Health inequalities for people with learning disabilities: why it matters and what emergency physicians need to know.

People with learning disabilities die on average 16 years earlier than the general population in England. They are a vulnerable group and may have unhealthy lifestyles and multimorbidity that lead to poor health outcomes. Worryingly, premature deaths are also more common and these often have contributory healthcare causes. This may be a result of staff lacking awareness, expertise and experience managing people with learning disabilities, the lack of reasonable adjustments, or discriminatory attitudes. Other issues include polypharmacy and inappropriate prescribing of sedatives, inappropriate use of do not resuscitate orders, and diagnostic overshadowing leading to delayed or misdiagnoses. Emergency physicians need to be aware of subtle or atypical presentations of illnesses such as sepsis. Carers and family can be vital informants, helping clinicians to interpret subtle signs and aid communication with people with learning disabilities. One simple approach to reasonable adjustments, as required by law, is the TEACH mnemonic: people with learning disabilities need more time (T), in a conducive environment (E), with clinicians approaching them with the right attitude (A) and an open mind. Good communication (C) is essential and clinicians must make every attempt to understand their patients and to be understood by their patients. Finally clinicians need to consider what 'help' (H) the patient and their carers or family needs. With the right approach, time and environment, emergency physicians can optimise the care delivered to people with learning disabilities to address their needs.

[Place of the BMT-i modular tool in the assessment of learning disabilities]. / Place de l'outil modulable BMT-i dans l'évaluation des troubles de l'apprentissage.

PLACE OF THE BMT-I MODULAR TOOL IN THE ASSESSMENT OF LEARNING DISABILITIES Twenty percent of children have difficulties learning to read, write, or count. Eight percent of children have a specific and durable impairment in the development of a learning or cognitive function or Learning Disabilities (LD), often called «dys¼ (dysphasia, dyslexia, dysorthography, dyscalculia, dysgraphia, etc.). This is a public health problem, which has been addressed by the Haute Autorité de Santé (HAS), which recommends a health program based on the needs of each child, coordinating education and health professionals - rehabilitation specialists and medical prescribers. The role of the child's doctor is essential in the first line of action to identify these problems, to examine the child, to prescribe reeducation when necessary and to follow the evolution. However, he has received little training. The modular BMT-i (computerized adaptable test battery) tool is validated, easy to use and reliable. It allows the screening of difficulties in each domain in 10 to 25 minutes in front of a complaint by selecting the appropriate tests. A choice of clinical situations helps to understand the disorders and the approach of the examination of the child, to inform the families of the results, to accompany them on the therapeutic project and to prescribe the care adapted to each situation.

PLACE DE L'OUTIL MODULABLE BMT-I DANS L'ÉVALUATION DES TROUBLES DE L'APPRENTISSAGE Vingt pour cent des enfants sont en difficulté pour apprendre à lire, écrire et/ou compter. Huit pour cent des enfants présentent une altération durable et spécifique du développement d'un apprentissage ou d'une fonction cognitive (« troubles spécifiques du langage et des apprentissages ¼ [TSLA]), souvent simplifié sous le terme « dys ¼ (dysphasie, dyslexie, dysorthographie, dyscalculie, dysgraphie, etc.). La Haute Autorité de santé s'est saisie de ce problème de santé publique et recommande un parcours de santé ciblé sur les besoins de chaque enfant, coordonnant professionnels de l'éducation et de la santé ­ rééducateurs et médecins prescripteurs. Le rôle du médecin est essentiel en premier recours pour identifier les enfants concernés, les examiner, prescrire les rééducations nécessaires et suivre l'évolution. L'outil modulable BMT-i (batterie modulable de tests informatisée) validé, simple d'utilisation et fiable, permet le dépistage des difficultés dans chaque domaine en dix à vingt-cinq minutes, en sélectionnant les épreuves adéquates. Un choix de situations cliniques aide à la compréhension des troubles et à la démarche de l'examen de l'enfant, afin d'informer les familles des résultats, les accompagner dans les actions à mener et prescrire les soins adaptés à chaque situation.

Health promotion for young people with profound and multiple learning disabilities.

Research confirms that children and young people with severe learning disabilities do not have the same level of access to high-quality care, health education and health promotion activities as children and young people without disabilities. This article discusses a quality improvement, action research project to investigate alternative approaches to health promotion that enhance the health and well-being of children and young people with complex neurodisabilities. The project involved assessment of school records and completion by staff of an eight-question survey. It found that the proactive approach of school nurses in raising awareness and understanding through questioning was positively received, and reinforced how meaningful and relevant information could be delivered to these young people. The project also had unexpected benefits, including more integrated team working, increased knowledge, greater awareness and understanding of the importance of health promotion participation, and student satisfaction.

Ascertaining educational outcomes after assessment in children with learning disorders.

