Mild Learning Disabilities Research Articles

Will we grow out of it? A psychotherapy group for people with learning disabilities

A forty-week psychotherapy group conducted along group analytic lines was run in an outpatient department of an NHS trust. The clients had mild learning disabilities. This was the first time that psychotherapy was offered to learning disabled clients within this trust. Many difficulties were encountered in the process of running the group, as has been the experience of others when running psychoanalytic groups with this population (Gravestock and McGauley 1994). Some of the difficulties related to contextual problems. Others were concerned with the painful process of the therapy itself. The pain of the process of thinking about oneself within the group and of being thought about by the therapist was very difficult for group members. This process highlighted the importance and meaning of thinking, and the difficulties associated with thinking for people with learning disabilities. As McCormack (1991) suggests, thinking brings awareness, but awareness can be extremely painful. The countertransference provided a powerful medium for understanding the struggles experienced by both the conductor and the group members. This paper begins with a description of some important aspects of what it means to have a learning disability. The paper then considers why a group analytic approach was chosen. Special emphasis is given to the importance of the countertransference in the process of conducting this group. Examples of feelings of shame, loss and rejection are described from group material and the powerful feelings of ambivalence and guilt evoked within the countertransference in the closing of the group are highlighted. Important contextual and practical considerations for conducting a psychotherapy group within a not familiar with psychodynamic ways of working are also Conducting psychotherapy with people with learning disabilities is not so different from conducting groups with any other client This paper aims to make this evident.

Secondary Barriers to Physical Activity for Adults with Mild and Moderate Learning Disabilities

Physical inactivity as a risk factor for coronary artery disease is comparable with the other three primary risk factors (hypertension, hypercholesterolemia and smoking history), but is significantly more prevalent. Evidence shows that people with learning disabilities are typically amongst the most inactive and sedentary members of the population, yet few studies have explained why. The aim of the present study was to establish whether adults with learning disabilities receive adequate support to be able to make choices to lead a physically active lifestyle. Participants volunteered from two residential homes and one social education centre in two cities in the north of England. Interviews were conducted with 24 adults with mild or moderate learning disabilities (mean age of 34 years). The interviews were recorded and transcribed and the content was analysed. An emerging theme was barriers to exercise, which were subsequently subdivided into primary and secondary barriers. Identified secondary barriers included: differences in how `ordinary living principles' were interpreted by day and residential carers; parental influence; arguments associated with integrated versus segregated leisure provision; and what is meant by `age appropriateness'.

WORKING WITH A MAN WHO HAS PRADER-WILLI SYNDROME AND HIS SUPPORT STAFF USING MOTIVATIONAL PRINCIPLES

This paper describes an intervention with a man who has Prader-Willi Syndrome (PWS) and mild learning disabilities in a residential setting. PWS is a chromosomal disorder that is characterized by a wide range of behavioural characteristics including overeating and challenging behaviour. The intervention was based on a range of principles derived from a motivational interviewing approach, which were embedded in a broader behavioural framework that was designed to assist in weight reduction and reduce challenging behaviour. Records of weight and challenging behaviour kept over time suggest that the approach had relatively little impact on overall weight. However, levels of challenging behaviour were reduced quickly and have been maintained at a stable and lower level. Weight has also been maintained at a reasonably constant level without confrontation with staff or excessive restrictions on the individual concerned. Relationships between the individual and staff in the home also improved over the course of the intervention.

Behavioural treatment of urinary incontinence and encopresis in children with learning disabilities: transfer of stimulus control.

Urinary and faecal incontinence present a considerable problem in people with learning disabilities, despite the general effectiveness of behavioural techniques in continence training. Children with learning disabilities and obsessional behaviour may be particularly resistant to toilet training, even where relatively cognitively able, and often despite a substantial degree of control over their eliminatory functions. Their resistance may be more appropriately regarded as a challenging behaviour and their incontinence better explained by factors other than a simple failure to learn. A 'stimulus-control' hypothesis proposes that the child's nappy (diaper)/potty/underwear has developed strong stimulus control over the elimination response. This report describes three case studies in which treatment-resistant children, aged between 8 and 12 years, with mild or moderate learning disabilities, were successfully treated for nappy-dependent nocturnal encopresis or diurnal urinary incontinence. The children were routine case referrals for whom previous attempts to train bowel or bladder control had failed. Behavioural techniques, such as 'shaping' (gradually increasing the proximity to the toilet), 'fading' (reducing the presence of the nappy), and rewards for eliminating, effected successful transfer of stimulus control over elimination from nappy to toilet. Treatment times varied, depending on the degree of the child's obsession and resistance to change.

