Past Meetings of the North Thames Graduate Psychologists Group

Dr Abigael San, Learning Disability (Meeting Minutes 28th August)

This month Dr Abigael San, a Chartered Clinical Psychologist talked about Learning Disabilities and her experiences of working on an adult inpatient ward. At the end she answered questions about her experience of the doctorate degree at UCL. The following minutes are based on her handout.

Definition/ prevalence/ causes of Learning Disabilities (LDs):

Sub-average general intellectual functioning + significant limitations in adaptive functioning (DSM IV, 2000)

Mild (IQ 55-70; 85%)
Moderate (IQ 35-55; 10%)
Severe (IQ 20-35; 3-4%)
Profound (IQ < 20; 1-2%)

Onset before 18 years
Many different etiologies - often unknown - final common pathway of various pathological processes affecting CNS function

Challenging behaviour (CB)

"behaviour of such intensity, frequency or duration that the physical safety of the person or others is placed in serous jeopardy or behaviour which is seriously likely to limit or deny access to and use of ordinary community facilities" Emerson et. al. 1987
Prevalence rates vary depending on definition, numerous studies, estimates between 6-30% (e.g. Qureshi, 1994)
CB is a social construct - behaviour that breaks societal rules - service providers have the problem
CB associated with severity of LD

Functions of CB

Demand avoidance, e.g. someone starts kicking after the breakfast and this leads to positive consequences
Self-stimulation, e.g. due to boredom
Seeking attention
Stress reduction
Communication
Biological

Causes of CB

Learned/institutionalised, e.g. copying other peoples behaviour
Emotion expression

Consequences of CB

Impair health, quality of life of PWLD & others
Abuse, exclusion, deprivation, neglect

Interventions for challenging behaviour

Clear description of the behaviour
Prevention
Antecedents (triggers) & consequences (positive reinforcers)
Change surroundings
Differential reinforcement of behaviours
Extinction
Time out from positive reinforcement
Functional communication training (if possible)
General positive reinforcement for appropriate behaviour
The least restrictive alternative, e.g. sedating medication

Dual Diagnosis

Coexistence of LD & mental illness (MI) same person
Not necessarily permanent
Varying estimates 12-39% (e.g. Reiss 1990) due to definitions, measurements, sample selection variance
PWLDs more valuable to developing MI

Biological
Psychological

Complex diagnosis & treatment due to communication, attention span, different presentation of distress etc.
Treatment - modification standard techniques, e.g. average length of session 25 minutes, taking drawing material to a session

Different approaches

CBT in a modified form, e.g. helping people to understand their emotions, as most commonly emotions are labelled for people with learning disabilities
Psychodynamic is used a lot in treating people with learning disabilities. The speaker doesn't understand why this is at it would not be her treatment of choice.
Systemic by taking the systems into consideration, such as family friends, day care centre etc.

Person centred planning

Answers to questions about Dr Abigael Sans work

Dr Abigael San works with on a ward with adult men and women. The aim is to treat the patients for about 3 month and then move them on. However it is sometimes difficult to find placement for them somewhere else.
The Mental Capacity act is used to assess whether patients can make their own decisions. The TV programme called "Richard is my boyfriend" was recommended, as it illustrates very well difficulties for people with learning difficulties when it comes to relationship and consent.
Group work is done on the ward, e.g. anger management, women group, sexual awareness and emotion group. However due to cost cuts they don't always take place.
A lot of bank staff work on the ward which sometimes makes care for patients difficult.
There are 2 psychologists working both part-time for the unit.
Dr Abigael San organised staff support groups and supported an assistant psychologist to do a user group and write a report about this.
The relationship between psychiatrists and psychologists at her workplace is positive and constructive.

Answers to questions about Dr Abigael Sans doctorate studies at UCL

Dr Abigael San told us that she got accepted to the course at her 4th application and enjoyed her doctorate very much.
She informed us that there is quite a lot of study time especially at the beginning.
She found that the placements were often very good. However it can become difficult if there are problems with Supervisors. Dr Abigael San recommended to really think about the following question which might be asked at the interview: "How would you deal with a difficult supervisor."
She recommended starting assignments early as work gets a lot towards the end.
The focus of the UCL course was on CBT and good research skills were taught. There was only limited teaching of psychodynamic.
Dr Abigael San felt that she was looked after well by the university.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
Emerson, Barret, S., Cummings, R., Hughes, H., McCool, C., Toogood, A. and Mansell, J. (1997). The special development team: developing services for people with severe learning disabilities and challenging behaviours. Canterbury: Institute of social and applied psychology, University of Kent at Canterbury.
Qureshi H (1994) 'The Size of the Problem' in Severe Learning Disabilities and Challenging Behaviours, Eds Emerson E, McGill P and Mansell J, Chapman & Hall.
Reiss, S. (1990) Prevalence of dual diagnosis in community based day programmes in the Chicago metropolitan area. American Journal of Mental Retardation, 94, 578-585.

NORTH THAMES GRADUATE PSYCHOLOGISTS' GROUP