Professional Documents
Culture Documents
Course
HANDBOOK
For
MODULE
DEVELOPERS
Wessex Deanery
School of Psychiatry
Contents
Page
Introduction 3
Appendices
− Appendix 1: The basic course structure 15
2
Introduction
Purpose of this handbook for Module Developers
This handbook has been written to help the people who are developing
modules (Module Developers) for the new MRCPsych teaching course (the
Course). It sets out:
• The overall concept of the Course
• The organisation and management of the Course
• The basic structure of the Course
• Varieties of module design
• A module design template
It’s also important for trainees to realise that a handbook can’t cover
everything to do with a module, let alone the course as a whole, otherwise it
will be unwieldy. There are other documents covering those matters. Module
Developers are encouraged to read the following related handbooks, and to
make references to them in the document they prepare for their own module.
- Course handbook
- Handbook for facilitators
- Guidance notes for educational supervisors
The course website: www.hampshirepartnership.nhs.uk/postgraduate
contains electronic versions of all these handbooks and other documents
relating to the course.
Module developers are also encouraged to read:
- the RCPsych document A competency based curriculum for Specialist
Training in Psychiatry
http://www.rcpsych.ac.uk/training/curriculum2010.aspx
- the RCPsych document Postgraduate Training in Psychiatry –
Essential Information for Trainees and Trainers, July 2008 (now
superseded by OP69 Specialist Training in Psychiatry)
http://www.rcpsych.ac.uk/publications/collegereports/op/op69.aspx
3
Overall concept of the Course
The new MRCPsych Course goes much further than the old course (which
focused almost exclusively on the Membership exams). It aims to provide
Core Trainees (CT 1-3) in Psychiatry in Wessex with:
• a sound and secure basis for their clinical practice at this level
• a strong platform for further specialty training in Psychiatry
• detailed support for their preparation for the MRCPsych exams
The Course has been revised because of changes in Psychiatric practice and
the introduction of a new curriculum by the Royal College of Psychiatrists and
a recommended syllabus for Core Training.
4
Basic structure of the Course
Overall, the Course, which as before runs on Thursdays during term time, is
divided into years (called ‘Parts’), each of these into specialty ‘Modules’ (with
Module leads), and each of these into content ‘Topics’. Each ‘Topic’ has a
weekly ‘Timetable’. Appendix 1 shows the overall structure of the course and
Appendix 2 the detailed timetable for a topic, outlining the roles of all the
participants in the course.
The course is a big departure from what most trainees have experienced in
the past. Partly this is because trainees are now expected to do much of the
work themselves. They are not being ‘spoon-fed’. This means that module
designers need to give careful attention to what is expected of trainees – what
their ‘task’ is each week. This is dealt with in some detail below.
On courses of this kind, trainees tend to ‘over work’, largely because they are
unclear what is expected of them, and also because they have still to learn
how to limit their learning to meet their personal educational needs. The
Steering Group’s expectation is that trainees would spend on average the
equivalent of one evening during the two weeks between sessions working on
their tasks, which they will have discussed and agreed with their colleagues in
their learning sets.
The ‘Parts’
The Course is made up of three ‘Parts’ – one for each of the three years of the
Core Training in Psychiatry. Part A is repeated every year for the new intake
of Trainees (CT1s). The second and third years (Parts B1 and B2), run in
alternate years (and are combined for CT2 and CT3 Trainees). Both Parts A
and B run on alternate Thursdays during term time. This means that each
week in term time there will be a Part running (either A or B), and so each
runs fortnightly during this time. This basic structure is shown
diagrammatically in Appendix 1 at the end of this Handbook.
The ‘Modules’
Each ‘Part’ is divided into ‘Modules’. These represent the major specialties
within Psychiatry, which are distributed across the three years as follows:
• Part A modules (for CT1 trainees, run annually)
- Core Psychiatry
- Human Development
- Psychotherapy
5
• Part B2 modules (for CT2 or 3 Trainees, run bi-annually)
− General Adult
− Old Age
- Child and Adolescent
- Learning Disability
Module Leads
Each ‘Module’ has a nominated ‘Module Lead’. Module Leads are part of the
Course Steering Group to ensure close linkage between modules, and that
Module content maps to the College curriculum and Membership exams.