OBJECTIVE: To survey educational outcomes after an interdisciplinary, neuropsychologically based team assessment for learning disorders. METHOD: Parents of 137 children who underwent a comprehensive interdisciplinary neuropsychologically based assessment for learning problems completed an online survey one to four years later. Questions pertained broadly to school outcomes: positive or negative school responses, changes in special education services, and parental perceptions about the helpfulness of those services. These outcomes were examined in relation to demographic characteristics and parent satisfaction with the evaluation. We also obtained recent performance on state-based academic testing for descriptive purposes. RESULTS: Parents reported that schools generally responded positively (78%), and 70% reported that their children had access to more or different special education services after the evaluation. Parents nearly uniformly (98%) viewed these services as helpful. Positive changes in education services were related to income (lower income received more services, p < .05) and parent satisfaction with the evaluation (p < .05). The intensity of special education services was strongly related to performance on state-based testing (p < .0001-p < .01). CONCLUSIONS: School response is a relatively objective and meaningful metric of educational outcome after neuropsychologically based evaluation for children with learning problems.

Development and validation of the Learning Disabilities Needs Assessment Tool (LDNAT), a HoNOS-based needs assessment tool for use with people with intellectual disability.

BACKGROUND: In meeting the needs of individuals with intellectual disabilities (ID) who access health services, a brief, holistic assessment of need is useful. This study outlines the development and testing of the Learning Disabilities Needs Assessment Tool (LDNAT), a tool intended for this purpose. METHOD: An existing mental health (MH) tool was extended by a multidisciplinary group of ID practitioners. Additional scales were drafted to capture needs across six ID treatment domains that the group identified. LDNAT ratings were analysed for the following: item redundancy, relevance, construct validity and internal consistency (n = 1692); test-retest reliability (n = 27); and concurrent validity (n = 160). RESULTS: All LDNAT scales were deemed clinically relevant with little redundancy apparent. Principal component analysis indicated three components (developmental needs, challenging behaviour, MH and well-being). Internal consistency was good (Cronbach alpha 0.80). Individual item test-retest reliability was substantial-near perfect for 20 scales and slight-fair for three scales. Overall reliability was near perfect (intra-class correlation = 0.91). There were significant associations with five of six condition-specific measures, i.e. the Waisman Activities of Daily Living Scale (general ability/disability), Threshold Assessment Grid (risk), Behaviour Problems Inventory for Individuals with Intellectual Disabilities-Short Form (challenging behaviour) Social Communication Questionnaire (autism) and a bespoke physical health questionnaire. Additionally, the statistically significant correlations between these tools and the LDNAT components made sense clinically. There were no statistically significant correlations with the Psychiatric Assessment Schedules for Adults with Developmental Disabilities (a measure of MH symptoms in people with ID). CONCLUSIONS: The LDNAT had clinically utility when rating the needs of people with ID prior to condition-specific assessment(s). Analyses of internal and external validity were promising. Further evaluation of its sensitivity to changes in needs is now required.

Early Child Development and Nutrition: A Review of the Benefits and Challenges of Implementing Integrated Interventions.

Poor nutrition (substandard diet quantity and/or quality resulting in under- or overnutrition) and the lack of early learning opportunities contribute to the loss of developmental potential and life-long health and economic disparities among millions of children aged <5 y. Single-sector interventions representing either early child development (ECD) or nutrition have been linked to positive child development and/or nutritional status, and recommendations currently advocate for the development and testing of integrated interventions. We reviewed the theoretical and practical benefits and challenges of implementing integrated nutrition and ECD interventions along with the evidence for best practice and benefit-cost and concluded that the strong theoretical rationale for integration is more nuanced than the questions that the published empirical evidence have addressed. For example, further research is needed to 1) answer questions related to how integrated messaging influences caregiver characteristics such as well-being, knowledge, and behavior and how these influence early child nutrition and development outcomes; 2) understand population and nutritional contexts in which integrated interventions are beneficial; and 3) explore how varying implementation processes influence the efficacy, uptake, and cost-benefit of integrated nutrition and ECD interventions.

Wordless intervention for people with epilepsy and learning disabilities (WIELD): a randomised controlled feasibility trial.

