Management

A multidisciplinary approach is appropriate, with a view to helping people with learning disabilities to integrate into the general community ('normalization') and meet such personal needs as close relationships and appropriate occupation.

Medical management includes diagnosis and treatment of physical and psychiatric problems. In clinical practice, the presence of LD in a given patient will be well known in most cases, but what requires to be dealt with may be a change in behaviour or the development of overt psychiatric symptoms.

Methods of assessment and treatment may need to be modified from those used for people without intellectual impairment (Bradley and Lofchy, 2005). However, it is important to talk to the patient as much as possible directly, not just to the caregivers, and to involve him in the assessment.

If psychotropic drugs are used, the optimum regimen has to be found by titrating the dose against the target problems, perhaps over a period of several months. LD patients tend to be very sensitive to the effect of medication; doses must therefore start low and be increased only cautiously and gradually, if necessary. Unwanted effects are also more frequent; it is a question of balancing the benefits and drawbacks of medication in an individual patient.

Psychologists are involved in assessing patients' overall intelligence, and any specific defects or abilities. They help to plan individual behavioural treatments, which can be useful even in severe cases for teaching self-care, practical skills, and social behaviour. Desirable behaviour or the acquisition of skills is given positive reinforcement by a tangible reward or approving attention. Undesirable behaviour may be a means of seeking attention, in which case it is best ignored, or it can be managed by occupying the patients with interesting alternative activities.

Social and educational aspects are important. Improving the environment of children from deprived backgrounds has been shown to lead to increases in IQ, although it is uncertain whether this improvement is maintained into adult life. Many parents of affected children prefer to keep them at home, and this is frequently possible with help from community services. Alternatives include sheltered accommodation such as locally based hospital units (LBHUs), community homes, and hostels provided by the local authority. Long-term hospital care is now discouraged, except for very severe cases or those with extremely 'challenging behaviour', but people with LD and superadded psychiatric or behavioural disorders may well require acute admission to specialist units from time to time.

Children with mild LD are placed in ordinary schools if possible. They will be 'statemented' by the local education authority, ensuring extra help in the classroom from learning-support assistants. Special schools exist for severe cases. Further training after school-leaving age is provided in adult training centres. Some patients can hold ordinary jobs, and others are employed in sheltered workshops.

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