פרופ' ג'רמי טורק: מוגבלויות: קללה או ברכה

Labelling & Classifications in Labelling & Classifications in Developmental Disabilities: Developmental Disabilities: Curse or Blessing?Curse or Blessing?Jeremy TurkJeremy TurkInstitute of Psychiatry, King’s College,University of LondonInstitute of Psychiatry, King’s College,University of London

Southwark Child & Adolescent Mental Health, Southwark Child & Adolescent Mental Health, Neurodevelopmental Service, Sunshine House,Neurodevelopmental Service, Sunshine House,South London & Maudsley NHS Foundation TrustSouth London & Maudsley NHS Foundation Trust

Great Ormond Street Hospitals NHS Foundation TrustGreat Ormond Street Hospitals NHS Foundation Trust

HistoricalHistoricalLes enfants du bon dieuChildren of a lesser god Irrecupables Incarceration & institutionalisationFatalistic nihilismNaïve idealismOvermedicalisation versus oversocialisation

What are developmental What are developmental disorders?disorders?Early onsetLong-termFrequently multipleInterferences in normally fluent skill acquisitionsNecessary for maximisation of potential and quality of life

Producing adverse physical & psychological functional consequences

& multiple social adversities & social disadvantage

Intellectual DisabilityIntellectual DisabilityGeneral level of intellectual functioning– Within the lowest 2-3% of the population– IQ less than approximately 70

Significant impairments in adaptive behaviours and life skills– Self-care– Self-occupancy– Self-sufficiency– Self-determination– Safety

DSM-5 Intellectual DisabilityDSM-5 Intellectual Disability Impairments of general mental abilities that impact

adaptive functioning & determine how well everyday tasks are coped with: 3 domains

Conceptual domain: language, reading, writing, maths, reasoning, knowledge, memory

Social domain: empathy, social judgement, interpersonal communication skills, making & retaining friendships

Practical domain: personal care, job responsibilities, money, recreation, organising school & work tasks

Diagnosis based on severity of deficits in adaptive functioning

DSM-5: Intellectual DisabilityDSM-5: Intellectual Disability Intellectual disability; not mental retardationAKA intellectual developmental disorderSpectrum of disability cognitively and functionallyAvoids hierarchical diagnosesMoves away from multiaxial classificatory systemsAll mental disorders considered on single axis and given

equal weight i.e. co-morbidities or co-occurrencesOften occurs with other mental disorders e.g. depression,

ADHD, ASD

What is IQ?What is IQ?

That which is measured by an IQ test

What does an IQ test measure?What does an IQ test measure?

IQThe ratio of chronological age to mental age

Multiplied by 100

Intellectual DisabilityIntellectual DisabilityMild 50 – 70Moderate 35 – 50Severe 20 – 35Profound < 20

Learning DifficultiesLearning DifficultiesModerate 50 – 70Severe < 50

Terminology Idiot, imbecile, feeble-mindedMental retardationMental subnormalityMental impairmentDevelopmental DelayLearning Disability, Learning DisabilitiesLearning difficulties Intellectual Disability

Autistic Spectrum

Disorder

A.D.H.D.

Intellectualdisability

Intellectual Disabilities, Autism Intellectual Disabilities, Autism Spectrum Conditions & ADHD:Spectrum Conditions & ADHD:

are developmental disabilities

are not psychiatric disorders

But they predispose individuals to mental health

problems for a variety of biological, psychological,

educational and social reasons

DSM-5 Autism Spectrum DisorderDSM-5 Autism Spectrum DisorderSingle diagnostic termCommunication deficits– Receptive & expressive– Verbal & non-verbal

Social impairmentsObsessional interests, behaviours, routines & insistence on

samenessFeatures from early childhood even if not recognised until

later

Attention Deficit-Attention Deficit-Hyperactivity DisordersHyperactivity Disorders Overactivity Inattentiveness Restlessness Fidgetiness Impulsiveness Distractibility All-pervasive

ADHD: DSM-5 CHANGESADHD: DSM-5 CHANGES Recognises adult presentations Children: at least 6 items from inattention

&/or hyperactive-impulsive group Adults: only 5 items needed Several symptoms must be present prior

to 12 years No exclusion criteria for those with ASCs

Prevalence: how common?Prevalence: how common? Intellectual Disability– Mild: 2-3%– Moderate-to-profound: 0.5%

ADHD / Hyperkinetic Disorder– DSM: 3-5%– ICD: 0.5-1%

Autism Spectrum Disorders 1-2%

Diagnosable Psychiatric Disorder Diagnosable Psychiatric Disorder with Significant Functional with Significant Functional Impairment in Young PeopleImpairment in Young PeopleGeneral population 7%

Physical Impairment 11%

Impaired brain functioning 33%

“Severe learning difficulties” 50%

Deprivation & disadvantage doubles the percentages

Cerebral PalsyCerebral PalsyPsychiatric disorder in 40%No gender predominance for boysHemiplegia:– 25% conduct/emotional disorder– 10% hyperkinetic disorder– 3% autistic disorder

Best predictor = low IQDisorders manifest identically to those of

psychosocial origin

Multi-axial Classification System1. Psychiatric diagnostic label(s) ADHD combined type2. Specific developmental delays (Specific learning

difficulties) working memory & fine motor impairments3. General level of intellectual functioning IQ = 634. Medical Associations Causal fragile X syndrome Consequential repetitive bruising & fractures Co-occurring epilepsy Coincidental & complicating eczema & hay fever

5. Social factors single parent, financial hardship6. Degree of functional impairment extreme

The Importance of DiagnosisThe Importance of Diagnosis(Turk, 2003)(Turk, 2003) the right of the individual & family to know relief from uncertainty facilitation of grief resolution focusing on the future genetic counselling information on likely strengths & needs early instigation of appropriate interventions linking with appropriate support networks

Advantages of LabellingAdvantages of Labelling Convenient & helpful shorthand Emphasises similarities & shared attributes Facilitates linking between diagnosis,

prevalence, symptomatology, treatments & supports & prognosis

Facilitates research Enables individuals and families to relate to

others with similar challenges

Disadvantages of LabellingDisadvantages of Labelling Oversimplifies & stereotypes complex life

situations Denies uniqueness of each individual Imposes “one size fits all” thinking by supporting

professionals Pathologises human developmental &

psychological variation Risks placing those at the margins statistically in

the margins of society