OBJECTIVE: To investigate the feasibility of a full-scale randomised controlled trial of a picture booklet to improve quality of life for people with epilepsy and learning disabilities. TRIAL DESIGN: A randomised controlled feasibility trial. Randomisation was not blinded and was conducted using a centralised secure database and a blocked 1:1 allocation ratio. SETTING: Epilepsy clinics in 1 English National Health Service (NHS) Trust. PARTICIPANTS: Patients with learning disabilities and epilepsy who had: a seizure within the past 12 months, meaningful communication and a carer with sufficient proficiency in English. INTERVENTION: Participants in the intervention group used a picture booklet with a trained researcher, and a carer present. These participants kept the booklet, and were asked to use it at least twice more over 20 weeks. The control group received treatment as usual, and were provided with a booklet at the end of the study. OUTCOME MEASURES: 7 feasibility criteria were used relating to recruitment, data collection, attrition, potential effect on epilepsy-related quality of life (Epilepsy and Learning Disabilities Quality of Life Scale, ELDQOL) at 4-week, 12-week and 20-week follow-ups, feasibility of methodology, acceptability of the intervention and potential to calculate cost-effectiveness. OUTCOME: The recruitment rate of eligible patients was 34% and the target of 40 participants was reached. There was minimal missing data and attrition. An intention-to-treat analysis was performed; data from the outcome measures suggest a benefit from the intervention on the ELDQOL behaviour and mood subscales at 4 and 20 weeks follow-up. The booklet and study methods were positively received, and no adverse events were reported. There was a positive indication of the potential for a cost-effectiveness analysis. CONCLUSIONS: All feasibility criteria were fully or partially met, therefore confirming feasibility of a definitive trial. TRIAL REGISTRATION NUMBER: ISRCTN80067039.

Beyond ADHD: How Well Are We Doing?

BACKGROUND AND OBJECTIVE: There has been increasing emphasis on the role of the pediatrician with respect to behavioral, learning, and mental health (MH) issues, and developmental behavioral rotations are now required in pediatric residency programs. We sought to examine whether this newer emphasis on MH is reflected in pediatricians' reports of their current practices. METHODS: Data from 2 periodic surveys conducted in 2004 and 2013 by the American Academy of Pediatrics were examined to see whether there were differences in self-reported behaviors of usually inquiring/screening, treating/managing/comanaging, or referring patients for attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, behavioral problems, or learning problems. We examined patterns for all practicing members and for those who practiced general pediatrics exclusively. RESULTS: There were few changes over the decade in the percentage who inquired or screened among all clinicians; among those exclusively practicing general pediatrics, the percentage who inquired or screened increased about 10% for ADHD and depression. ADHD remained the only condition for which the majority of respondents treated/managed/comanaged (57%). While there was some increase in the percentages who treated other conditions, the other conditions were usually treated by <30% of respondents. A similar pattern of results was observed in analyses adjusted for physician, practice, and patient characteristics. CONCLUSIONS: Despite the changing nature of pediatric practice and increased efforts to emphasize the importance of behavior, learning, and MH, the pediatric community appears to be making little progress toward providing for the long-term behavioral, learning, and MH needs of children and adolescents in its care.

Characteristics of people who rapidly and frequently reattend the emergency department for mental health needs.

OBJECTIVE: This paper identifies the characteristics of emergency department (ED) attendees with a referral to their Mental Health Liaison Service (MHLS) who are at increased risk for rapidly reattending, attending frequently, or attending intensely at this service (which is defined here as rapid and frequent reattendance). METHODS: A retrospective 5-year longitudinal study was conducted of all visitors (n=24 010) attending four busy EDs with a referral to their MHLS from the beginning of 2009 until the end of 2013. A Cox proportional hazards regression was used to identify factors associated with intense use, and a negative binomial regression was used to identify factors associated with frequent attendance. RESULTS: People with certain characteristics were more likely to make 'intense' use of mental health emergency services, which we define as shorter time to reattendance and a higher number of visits over 5 years. The people more likely to make intense use are more likely to have certain clinical diagnoses such as substance misuse, stress disorder, personality disorder and learning disability, to have certain social characteristics such as not being in a relationship, or living alone, and to have healthcare issues such as having been detained under the Mental Health Act and having a greater number of care coordinators over 5 years. CONCLUSION: Individuals with certain clinical and social characteristics were significantly more likely to reattend EDs and have referral to MHLS rapidly and frequently (i.e. intensely).

'A whole world of opportunity'.

Last year, NHS England announced that 74 trusts had been awarded a total of around £30 million from the Nursing Technology Fund. This is for projects to support nurses, midwives and health visitors make better use of digital technology for safer, more effective and efficient care.

Comparing service use and costs among adolescents with autism spectrum disorders, special needs and typical development.

Autism spectrum disorder is a complex condition that requires specialised care. Knowledge of the costs of autism spectrum disorder, especially in comparison with other conditions, may be useful to galvanise policymakers and leverage investment in education and intervention to mitigate aspects of autism spectrum disorder that negatively impact individuals with the disorder and their families. This article describes the services and associated costs for four groups of individuals: adolescents with autistic disorder, adolescents with other autism spectrum disorders, adolescents with other special educational needs and typically developing adolescents using data from a large, well-characterised cohort assessed as part of the UK Special Needs and Autism Project at the age of 12 years. Average total costs per participant over 6 months were highest in the autistic disorder group (£11,029), followed by the special educational needs group (£9268), the broader autism spectrum disorder group (£8968) and the typically developing group (£2954). Specialised day or residential schooling accounted for the vast majority of costs. In regression analysis, lower age and lower adaptive functioning were associated with higher costs in the groups with an autism spectrum disorder. Sex, ethnicity, number of International Classification of Diseases (10th revision) symptoms, autism spectrum disorder symptom scores and levels of mental health difficulties were not associated with cost.

