaviour, a statistic that tends to
hide the nature and destructive intensity of the disturbance.8
What form does it take?
Young people with a learning disability have the full range of
psychiatric disorders but this is coloured by the disability so
that, where communication is impaired, it is difficult to iden
tify a disorder if the diagnosis relies predominantly on subjective
347
ASSESSMENT
Assessment (Table 3)
Childrens services are coming together to work in a more closely
coordinated fashion, with common referral pathways, easier
cross-referral and shared skills and resources. The aim is to reduce
repetitious assessment and delay for a child moving through the
different tiers, disciplines and agencies of a complex network of
services. Much of the initial data-gathering might be done by a
primary mental health worker, the psychiatrist and other (scarce)
professionals coming in later, taking their cue through a shared
referral meeting. If this includes people from other agencies, such
as the educational psychologist and social worker, it is important
that this is agreed with the family in establishing the contract of
confidentiality.10,5
The community bias, with team members regularly going into
schools and homes, encourages face-to-face discussion with refer
rers as well as information-gathering from the different areas of
the childs life. The extent of confidentiality should be clear and
feedback (including the copying of letters) agreed with the fam
ily. Work should be centred on the child and their family who,
as far as possible, should be seen in their preferred settingrather
PSYCHIATRY 5:10
348
ASSESSMENT
DSM-IV. For many, this is the first step in planning their manage
ment but, as such, should be only one part of a broad, multidisci
plinary assessment that takes account of the following:
Level of cognitive ability identifying discrepancies between
verbal and performance abilities as well as the diversity of spe
cific disabilities that can accompany any neurodevelopmental
disorder. This requires instruments such as the Wechsler Intel
ligence Scale for Children (WISC).
Functional ability acknowledging the extent to which less
obvious problems can increase the degree of handicap. These
can be in a wide variety of areas, including social relationships,
communication (receptive and expressive), imagination and ex
ecutive function. Measured by instruments such as the Vineland
Adaptive Behaviour Scale, the effect of specific disabilities can
be to reduce an individuals ability to look after themselves, to
function independently or to cope with other people.
Other (comorbid) developmental disabilities notably autism,
attention deficit disorder, tics, sensory anomalies and dyspraxia,
as well as epilepsy.
Mental capacity the criteria and their underlying principles
are well established. While a minor does not have the legal com
petence to refuse treatment (including detention in hospital), if
they meet the capacity criteria to the extent that they are consid
ered sufficiently (Gillick) competent they may accept treatment
which does not require a parental proxy decision.11
Other elements such as the risk of coming to harm or of
offending.
The aim of this wider assessment is to provide a detailed plan
that will assist the child, through the appropriate teaching and
training and with the help of their family and professionals, to
lead as full and as normal a life as possible.
Management
The first move is to treat anything that might be causing dis
comfort: a task that might range from making the environment
less complex through to treating an underlying physical problem
such as toothache, gastritis or epilepsy. Poor communication is
a frequent source of misunderstanding and frustration (Table 2).
It is essential to keep a sense of objectivity (and to listen to what
others think). Just as McCarthy saw communism behind all of
Americas ills, it is easy to ascribe disturbance to a particular
form of pathology and, on this basis, to embark on evermore
adventurous therapeutic trials.
Limited communication has led to an emphasis on behav
ioural and systemic approaches to treatment, although there
is a returning recognition of the part that the individual psy
chotherapies might play. Psychoactive medication has a bigger
role than in mainstream child psychiatry but is often overused.
Children may show a startling sensitivity or insensitivity to
medication and, such is the individual variation in absorption
and metabolism, that there is little to be gained by calculat
ing fractional dosages based on, for example, body weight or
age. Compliance is the major hurdle so that drugs should be
easy to dispense and may need to be masked by fizzy drinks
or favoured foods such as tomato sauce (i.e. off-label). A sub
stantial amount of prescribing is off-licence because it is often
not worth the manufacturers while to pursue a licence for this
small niche market.
PSYCHIATRY 5:10
349
ASSESSMENT
Conclusion
This psychiatry is multidisciplinary and multiagency, truly in the
community and set in a service that combines prevention with
treatment. It represents real developmental psychiatry, each case
bringing a satisfying mix of psychodynamic, behavioural and
biological factors.
References
1 Department of Health. New ways of working for psychiatrists:
enhancing effective, person-centred services through new ways of
working in multidisciplinary and multiagency contexts. London:
Department of Health, 2005.
2 OBrien G. Defining learning disability: what place does intelligence
testing have now? Dev Med Child Neurol 2001; 43: 5703.
3 Bicknell J. The psychopathology of handicap. Br J Med Psychol
1983; 56: 16778.
4 World Health Organization. The ICD-10 classification of mental
and behavioural disorders: clinical descriptions and diagnostic
guidelines (ICD-10). Geneva: World Health Organization, 1992.
5 Royal College of Psychiatrists. Good psychiatric practice:
confidentiality and information sharing CR133. London: Royal
College of Psychiatrists, 2006.
6 Emerson E. Prevalence of psychiatric disorders in children and
adolescents with and without intellectual disability. J Intellect
Disabil Res 2003; 47: 518.
7 Green H, McGinnity , Meltzer H, Ford T, Goodman R. Mental health
of children and young people in Great Britain, 2004. London:
Department of Health, 2005.
8 Kiernan C, Qureshi H. Challenging behaviour. In: Kiernan C, ed.
Research to practice? Implications of research on the challenging
PSYCHIATRY 5:10
Useful contact
Those who wish to know more about the professional
network of psychiatrists with a special interest in children and
adolescents with a learning disability should contact Dr. Chris
Speller: chris.speller@kennetandnwilts-pct.nhs.uk
Practice points
Psychiatry is only one component of the services that are
required for a child with learning disability, their wider remit
including family support and the prevention of disorder
The psychiatrist has to work with and through other
disciplines and agencies: good relationships are essential to
the welfare of the patient
Besides making it easy to miss a diagnosis, the complex mix
of factors encourages overdiagnosis: the psychiatrist should
be open to the views of colleagues
350