Losing the diagnosis: when LD criteria are no longer

met

Dr Jana de Villiers, Consultant PsychiatristDr Mike Doyle, Forensic Psychologist

Fife Forensic Learning Disability Service5 November 2014

Diagnosis of LD

• Significant cognitive impairment (usually IQ<70 on standardised assessment)

• Global impairment evident across domains from developmental period onwards (<18 years)

• Functional impairment (ie require support to manage daily life across a range of domains)

• Implication that it is a lifelong enduring condition

Webb and Whitaker (2012)

• ‘A person can be regarded as having a learning disability if:– They are judged to be in need of community care

or educational services due to a failure to cope with the intellectual demands of their environment

AND are suffering significant distressOR are unable to take care of themselves or their

dependentsOR are unable to protect themselves or their dependents

against significant harm or exploitation’

‘The issue is not what somebody’s IQ is, but whether they are able to cope…’

IQ distribution

LD diagnosis and the Criminal Justice System

• Diagnosis has a significant impact on suspect interviews, Court proceedings, sentencing, risk assessments and access to treatment programs

• In most states of USA, death penalty cannot be applied to offenders with a diagnosis of LD

• Also grounds for detention under mental health legislation

Legal criteria

Clinical practice

Case study

• 23 year old man • Parents well known to social work throughout

his childhood• Domestic violence

• ‘Extreme physical chastisement’ by his father• Child Protection Register 1999 (aged 8) under

category ‘emotional abuse’• ‘Lack of parental care’• In care aged 9

• Cruelty towards animals from age 8• ‘Serious attachment difficulties’• Age 13: ‘a serious threat to other vulnerable

children and teaching staff’• Age 13: convicted of assault with intent to

ravish• Age 14: theft of female underwear• Age 15: broke a member of staff’s leg

• Age 15: Convicted of assault with intent to rape– 3 years probation plus a SOPO– Secure accommodation

• Age 16: WAIS-III IQ=69• On 18th birthday made subject to a CTO (under

category of LD) and transferred to Levendale ward (locked ward)

• SALT assessment age 20: poor comprehension, poor auditory memory and poor retention

• Did well over next 8 months – discharge planning considered

• Engagement declined• Increasing threatening behaviour – including

threats to kill RMO• Offensive language towards females• Age 20: took photograph of teenage girl out of

bedroom window using MP4 player• Extremely disruptive on ward

• Transferred to regional low secure unit• Initially responded well• 2012: – Sexualised threats (in breach of SOPO)– Charged with assault to injury of female member

of staff• Over next few months ‘increasing maturity’

noted• Oct 2013: Serious assault on male charge

nurse

• March 2014: referred for second opinion to Dr Douds, TSH

• Verbal threats, pacing hub area, ‘goading’ staff• ‘If you did what I want, there wouldn’t be an

issue.’• Lunged towards charge nurse – alarms

activated• April 2014 – attempted to headbutt a female

member of staff

• May 2014: referred to Rowanbank, seen by Dr Appan– “would benefit from a period of care in an

environment of higher security”• Lack of medium secure beds in Scotland,

therefore transferred to TSH under ‘exceptional circumstances clause’

• Northgate assessment queried LD diagnosis

• WAIS-IV completed at TSH July 2014:– Verbal comprehension: 81 (low average)– Perceptual reasoning: 96 (average)– Working memory: 63 (extremely low)– Processing speed: 84 (low average)

• Full scale IQ = 79 (borderline)

• Functional assessment did not demonstrate significant impairment

…therefore does not meet criteria for a learning disability

…and therefore detention criteria for CTO are no longer met, but risk to others remains

Changes in IQ scores

• Chance error– Examiner technique, cooperation, stress, mental illness

• Systematic error– Flynn effect– Instability of score at extremes of distribution– Changes to cognitive assessment scales/differences

between scales• True change in IQ– Dietary changes, education, intellectual stimulation

The Flynn Effect

Proceedings of the National Academy of Sciences of the USA, January 10, 2012

• “An unusually large increase in both average education and average IQ is apparent at the same time as the reform was introduced”

• “…an additional 1y of schooling raising IQ by a statistically significant 3.7 points.”

IQ and LD

• WISC normed 1947 – by 1972 only 0.54% of population would qualify as LD due to Flynn effect

• WISC-R normed 1972, and LD population suddenly jumped again to 2.27%, and percentage started to erode again until next norming

‘The Stability of IQ in People of Low Intellectual Ability’

• Literature review published in ‘Intellectual and Developmental Disabilities’ April 2008

• 57% of IQs changed by <6 points but 14% changed by 10 points or more

Changes to cognitive assessments…

True ‘change’ in cognitive abilities?

True ‘change’ in cognitive abilities?

• Account for why IQ Scores lower in 2007

• Account for why IQ scores higher in 2014

Early negative experiences and IQ

• Impact of possible (early) psychological trauma on IQ.– Children & adolescent victims of abuse or witnesses to

violence show deficits in language development, attention, abstract reasoning & executive functioning

Culp et al, 1991; Beers & De Bellis, 2008, Kira et al, 2012, 2014

Early negative experiences and IQ

• Association between some trauma types (e.g. exposure to violence and assault) ...and significant decrements in IQ or one of its components’

Kira et al, 2012

• Changes in Care Giver -VE IMPACT ON Working Memory (& Processing Speed)

• Father or Abandonment Processing Speed• Mother Abandonment Perceptual Reasoning• Foster care Perceptual Reasoning & Working

MemoryMr. X scored sig lower on WM and non-sig lower on PS in 2007 Age 9 Mr. X. Scored 91 on ‘Spatial Ability’

Early negative experiences and IQ

• Impact on IQ of therapeutic interventions for psychological trauma.

• ‘Children who are neglected have ...lack of exposure to different aspectts of cognitive enrichment that contribute to enhanced IQ expression.

• ‘Wraparound multisystemic, multi-modal and multi-component interventions proved to be effective with adolescent victims of cumulative attachment trauma disorders’

– Kira et al, 2012.

• Impact of environmental factors associated with poverty, e.g. diet

Case study

• WAIS III vs WAIS IV• Experience of psychological trauma• Limited intellectual stimulation in childhood• Disrupted education• Once in low secure setting received skill

development and problem solving training• = True change in cognitive ability

Implications for clinical practice

• Cognitive assessments in adolescence/early adulthood liable to change once individual is in a structured setting

• Effect on cognitive functioning/IQ scores of early trauma

• There may be clues in early intellectual assessments that cognitive level may improve over time

janadevilliers@nhs.net

mdoyle@nhs.net