3. General Learning Disability

General Learning Disability

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

The World Health Organization (WHO) has defined learning disabilities as a state of arrested or incomplete development of mind. Somebody with a general learning disability is said to have a significant impairment of intellectual, adaptive and social functioning. A learning disability is not acquired in adulthood and is evident from childhood.

The term general learning disability has now been recommended in the UK to replace terms such as mental handicap or mental retardation. A child with a general learning disability finds it more difficult to learn, understand and do things compared with other children of the same age. The degree of disability can vary greatly, being classified as mild, moderate, severe or profound.
 
General learning disability must be differentiated from specific learning difficulty (eg, dyslexia) which means that the person has one difficulty such as in reading, writing or understanding, but has no problem with learning in other areas.

People with intellectual disabilities have an increased prevalence of health problems and their health needs are often unrecognised and unmet.[1]

A classification of mild, moderate, severe and profound has been used to describe the degree of learning disability. The measure of IQ has been used to define the severity of learning disability: a person with an IQ of less than 20 would be described as having a profound learning disability, an IQ of 20-34 a severe learning disability, 35-49 moderate, and 50-70 mild learning disability.

However, this classification is in many ways inappropriate because each person with general learning disability must be assessed and treated as an individual. A person's degree of intellectual impairment provides very little information about a person's social, educational and personal needs, and the kind of help and support he or she might require.

People with profound learning disabilities will often need the same level of support for long periods of time. People with mild learning disabilities often require a variable level and type of support, which may change in response to changing circumstances.

  • Epidemiological research shows a prevalence of intellectual disability of about 0.7%.[1]
  • It has been estimated that 1,191,000 people had learning disabilities in England in 2011, including:[3]
    • 286,000 children (180,000 boys, 106,000 girls) aged 0-17.
    • 905,000 adults aged 18+ (530,000 men and 375,000 women), of whom 189,000 (21%) were known to learning disabilities services.
  • The population for people with learning disabilities shows a sharp reduction in prevalence rates after age 49 due to reduced life expectancy. A sharp increase in prevalence for males under 20 may reflect increased survival rates among more severely disabled children.[3]
  • The number of people with intellectual disabilities increased by 53% over the 35-year period from 1960 to 1995 (as a result of improved socio-economic conditions, intensive neonatal care and increasing survival).[4]
  • The presentation will depend on the cause.
  • Generally poor performance on tasks such as learning, short-term memory and problem solving.
  • Frequently associated with specific congenital syndromes - eg, Down's syndrome, fragile X syndrome.
  • Assessment needs to consider the possible cause - eg, family history, birth history, functional disability and associated medical, psychological and social difficulties.
  • Physical:
    • Motor and mobility problems.
    • Abnormalities of movement.
    • Speech, hearing and visual impairment.
    • Epilepsy.
    • Urinary and faecal incontinence.
    • There is evidence of increased risk of obesity, fractures, poor oral health (including dental caries and loss of teeth), constipation and gastro-oesophageal reflux disease.[1]
  • Psychological (the following are more common in patients with learning disabilities):
    • Schizophrenia.
    • Anxiety and depressive disorders.
    • Personality disorder.
    • Early-onset dementia.
    • Autism.
    • Hyperactivity and attention deficit hyperactivity disorder.
    • Eating disorders, including rumination, food faddiness, anorexia nervosa and bulimia nervosa, which are common.
  • Behaviour:
    • Threatening their own safety or that of others.
    • Seemingly violent but harmless behaviour (often interpreted as aggression).[5]
    • Temper tantrums.
    • Criminal activity.
  • Sleep disorders.
  • Focus on abilities and not disabilities. Talk respectfully, take time and explain what is happening.
  • Always greet the person first, before addressing the accompanying person.
  • Check if your patient has verbal capacities. There may be an imbalance between receptive and expressive language skills.
  • Obtain the medical history as far as possible from the patient; otherwise, an accompanying person should complete it.
  • Make it clear that, if the patient wants the accompanying person to leave at any moment during the consultation, he or she can indicate that.
  • When communicating with people with learning disabilities:[6]
    • Ensure that your communication is clear, with simple language and short sentences.
    • Explain any difficult or unfamiliar words.
    • Check that the person has understood - eg, ask them to tell you in their own words what you have just said.
    • Give the person time to respond.
    • Use gestures to emphasise your communication - eg, point to the part of the body you are talking about.
    • Use pictures or objects to demonstrate what you are going to do before you do it.
    • Be aware of any additional disabilities such as hearing or visual impairment
  • 'Total Communication' is about using a number of communication methods together to support people with complex needs. This may include a mixture of speech, gesture and accessible written information or pictures.[6]
  • Management includes multidisciplinary support for both the child and the rest of their family. The person with mental handicap and their carer(s) and family need a great deal of physical and emotional support.
  • Psychological, psychosocial, and educational interventions for deprived children with low IQ have been shown to have positive effects on behaviour, overall adjustment and possibly also on IQ.[5]
  • Behavioural treatment methods for self-injury in learning disability are probably effective if used systematically by people who are well trained in such methods.[5]
  • Psychotropic drugs are often used but rarely produce significant benefits.
  • Direct support and coaching of young people with learning disability are efficient ways to improve their integration into employment.[5]
  • If a person presents with challenging behaviour, assess for physical (for example, pain such as toothache, earache) and other sources of discomfort before treating the behaviour as psychiatric and prescribing psychotropic drugs.[1]