Familial Syndromic Esophageal Atresia Maps to 2p23-p24

Esophageal atresia (EA) is a common life-threatening congenital anomaly that occurs in 1/3,000 newborns. Little is known of the genetic factors that underlie EA. Oculodigitoesophageoduodenal (ODED) syndrome (also known as "Feingold syndrome") is a rare autosomal dominant disorder with digital abnormalities, microcephaly, short palpebral fissures, mild learning disability, and esophageal/duodenal atresia. We studied four pedigrees, including a three-generation Dutch family with 11 affected members. Linkage analysis was initially aimed at chromosomal regions harboring candidate genes for this disorder. Twelve different genomic regions covering 15 candidate genes (approximately 15% of the genome) were excluded from involvement in the ODED syndrome. A subsequent nondirective mapping approach revealed evidence for linkage between the syndrome and marker D2S390 (maximum LOD score 4.51 at recombination fraction 0). A submicroscopic deletion in a fourth family with ODED provided independent confirmation of this genetic localization and narrowed the critical region to 7.3 cM in the 2p23-p24 region. These results show that haploinsufficiency for a gene or genes in 2p23-p24 is associated with syndromic EA.

The diagnosis of schizophrenia in the borderline learning-disabled forensic population: six case-reports

Population surveys indicate an increased prevalence of schizophrenia in the learning-disabled population. Extensive assessment and observation may be necessary to detect schizophrenia which may be undiagnosed and directly related to offending behaviour. Six male patients admitted to an open forensic psychiatric unit for people with mild and borderline learning disability are presented: in these men schizophrenia was previously unrecognized. Treatment led to a marked clinical improvement. There is a need to be particularly aware of the possibility of schizophrenia in this population.

Rett syndrome: methyl-CpG-binding protein 2 mutations and phenotype-genotype correlations.

Rett syndrome (RTT) is an X-linked dominant neurodevelopmental disorder that manifests in females, typically after the first year of life. It is a leading cause of mental retardation and autistic behavior in girls and women; a hallmark of the disease is incessant hand movements in the form of wringing, twisting, or clapping. It was recently discovered that RTT is caused by mutations in the methyl-CpG-binding protein 2 (MECP2) gene. MECP2 assists in the transcriptional silencing process via DNA methylation; we hypothesize that disruption of this gene alters the normal developmental expression of various other genes, some of which must account for the peculiar neurologic phenotype of RTT. Molecular studies have identified MECP2 mutations in up to 80% of classic RTT patients; mutation type has some effect on the phenotypic manifestation of RTT, but the pattern of X inactivation seems to determine phenotypic severity. Favorable (skewed) X inactivation can so spare a patient from the effects of mutant MECP2 that they display only the mildest learning disability or no phenotype at all. The unmitigated impact of mutant MECP2 can be inferred from the few males who have been born into RTT kindreds with such severe neonatal encephalopathy that they did not survive their second year. MECP2 mutations thus manifest in a far broader array of phenotypes than classic RTT. This discovery should prove helpful in diagnosing cases of mild learning disability or severe neonatal encephalopathies of unknown cause and also should provide insight into the pathogenesis of RTT.

Psychosocial characteristics of Greek young offenders

This paper presents the psychosocial characteristics of Greek young offenders attending a probation service. Measures included the Rutter and Graham Semi-Structured Child Psychiatric Interview, the Raven's Standard Progressive Matrices, and the Family Adaptability Cohesion Evaluation Scale. The age-range of the subjects was 12 to 18.6 years, the majority being between 15.5 and 17 years. The main offences were theft, physical violence and damage of property. Characteristics included recurrent offending (48.3%), coming from broken families (58.3%), family history of mental health problems (26.7%), and a high rate of borderline to mild learning disability (36.3%). Young people described dysfunctional patterns in their immediate families, particularly in the dimension of adaptability, on which almost all families (96.7%) were categor-ized as disengaged. There were high rates of affective disorders, as 22% of the young people fulfilled diagnostic criteria for major depression and 22% for dysthymic disorder. The findings are discussed in a sociocultural context, in comparison with previous research from western societies.

Using Social and Educational Approaches to Enable a Man with Learning Disabilities to Develop his Sexual Identity and Orientation

This paper describes the obstacles encountered by a young, gay man with a mild learning disability. His referral for ‘challenging behaviour’ to the Personal Relationships and Sex Education Team initiated a one‐to‐one sex education programme. When the work had been completed his frustration grew as he could not apply his learning and he desperately wanted a sexual partner. The work took a new direction to find a gay befriender to assist our client to access his community and continue his learning. This case study highlights the need for carers and professionals to assist people with learning disabilities to break down the barriers of community resistance that prevents them from integrating and developing their chosen sexual identity.