Module leads are expected to attend the Course at the start of their Module
(and if possible at other times as well). They are asked to:
• introduce themselves and their colleagues to the trainees
• introduce the Module
• establish the significance and importance of the module for Psychiatric
practice
• outline the scope of the module (what it is intending to cover)
• say how the module will go about achieving this (and how this
reinforces the educational principles of the Course as a whole)
• indicate any particular features of the module that are ‘out of the
ordinary’, and say how trainees might need to adapt to this.
NOTE: In the larger Modules (e.g. General Adult and Old Age, and where
other Psychiatric specialties feature at different times within Parts A and B)
there will be several Modules that together make up teaching across the
course for that specialty. In these cases, there is likely to be more than one
Module Lead – perhaps two or three, each taking responsibility for running a
particular aspect of the specialty. It is important, here, that the teaching of the
specialty is planned ‘as a whole’, with clear links between the different
sections, and that there is one overall Module Co-ordinator.
Learning Sets
Much of the work on the Course occurs in small groups called ‘learning sets’
with about eight or nine trainees per group. (In Part A there will be three or
four groups – four or five in part B).
6
Learning Sets are encouraged to meet ‘outside of’ the Course that is, in the
intervening fortnight between the timetabled elements of the Course, and also
outside of ‘term time’. This can include meetings specifically for exam
preparation and revision (which is recommended for greater exam success).
Each Part A Learning Set has a ‘Mentor’, specifically assigned to work with a
Learning set for a year (and possibly longer). Mentors are volunteers from the
steering group who are experienced clinicians with a strong interest in
education.
Learning Set Mentors meet their trainees early on in the Course to get to
know the Trainees and to discuss how they might be most helpful. Help might
involve meeting with the Learning Set outside ‘timetabled’ and/or ‘term’ time.
The purpose of having a mentor is to offer Trainees a vision of the ‘wider
perspective’ of the Course – an overview – for Trainees to see how the
modules link together for high quality clinical practice, and to enable Learning
Set members to get the most out of their work together.
Topics
Each ‘module’ is divided into a series of ‘Topics’. These form the ‘content’ of
the Course. Topics are agreed by Module Leads in their teams, and discussed
with the Steering Group. They map the Topics against the College curriculum,
though not all of the curriculum content is ‘covered’ by the Course – no course
can ever do this, so Trainees will still need to do their own private study to
cover everything that is needed to pass the Membership exams.
Topics can appear very large, and this can make it difficult for trainees to see
what they might work on. Early experience of running the course shows that
trainees took on far too much work in the fortnight between sessions. This can
be avoided in the module design through the tasks that trainees are set each
week.
Setting tasks
Task setting is a crucial element of the plans for all modules. The tasks that
trainees work on in their learning sets provide the essential basis for their
learning. Quality learning comes from quality tasks. This section-
7
3. Responds constructively to the problems and suggestions that have been
raised by trainees and facilitators in their feedback so far to the course
team.
1. Avoiding too broad a subject - especially where the topics are very large
(e.g. some areas of the General Adult and Old Age Modules) trainees
need rather specific guidance and clear indications of their tasks whilst
working in their learning sets. This can include:
• suggested questions for trainees to think about when approaching
the task they have been set
• detailed tasks to give trainees a clear indication of what is expected
of them.
2. Ensuring tasks provide clear links to trainees’ clinical practice, learning
opportunities in their current work, discussions they might have with their
educational supervisor, basic knowledge (e.g. in text books) and other
relevant resources (e.g. u-tube downloads) they could explore.
3. Avoiding very abstract/science based tasks (e.g. neurochemistry). While
trainees will need to develop a sound knowledge base of knowledge in
those areas, they can do this best through being set learning tasks that
help them make links between basic science and their clinical work.
4. Avoiding designing tasks around ‘chapters’ of text books. This merely
encourages a limited approach to ‘researching’ a topic, as it focuses
trainees attention only on one (or a limited) knowledge area and
discourages them linking together various knowledge areas.
5. Designing tasks that start from ‘real cases’ and move towards
understanding the underlying basic science rather than the other way
round. People learn theory best from practice – they don’t ‘apply’
knowledge to practice.