Annual health screening

Mental illness, chronic health problems, epilepsy, and physical and sensory problems are more common and people with learning disabilities are less likely to receive regular health checks and access routine screening.[7]

The Royal College of General Practitioners has published 'A Step by Step Guide for GP Practices: Annual Health Checks for People with a Learning Disability'.[7]

  • A recent randomised controlled trial on annual health screening in people with intellectual disabilities found an improvement in health in the intervention group.[1]
  • Health management plans should be evaluated annually and should include case finding, appropriate monitoring of existing health needs, promotional activities and disease prevention.[1]
  • As a minimum, the health check should include:[8]
    • A review of physical and mental health with referral through the usual practice routes if health problems are identified:
      • Health promotion.
      • Chronic illness and systems enquiry.
      • Physical examination.
      • Epilepsy.
      • Behaviour and mental health specific syndrome check.
    • A check on the accuracy of prescribed medications.
    • A review of co-ordination arrangements with secondary care.
    • A review of transition arrangements where appropriate.
  • One example of a form that can be used is the Cardiff Health Check for People with a Learning Disability.[7]

See also separate articles Consent to Treatment (Mental Capacity and Mental Health Legislation) and Mental Capacity Act.

  • There may be an incongruence between receptive and expressive verbal skills. It may take time to realise that, although a person is giving clear answers, he or she does not understand the question.
  • Assessment of mental capacity is specific for each individual decision at any particular time. People are considered to lack capacity if they have an impairment that causes them to be unable to make a specific decision. The person should be able to understand, retain and weigh the information provided and communicate their decision.
  • Behavioural problems: these include distractible, overactive, impulsive, repeated self-injury, stereotyped repetitive and purposeless activities.
  • Sexual problems: curiosity about other people's bodies may be misunderstood as sexual; inappropriate behaviour - eg, masturbation in public.
  • Physical disorders are more frequent. The most common physical health problems are epilepsy, mobility problems, and sensory problems.[1]
  • Disorders of vision and hearing are also more frequent.
  • Effects on the family: parental rejection, physical and emotional stress in caring for a child with learning disability, difficulty with family dynamics with other siblings, and increasing difficulty, as the child gets older, with isolation, contraception, etc.
  • Most adults with learning disability have very limited economic resources.
  • People with severe learning disability have a particularly poor outlook. Those with mild learning disability and borderline intelligence also do poorly in terms of adaptive functioning.[5]
  • The median age at death for people with learning disabilities is about 25 years younger than for those who do not have learning disabilities.[3]
  • Although life expectancy is increasing, with people with mild learning disabilities approaching that of the general population, the mortality rates among people with moderate to severe learning disabilities are three times higher than in the general population.[7]
  • Both the scope and pattern of disease mortality and cause-specific mortality tend to become increasingly similar to those of the general population after the age of 40 years.[5]
  • Early and effective management of problems during the antenatal period and during intrapartum care.
  • Early and effective management of problems in the neonatal period and early childhood.
Provide feedback

Further reading & references

  1. van Schrojenstein Lantman-de Valk HM, Walsh PN; Managing health problems in people with intellectual disabilities. BMJ. 2008 Dec 8;337:a2507. doi: 10.1136/bmj.a2507.
  2. British Institute of Learning Disabilities
  3. People with Learning Disabilities in England 2011; Learning Disabilities Observatory
  4. Cooper SA, Melville C, Morrison J; People with intellectual disabilities. BMJ. 2004 Aug 21;329(7463):414-5.
  5. Gillberg C, Soderstrom H; Learning disability. Lancet. 2003 Sep 6;362(9386):811-21.
  6. Supporting patients with learning disabilities; Imperial College Healthcare NHS Trust
  7. A Step by Step Guide for GP Practices: Annual health checks for people with a learning disability; Royal College of General Practitioners (2010)
  8. Clinical directed enhanced services (DESs) for GMS contract 2008/09; Learning disabilities (March 2009)
Original Author: Dr Naomi Hartree Current Version: Peer Reviewer: Prof Cathy Jackson
Last Checked: 25/01/2013 Document ID: 2452  Version: 24 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.