ASSESSMENT IN LEARNING DISABILITY

RT Alexander Consultant Psychiatrist, St John’s House Hospital, PiC LD Services, Diss, Norfolk & Hon Visiting Clinical Fellow, University of Leicester

Assessments

• The ‘IS …….’ question • The ‘CAN ……’ question • The ‘WHY ……’question …. assessment of the learning disability itself and assessment of behavioural or psychiatric morbidity in those with learning disability.

Assessment of LD

• • • Developmental delays Intellectual functioning & IQ Adaptive functioning

Developmental milestones

• Motor- fine and gross • Language • Social

• EMIQ 1

Developmental history

Options a. 6 months b. 9-10 months c. 18 months d. 2 years e. 3 years f. 7 years Lead in • Match the developmental milestones below with the age by which it is usually achieved Milestones 1. Joins 2 or 3 words in a sentence 2. Builds a tower of 3-4 cubes 3. Transfers objects from 1 hand to the other 4. Picks up objects using a pincer grip 5. Undresses with assistance

Developmental milestones

MOTOR • Walks alone by 18 months • • LANGUAGE • 2-3 words by 1 year 2-3 words in sentence by 2 years Speaks in sentences by 3 years (Ref: Pg 8-9, Seminars in C&A Psych)

Developmental milestones

• • SOCIAL • Social smile by 3 months Waves goodbye by 1 year Parallel play by 2 years and co-operative play by 3 years • Dresses and undresses with assistance by 4 years and alone by 5 years (Ref: Pg 8-9, Seminars in C&A Psych)

Intellectual functioning and IQ

• EMIQ 2

Intellectual functioning and IQ

Options a.

Below 10 b.

Below 20 c.

d.

e.

f.

g.

Mental age of 3 to under 6 years 35- 49 mental age of 9 to under 12 years 60-80 71-84 Lead in • Match the diagnostic categories below with the most appropriate IQ scores or mental ages Options 1.

Borderline Intellectual functioning in DSM IV 2.

3.

Mild mental retardation in ICD 10 Moderate mental retardation in ICD 10 4.

5.

Severe metal retardation in ICD 10 Profound mental retardation in ICD 10

Intellectual functioning and IQ

ICD 10 (DCR) DSM IV Borderline intellectual functioning Mild MR 71-84 50-55 to Approx 70 Moderate MR Severe MR 50-69 (m.a 9- under 12) 35-49 (m.a 6- under 9) 20-34 (m.a 3- under 6) 35-40 to 50-55 20-25 to 35-40 Profound MR Below 20 (m.a less than 3) Below 20-25

WAIS-R

• • • • • Comprehensive test of cognitive ability in adults aged 16 and over Takes around 60-90 minutes 6 verbal sub tests: Information, comprehension, arithmetic, digit span, similarities, vocabulary 5 performance sub tests: picture arrangement, picture completion, block design, object assembly, digit symbol Scores for VIQ, PIQ, FSIQ. The FSIQ is a standard score with a mean of 100 and a standard deviation of approximately 15.

Raven’s Progressive Matrices

• • • • Suitable for ages 6 onwards Raven’s standard progressive matrices (SPM), coloured progressive matrices (CPM), advanced progressive matrices (APM) Designed to measure a person’s ability to form perceptual relations and to reason by analogy independent of language and formal schooling.

60 items arranged in 5 sets.

National Adult Reading Test (NART)

• • • Devised to investigate the presence of intellectual deterioration. (Originally devised for use in dementing patients).

May therefore be useful for predicting pre-morbid IQ Clinical scenarios

Psychometric tests

• EMIQ 3

Psychometric tests

d.

e.

f.

g.

Options a.

b.

c.

Pre-morbid intelligence Non-verbal intelligence Propensity for depression Brain damage Executive function Verbal and non verbal sub-tests Artistic potential Lead in Match the tests below with one most appropriate characteristic or function above Tests 1.

2.

3.

4.

5.

Wisconsin Card Sorting Test National Adult Reading Test Wechsler Adult Intelligence Scale- Revised Halstead- Reitan Battery Raven’s Progressive Matrices ( Modified from Get Through MRCPsch Parts 1 & 2: 1001 EMIQs, Ed: A Michael, Royal Society of Medicine Press, 2004)

Adaptive functioning

• Adaptive behaviour refers to the performance of daily activities required for personal and social sufficiency.