6. Reflecting and reinforcing the educational principles of the course:
• ‘research’ – trainees doing the work by exploring, being curious,
solving problems they see in their own practice, etc.
• development of each individual’s training needs
• Developing good clinical practice
• develop a deeper understanding of the underpinnings of clinical
practice
• encourage reflection
• developing a sound knowledge base – for their clinical practice as
well as to pass the Membership exams!
Task Allocation
8
Task Setting Sessions
1. Facilitator input during these sessions is vital. Trainees often find it useful
to have guidance in the refining of the task(s) that they have been set.
2. Tasks work well which reinforce the need for trainees to focus on areas of
interest/educational development/relevance which reflect their particular
stage of development.
3. Facilitators need to be clear what tasks are being set, and to have been
given clear guidance by the module developer(s) and topic lead facilitator
prior to the session (e.g. during the lunch break if the topic begins in the
afternoon).
4. It is important that facilitators observe how the learning sets are dealing
with the task(s) they have been set, how they are planning what to do, the
‘division of labour’, the writing up of their work plan, etc.
With these suggestions in mind and to try and maintain and reinforce a
consistent and clear approach for trainees and facilitators:
• each set of tasks could include an introductory statement reinforcing the
message that they are focussing on specific areas and are not designed to
cover the entire curriculum. That they should be viewed as a framework for
further study which will be guided by each trainee’s needs and pace.
• when deciding on a task, to consider how they can be most helpfully
designed to guide trainees on making those important links with everyday
clinical practice, educational supervision, WPBAs etc.
• tasks might be also be accompanied by a list of suggestions for how
trainees might approach their tasks in relation to other domains of their
training. These should not be exhaustive or absolute but reflect the
principles behind the course.
• trainees should be encourage to adapt their tasks to what is useful/
appropriate in their current placements and might call on the guidance of
facilitators in the planning process
• look at examples of tasks that have been set in previous (or other)
modules that have been found to work well. Examples are shown in
− Appendix 3 Core Psychiatry - Old Age: Topic - Memory
− Appendix 4 Core Psychiatry - Adult: Topic - Anxiety
− Appendix 5 Substance misuse: Topic - Alcohol use disorders
9
Facilitators
Facilitators help trainees in their Learning Sets get the most out of the Course
by working with them to carry out the activities relating to the weekly topics
that have been devised by the module leads (see Handbook for Facilitators).
Module Leads are responsible for identifying suitable Facilitators for their
module. A list of people who have volunteered to be Facilitators is held at the
Postgraduate Centre in Southampton. It is essential that Facilitators have
attended a Facilitator Development session, and that they understand the
nature of the Course, its underpinning educational principles, and the role of
Facilitators.
Masterclasses
10
Masterclasses can take different forms. Some examples that have been
shown to work well are:
• special topics
• difficult, rare or interesting case presentations
• specialist input (e.g. from experts working in the field)
• specialist input from practitioners in the field e.g.
service users
social workers
nurses
occupational therapists
physiotherapists
police
solicitors
• visits (e.g. to special units)
• laboratory work (e.g. neuroanatomy)
• visits by theatre groups (people who act out relevant scenarios)
11
Varieties of Module design
This section of the Handbook deals specifically with the all important
educational process of the Course, which is different from what went before.
For this reason, we have included examples of some of the Module designs
that have occurred already. Some are still ‘work in progress’ but show where
the developers’ thinking is at present.
When the Course was initially being devised, each of the prospective Module
Leads that had been identified by the steering group were encouraged to
develop their module in a way that they felt best suited their specialty area,
the topics they wished to cover, and the resources they had available
(including the Facilitators they could call upon). This led to a range of different
formats, all within the general principles of the Course. The Steering Group
fully supports this approach, and wishes to encourage imaginative and
creative plans from future module leads in developing their modules. Having
said this, the process for each module needs to reflect the underpinning
educational principles of the course as a whole.
Below we give examples of how different module leads have planned their
approach to achieving their aims, each with comments that might be helpful to
other Module Developers.
The Topic example shown here is ‘Memory’. All Learning Sets are given the
same case vignette, plus some general notes to guide their discussion.