Rett Syndrome and Beyond: Recurrent Spontaneous and Familial MECP2 Mutations at CpG Hotspots

Rett syndrome (RTT) is a neurodevelopmental disorder characterized by loss of acquired skills after a period of normal development in infant girls. The responsible gene, encoding methyl-CpG binding protein 2 (MeCP2), was recently discovered. Here we explore the spectrum of phenotypes resulting from MECP2 mutations. Both nonsense (R168X and R255X) and missense (R106W and R306C) mutations have been found, with multiple recurrences. R168X mutations were identified in six unrelated sporadic cases, as well as in two affected sisters and their normal mother. The missense mutations were de novo and affect conserved domains of MeCP2. All of the nucleotide substitutions involve C-->T transitions at CpG hotspots. A single nucleotide deletion, at codon 137, that creates a L138X stop codon within the methyl-binding domain was found in an individual with features of RTT and incontinentia pigmenti. An 806delG deletion causing a V288X stop in the transcription-repression domain was identified in a woman with motor-coordination problems, mild learning disability, and skewed X inactivation; in her sister and daughter, who were affected with classic RTT; and in her hemizygous son, who died from congenital encephalopathy. Thus, some males with RTT-causing MECP2 mutations may survive to birth, and female heterozygotes with favorably skewed X-inactivation patterns may have little or no involvement. Therefore, MECP2 mutations are not limited to RTT and may be implicated in a much broader phenotypic spectrum.

Cognitive deficits after cryptogenic infantile spasms with benign seizure evolution.

Between 1989 and 1994, 18 children with cryptogenic infantile spasms-defined by normal development before onset of spasms, symmetrical hypsarrhythmia or multifocal spikes, and typical spasms on presentation, and no abnormal findings on aetiological studies including neuroradiology-were diagnosed and treated. To assess the risk of cognitive impairment later in life, 15 of these 18 children whose spasms completely resolved within the first year of life were studied. Age at onset of spasms varied between 4.4 and 9.8 months (mean 6.5 months). Children were effectively treated with adrenocorticotrophic hormone (10 children), pyridoxine (three), vigabatrin (one), or sodium valproate (one). Spasms lasted between 11 and 138 days (mean 50 days) and stopped between the age of 6.3 and 10.2 months(mean 8.1 months). EEGs normalized between the age of 7.1 and 13.2 months (mean 9.4 months). Early development was assessed on presentation and within a few months after spasms had stopped. A detailed neuropsychological assessment was performed between the age of 4.0 and 5.9 years. Twelve children had normal intelligence; specific cognitive deficits were found in five. Three children had mild learning disability. Abnormal developmental status at age 8 to 15 months after complete resolution of spasms and EEG abnormalities was associated with cognitive deficits at age 4 to 6 years.

Cognitive deficits after cryptogenic infantile spasms with benign seizure evolution

Between 1989 and 1994, 18 children with cryptogenic infantile spasms ‐ defined by normal development before onset of spasms, symmetrical hypsarrhythmia or multifocal spikes, and typical spasms on presentation, and no abnormal findings on aetiological studies including neuroradiology ‐were diagnosed and treated. To assess the risk of cognitive impairment later in life, 15 of these 18 children whose spasms completely resolved within the first year of life were studied. Age at onset of spasms varied between 4.4 and 9.8 months (mean 6.5 months). Children were effectively treated with adrenocorticotrophic hormone (10 children), pyridoxine (three), vigabatrin (one), or sodium valproate (one). Spasms lasted between 11 and 138 days (mean 50 days) and stopped between the age of 6.3 and 10.2 months(mean 8.1 months). EEGs normalized between the age of 7.1 and 13.2 months (mean 9.4 months). Early development was assessed on presentation and within a few months after spasms had stopped. A detailed neuropsychological assessment was performed between the age of 4.0 and 5.9 years. Twelve children had normal intelligence; specific cognitive deficits were found in five. Three children had mild learning disability. Abnormal developmental status at age 8 to 15 months after complete resolution of spasms and EEG abnormalities was associated with cognitive deficits at age 4 to 6 years.