One size does not fit all: improving clinical practice in older children and adolescents with language and learning disorders.

PURPOSE: In the lead article for this clinical forum, Kamhi (2014) suggests ways that current knowledge on instructional practices in learning and language can be applied to clinical practice in language disorders. I propose that Kamhi's suggestions are in need of fine-tuning for older children and adolescents with language disorders. A one-size-fits-all approach to language intervention across a broad age range is untenable due to unique needs and capabilities of this older population. METHOD: Three intervention goal priorities for older students are presented with supporting research: complex (multiclausal) sentences, verb structure, and expository text. Methodologies for teaching complex sentences are discussed next, including topics of content/form balance and treatment intensity. These goals and methods are designed to assist students with language disorders in the comprehension and production of complex language they encounter in school. CONCLUSION: Guidance for high-priority language intervention goals with older students comes from a consideration of language needs in academic settings and language weaknesses that persist in this population. Although current research offers support for these goals, less is known about methodological variables such as treatment intensity.

Making music, making friends: Long-term music therapy with young adults with severe learning disabilities.

This collaborative practitioner research study emerged from music therapists' concerns about the value of improvisational, music-centred music therapy for young adults with severe learning disabilities (SLDs), given the long-term nature of such work. Concerns included the relevance, in this context, of formulating, and reporting on, therapeutic aims, development, change; and working in 'goal-oriented' way. Focus groups with the young adults' families and a range of professionals suggest that, rather than leading to developmental change, long-term shared therapeutic musicking provides young adults with ongoing opportunities for experiencing confidence and self-esteem, with feelings of shared acceptance and success, and also provides young adults and their families with opportunities for developing and sustaining friendships. In addition, families experienced meeting other parents and carers in the communal reception area as supportive and countering their isolation. Focus groups assigned intrapersonal, relational and social values to long-term music therapy for young adults with SLDs.

An assessment of error-correction procedures for learners with autism.

Prior research indicates that the relative effectiveness of different error-correction procedures may be idiosyncratic across learners, suggesting the potential benefit of an individualized assessment prior to teaching. In this study, we evaluated the reliability and utility of a rapid error-correction assessment to identify the least intrusive, most effective procedure for teaching discriminations to 5 learners with autism. The initial assessment included 4 commonly used error-correction procedures. We compared the total number of trials required for the subject to reach the mastery criterion under each procedure. Subjects then received additional instruction with the least intrusive procedure associated with the fewest number of trials and 2 less effective procedures from the assessment. Outcomes of the additional instruction were consistent with those from the initial assessment for 4 of 5 subjects. These findings suggest that an initial assessment may be beneficial for identifying the most appropriate error-correction procedure.

[Role of pediatricians in the diagnosis and therapy of dyslexia, dysgraphia and dyscalculia]. / A családorvosok szerepe a dyslexia, dysgraphia és dyscalculia diagnosztikájában és terápiájában.

Pediatricians play an important role in the diagnosis and therapy of children with dyslexia, dysgraphia or dyscalculia. These syndromes strongly affect children's school performance. Children with dyslexia, dysgraphia or dyscalculia show a significant underachievement in reading, writing or counting and their failure to meet the school requirements undermines their self confidence and positive self-concept. As a result, children with learning problems often become aggressive, frustrated or play the clown in the classroom. According to the Hungarian law children with any learning difficulties have the right to get special education by their specific symptoms. In the realisation of the law and equity the pediatrician's expertise is essential and has an important role in the therapeutical procedures. However, the pediatrician's role is more complex than writing an opinion. Pediatricians can help by giving a detailed description about these syndromes and explain them how they can help their child, what are the main difficulties during the child's studies, what kind of therapies can be efficient and how they can make their child's school years easier. During the assessment most of the parents ask the following questions: What does dyslexia, dyscalculia or dysgraphia exactly mean? Is it a handicap or a learning difficulty? Could the child live a normal life? With the proper answer and with an inclusive attitude pediatricians can help both the parents and the children to create a liveable lifestyle and make their children's schoolwork more successful. The authors' opinions are to close the medical and the pedagogical view, because without the cooperation of these two scientific fields, the theme affected parents, children and teachers cannot get proper help to find better solution and support for their problems. In the survey the authors intend to give a complex view about the symptoms of these syndromes and try to give useful advice for pediatricians how they can support their patients emphasizing the key role of pediatricians and clinical expertises in the early recognition and therapy.