It is recognised that trainees will almost certainly come with different kinds
(and levels) of clinical experience, and their current clinical placement may or
may not be in Old Age Psychiatry. Nevertheless, ‘memory’ is a feature of
clinical conditions in other psychiatric specialties, and the work of the group
can draw on each member’s experience. This is shown in the Appendix in
terms of how a Learning Set, given the Task shown, divides up the work.
12
As Module Developers, this example shows you what can be achieved when
trainees are given responsibility to learn. Your task is to devise modules and
to support trainees’ work on them to achieve this!
Learning Disability
This module is not due to commence until May 2011, yet is in an advanced
stage of development, as is shown in Appendix 6.
13
A Suggested Design Template for Modules
Having said this, the Steering Group also recognises that Module Developers
might welcome some prompts to achieve this. Below we list some headings
which they might find useful. If all Module Handbooks have the same or a
similar format, there will be consistency across the Course as a whole, and
trainees will find a common approach familiar to them.
• A contents page
• An introduction to the module
− Aims and objectives
− Areas of the MRCPsych Syllabus Covered
− Suggested Resources
− Timetable
• Historical background to the specialty
• Details of each week’s work
− Introduction
− Objectives
− Case problem
− Issues to be considered
− Resources
− Tasks for Learning Sets
• References
• Appendices
14
Appendix 1
APPENDIX 1:
APPENDIX 2
MRCPsych Course: Topic timetable
This timetable is a recommended format. It is based on evaluations of the course in terms of ‘what works best’. In some
circumstances it may be modified for a particular topic. Generally, a topic will conclude before lunch and a new topic commence
after lunch, though again this may be modified for particular modules and topics. Where a module or a topic departs from this
suggested format, this (and the rationale behind the change) should be clearly described in the module handbook, and clarified to
trainees at the time.
12:00 Conclusion of previous topic Trainees Write reflections on topic and complete topic feedback sheet
16
Appendix 2
13:30 Group work in Learning sets Trainees In learning sets: Work on task(s), agree scope and range, identify
resources/materials, agree individuals’ work, discuss how to proceed,
plan homework, discuss when next to meet, prepare written plan of
action, identify learning set leader for topic, hand plan of action to
Postgrad Education Coordinator
Topic lead and facilitators Rotate between learning sets offering suggestions and advice,
managing expectations, being realistic, keeping learning sets focused on
their task(s).
Intervening Learning sets work on agreed Trainees Work individually and (where possible) in learning sets.
fortnight tasks Learning set mentors Meet/communicate with learning set (as required)
Educational Supervisors Discuss topic with their trainee, contribute to trainee’s work on topic
17
Appendix 2
09:15 Group work in learning sets Trainees In learning sets, discuss work during intervening fortnight, share and
discuss findings, agree and prepare presentation of findings.
Topic Lead and facilitators Rotate between learning sets offering suggestions and advice,
managing expectations, being realistic, keeping learning sets focused on
their task(s).
10:00 Plenary presentations Trainees 5 minute presentations plus 5-10 minutes discussion per learning set,
top 5-10 learning points/tips/conclusions
Topic Lead. Leads discussion (actively, so as to cement understanding of the topic):
observes, listens, time-keeps, validates (inc. corrects where necessary)
learning sets’ presentations, aids discussion, gives feedback to learning
set/individual presenters (where necessary or possible – some individual
feedback may need to be in private).
Facilitators Contribute actively to discussion.
12:00 Conclusion of topic Trainees Trainees write reflections on topic and complete topic feedback sheet
18
Appendix 3
APPENDIX 3
Topic: MEMORY
Case vignette:
A 75 year old married man is referred by his GP to your out-patient clinic with
memory problems. Over the last 6 to 12 months he has been having
difficulties remembering appointments and getting confused with times and
dates. His wife has noticed a change and is very concerned as he is still
driving his car and has got lost on several occasions. He has no past
psychiatric history and is physically fit except for hypertension controlled with
medication.