A Locus for Isolated Cleft Palate, Located on Human Chromosome 2q32

We present evidence for the existence of a novel chromosome 2q32 locus involved in the pathogenesis of isolated cleft palate. We have studied two unrelated patients with strikingly similar clinical features, in whom there are apparently balanced, de novo cytogenetic rearrangements involving the same region of chromosome 2q. Both children have cleft palate, facial dysmorphism, and mild learning disability. Their karyotypes were originally reported as 46, XX, t(2;7)(q33;p21) and 46, XX, t(2;11)(q33;p14). However, our molecular cytogenetic analyses localize both translocation breakpoints to a small region between markers D2S311 and D2S116. This suggests that the true location of these breakpoints is 2q32 rather than 2q33. To obtain independent support for the existence of a cleft-palate locus in 2q32, we performed a detailed statistical analysis for all cases in the human cytogenetics database of nonmosaic, single, contiguous autosomal deletions associated with orofacial clefting. This revealed 2q32 to be one of only three chromosomal regions in which haploinsufficiency is significantly associated with isolated cleft palate. In combination, our data provide strong evidence for the location at 2q32 of a gene that is critical to the development of the secondary palate. The close proximity of these two translocation breakpoints should also allow rapid progress toward the positional cloning of this cleft-palate gene.

What Choice: A Consideration of the Level of Opportunity for People with Mild and Moderate Learning Disabilities to Lead a Physically Active Healthy Lifestyle

This paper addresses two questions. Firstly, do inequalities of opportunity exist between the general population and adults with mild and moderate learning disabilities to lead a physically active lifestyle? Secondly, should the provision of equivalent opportunities be considered a human right? For the learning disability population the right to opportunities to be physically active can be divided into primary and secondary rights, the former is the right to opportunities, the latter is whether and how the opportunities are taken up. The principle of distributive justice gives people with a learning disability the same right as others to be physically active. Realisation of such a right would bring the potential for tangible health benefits. This review suggests that care in the community is insufficiently resourced to provide adequately beyond basic needs and that significant inequalities do exist between the general and learning disability populations in relations to opportunities and choices to be physically active.

Using the cognitive interview with adults with mild learning disabilities

Forty-seven adults with mild learning disabilities (mild intellectual disabilities) attending day-centres and thirty-eight adults from the general population viewed a videorecording of an accident. A day later the participants were interviewed using either a cognitive interview (CI) or a structured interview (SI, a control interview). Compared with their counterparts with learning disabilities, adults from the general population recalled more correct information and made fewer confabulations about persons and objects. Nevertheless, the type of interview had an impact. For both groups, the CI was more effective than the SI in enhancing recall although, for the ‘learning disabilities’ group, the CI also produced a disproportionate increase in the reporting of person confabulations. All the same, the accuracy ratios were similar across interview types (80% for the CI and 82% for the SI). It is suggested that the CI could be helpful in assisting people with learning disabilities to provide information about events they have seen.

Primary and secondary barriers to physically active healthy lifestyles for adults with learning disabilities

Purpose: Evidence shows that those with a learning disability are typically amongst the most inactive and sedentary members of the population, yet few studies have focused on the determinants of physical activity. The aim of the present study was to establish whether a group of 24 adults with mild and moderate learning disabilities receive adequate support to be able to make choices to lead a physically active lifestyle. Method: A descriptive study was used based on interviews with 24 adults with learning disabilities (mean age of 34 years) triangulated by day time and residential care workers. Participants volunteered from two residential homes and one social education centre (SEC) in a city in the North of England. Results: The participants face a set of primary barriers that prevent them from having a choice to adopt the Department of Health's recommendations for physical activity. Identified barriers included: unclear policy guidelines in residential and day service provision together with resourcing, transport and staffing constraints; participant income and expenditure; and limited options for physically active community leisure. Conclusions: These are barriers that are widely acknowledged and understood by day and residential staff and participants in the study, but are arguably poorly understood by policy makers, health promotion agencies, commissioners and providers of learning disability services. The current lack of resources and inadequately specified responsibilities associated with community care deny many people with learning disabilities real choices to live a physically active healthy lifestyle.

New Screening Tests to Identify Young Children at Risk for Mild Learning Problems

Each of 34 prekindergarten and 39 kindergarten children with mild learning problems, those with mild mental retardation or learning disabilities, was matched with a child without learning problems on the basis of age, gender, and race/ethnicity. All children were presented the same cognitive screening test, which consisted of eight tasks. For the prekindergarten group, 91% of the children with learning problems and 91% of those without problems were accurately classified using a subset of five tasks. Two of these were identification tasks, where the children had only to point to choices provided; the other three tasks required children to generate verbal responses. For the kindergarten sample, the highest level of classification accuracy achieved for the children with mild learning problems was 87% and for the children without learning problems, 77%. These levels were also based on a subset of five tasks, but this subset consisted of four identification tasks and one generating task. Levels of classification accuracy were higher for the children classified as having mild mental retardation than for the group classified as having learning disabilities. Females had slightly higher scores than males on the kindergarten test, and the White/non-Hispanic group had higher scores than the other ethnic/racial groups on the prekindergarten test.