Adaptive functioning

Conceptual Skills Social Skills Practical Skills American Association on Mental Retardation (2002)

Adaptive functioning

Conceptual Skills Receptive and expressive language Reading and writing Money concepts Self direction American Association on Mental Retardation (2002)

Adaptive functioning

Practical Skills Personal activities of daily living such as eating, dressing, mobility,and toileting Instrumental activities of daily living such as preparing meals, taking medication, using telephone, managing money, using transportation and doing housekeeping activities.

Occupational skills Maintaining a safe environment American Association on Mental Retardation (2002)

Adaptive functioning

Social skills Interpersonal Responsibility Self-esteem Gullibility (likelihood of tricked or manipulated) Follows rules Obeys laws Avoids victimisation American Association on Mental Retardation (2002)

Vineland Adaptive Behaviour Scales

Communication Receptive, expressive, written Daily Living skills personal , social, community Socialisation interpersonal relationships, play and leisure, coping skills Motor Skills fine, gross

• Mental age equivalents, adaptive behaviour composite scores, etc.

The ‘WHY…’ question

• • Diagnostic frameworks and the psychiatry of learning disability Multi axial systems

Axis

I II III IV V

ICD 10 (MR) DC-LD DSM- IV

Severity of retardation and problem behaviours Severity of LD A: Associated medical condns causative of MR B: other medical condns Associated psychiatric disorders Global assessment of psychosocial disability (WHO DAS-S) Associated psycho-social situations Cause of LD A: Developmental disorders B: Psychiatric illness C: Personality disorders D: Problem behaviours E: Other disorders Appendix 1: LD syndromes and behavioural phenotypes Appendix 2: ICD 10 chapters other than V- medical conditions Appendix 3: Factors affecting health status and contact with health services Clinical disorders, other conditions that may be the focus of clinical attention PD MR General medical condition Psychosocial and environmental problems GAF Score

1.

2.

3.

Degree of learning disability Pervasive developmental disorders Other developmental disorders 4.

5.

6.

7.

Personality disorders Mental illnesses 8.

Substance misuse/ dependence Physical disorders including epilepsy and syndromes Psychosocial disadvantage (eg: abuse) 9.

Global functioning (eg: GAF score) 10.

Behavioural problems (“challenging behaviour”)

PSYCHIATRIC ASSESSMENT IN LEARNING DISABILITY

• • Challenging behaviour vs psychiatric problems The Emerson papers (1995,1999)

Four types of relationships between challenging behaviour and psychiatric disorder 1.

2.

3.

4.

Family factors: similarity between CB and CD CB as atypical presentation of psychiatric disorder CB as a secondary feature of psychiatric disorder (in severe ld) Psychiatric disorder establishes a motivational basis for CB

Psychiatric assessment

Particular attention to 1.

Level of understanding and communication ability 2.

3.

Details from informants and direct observation History of presenting problem over time 4.

5.

Developmental history Physical disabilities (vision, hearing, etc) and medical conditions

• Psychiatric aspects in the next session

Assessment and diagnosis

• EMIQ 4 & 5

Assessment and diagnosis

Options a.

b.

c.

d.

e.

f.

g.

h.

Asperger syndrome Dementia Depressive episode Fragile X Syndrome Rett’s syndrome Lesch-Nyhan syndrome Panic with agoraphobia William’s syndrome Lead in Select one most appropriate provisional diagnosis for each of the following descriptions 1.

2.

3.

4.

A 44 year old man with Down’s syndrome presents with withdrawn behaviour, loss of confidence, forgetfulness, aggression and weight loss. Physical investigations including thyroid functions are normal.

A 44 year old man with Down’s syndrome presents with withdrawn behaviour, loss of confidence, forgetfulness, aggression and weight loss. His thyroid functions are normal and symptoms worsened in spite of anti-depressant treatment.

A 4 year old girl’s developmental milestones were normal till 18 months. Subsequently she became withdrawn, lost most of her developmental milestones, developed hand wringing movements, hyperventillation and breath-holding spells and epilepsy.

A 31 year old man with borderline intellectual functioning is detained in a secure unit following a charge of arson. He has a special interest in lighters and can talk at length about various lighter models, their drawbacks, year of manufacture, etc.

Assessment and diagnosis

d.

e.

f.

g.

Options a.

b.

c.

Affectionate, clownish and easily amused Compulsive and severe self mutilation Dementia like picture in the 5 th decade Extraordinary verbal facility Increased appetite, obesity, incessant skin picking Gaze aversion and social avoidance Learning disability and a schizophrenia like psychosis Lead in Select one option for each of the following descriptions/ behaviour phenotypes Syndromes 1.

Fragile X syndrome 2.

Prader Willi syndrome 3.

4.

5.

Lesch Nyhan syndrome Velocardiofacial syndrome William’s syndrome