Letters to the Editor

Back to table of contents Previous article Next article Letter to the EditorFull AccessLetters to the EditorANTHONY DAVID, M.D., M.R.C.PSYCH., ANTHONY DAVIDSearch for more papers by this author, M.D., M.R.C.PSYCH., London, U.K. Published Online:1 Nov 1998https://doi.org/10.1176/ajp.155.11.1626nAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Russell and colleagues have made an important contribution to the literature on intellectual functioning in patients with schizophrenia. However, their claim that intellectual decline is “a myth” overstates the case. The first problem is one that the authors partially acknowledge, namely, the biased nature of their study and, hence, the lack of generalizability. Their own data from a representative population-based cohort (1) show that the premorbid IQ deficit in children who later develop schizophrenia is one-third of a standard deviation (i.e., around 5 IQ points). Equivalent figures from a later U.K. national cohort suggest that the deficit may be around one-half of a standard deviation (i.e., 8 IQ points) (2), as do the data from the Swedish conscript cohort (3). The mean childhood IQ of their current group was 84.1, that is, just over one standard deviation below the mean. Hence, it is not representative of preschizophrenic children.The next problem is the lack of control for a period effect, that is, changes in IQ in the population over time. Evidence from the United States shows that children’s intelligence has increased by approximately 3 points per decade since the 1930s (4, 5), and anecdotal reports from the United Kingdom suggest similar trends in educational attainment. IQ tests standardized at the same time but employed years apart should reveal an increase.In addition, research with groups with mild and moderate learning disability (6–9) shows that subjects tested on the WISC and later on the WAIS (or their revisions) consistently show an apparent improvement due to psychometric properties of the scale, separate from the period effect. Hence, the lack of increase (or the slight decrease) in scores reported by Russell et al. masks a larger decrease in IQ over the follow-up period. Such a decrease is suggested by well-controlled, albeit cross-sectional, studies of first–onset cases -10) in which schizophrenic patients’ cognitive measures are more than one to two standard deviations below the control mean.Finally, a difficulty arises in the comparison of results from the WISC-R and the WAIS-R. Russell et al. quote correlation coefficients between the two scales, but this is misleading. There would be a perfect correlation between the scales even if one were consistently 10 points higher than the other. We need to know the slope of the regression line and its intercept.So what do we know for sure about IQ and schizophrenia? There is a slight reduction in the average IQ of children and young people who later develop schizophrenia. It is likely that there is a further reduction between childhood and the first onset of the disorder, although truly longitudinal data on this point are sparse. Whether there is a further deterioration in intellect in most cases over the course of the disorder is still an open question.

Paroxysmal dystonic choreoathetosis

A 30-year-old man with mild learning disability (IQ:72) and cerebral palsy with mild generalized choreoathetosis was referred with paroxysmal motor disorder and episodic depressive mood disorder. Aged 11 months, he had developed episodes of alternating flaccid hemiparesis followed by episodes when he was unable to move or talk but remaining conscious lasting from several minutes to longer. Episodes could be precipitated by excitement such as opening Christmas presents or, later, his favourite football teams scoring a goal or losing. His longest interictal period had been 4 weeks. There was a family history of epilepsy. His EEG aged 6 showed paroxysmal spike and slow waves but no change during episodes of weakness. There was no improvement with phenobarbitone or phenytoin. Aged 1 I, oculogyric crises started during episodes. Aged 19, the EEG showed photosensitivity but was otherwise normal. Episodes were made worse with Sinemet or amphetamines. From age 20, he regularly needed 2 to 5 days a month off work because of episodes. From age 27, episodes could be followed by depression lasting days to months, including suicidal attempts such as swallowing bleach aged 29. Once started on carbamazepine 400 mgs daily, he still had episodes every 2 weeks but has not needed any further time off work, has had no further depressive episodes and is now able to live independently. He could still have rare episodes lasting up to 3 days such as when England won at Wembley.

Trainees' assessment and management of mental illness in adults with mild learning disabilities

Recommended changes in services for adults with mild learning disabilities are likely to have training implications. A case vignette study examined the effect of coexistent mental illness and learning disability on trainees' clinical assessment and management. Mental illness was more likely to be diagnosed in those with a mild learning disability than in a control group who had no learning disability. Despite this, the learning disability group was less likely to receive treatment. Service and training issues are discussed.