Each Learning Set will be given a Task, and must decide what ‘research’
needs to be done between now and two weeks’ time in order to have an
informed discussion within their Learning Set then. The task should be divided
up appropriately between individual members of the Learning Set with the
intention that each member ‘shares’ what they have prepared on returning in
two weeks’ time. Each Learning Set will then decide how best to summarise
its effort and an elected ‘Learning Set leader’ for the week will present the
summarised findings to the larger year group in a fortnight’s time.
How you divide the task up within your Learning Set is up to you. Each task
will require a mix of ‘researching’ using textbooks, literature, online resources,
clinical cases and conversations with colleagues and educational supervisors.
It may be that some members of the Learning Set will be better placed than
others to use particular resources depending on their current clinical work or
previous experience. We hope that individuals will have the opportunity to use
a variety of different approaches over the year and would encourage you to be
as creative as you want in tackling your part of the task.
The case vignette is designed as a starting point to guide you through the task
but we encourage you to use examples from your own clinical practice as well
wherever possible. We recognise that the topic of the week can seem
daunting at first, so you can if you want interpret it as narrowly or as broadly
as you wish, depending on the experience of the people in your Learning Set.
You might refer to the College Curriculum to help guide you but it is ultimately
for you to decide on the approach that will be of most value for your own
learning.
It is really important that you record all of this in your portfolio, which is
primary there to help you learn – when you write things down you see them
more clearly (and perhaps understand them for the first time!). Your portfolio
is also a visible record of your achievements. You can use it to show yourself
19
Appendix 3
what you have done and learnt, and you can show others too (i.e. it can be
used as concrete evidence to assess your progress).
Prompts:
• Think about how you might divide up the task into specific areas.
• What are the important areas to be covered and how might each of
these be ‘researched’ most effectively?
• Could some of the more common conditions be seen on your ward?
• Might there be an opportunity to do a Case Based Discussion or Mini-
Ace as a starting or end point of your individual work?
• Do any members of the group have access to useful resources in their
clinical setting? e.g. Memory Clinic
• Are there any differential diagnoses for this man that might present
more frequently in the adult mental health setting?
• Could you relate these to any of your patients if you are working in this
field?
• How might you use this task to prompt discussion with your educational
supervisor?
• Can you identify any clinicians or members of the MDT that might be
useful to talk to as part of researching this task? e.g. CPN, OT, Clinical
Psychologist
• What other resources are available: textbooks, relevant literature,
online information, u-tube video?
What might the differential diagnoses be for this patient and what are
the associated clinical features that would aid in diagnosis?
[Below is what the members of Learning Set 1 might decide would be their
Work Plan for this Topic.]
Plan:-
• Do some background reading on the subject from recommended
textbooks
• In the course of his clinical duties will interview a patient with each
condition and write up a clinical summary.
20
Appendix 3
Plan:-
• Do some background reading on functional mental illness and memory
impairment.
• Do a CBD with educational supervisor on patient seen in clinic.
• Write a reflective piece on the topic following the CBD with the intention
of sharing this with the group.
Plan:-
• Drawing on the work done to prepare for this and additional information
which may be gathered during the audience discussion will prepare a
summary of relevant material for the group.
• In addition will do some further reading on dementia in Parkinson’s
disease and fronto-temporal dementia and prepare a written summary.
Plan:-
• Do some background reading on the rarer forms of dementia such as
Pick’s Disease, Huntingdon’s and CJD.
• Will discuss any issues raised in educational supervision.
• Will write a summary of clinical features to be shared with the group.
21
Appendix 3
Agrees to focus on current clinical experience and relate this to the topic
Plan:-
• Will do a Mini-Ace with educational supervisor on this patient focusing
on the assessment of memory.
• Do some background reading on alcoholic dementia and delirium
• Will prepare a short PowerPoint presentation on the clinical features of
these conditions to share with the group.
22
Appendix 4
APPENDIX 4
Task 1
“Research” some important diagnoses within the area of Anxiety
Disorders. This group should focus on what diagnoses present in
clinical practice and the clinical features of these.
Task 2
“Research” important aetiological factors in the development of Anxiety
Disorders and consider what epidemiological and prognostic factors
might be important.
23
Appendix 4
What experiences you have available in your everyday clinical practice that
might help to guide you on some further exploration. This exploration could
focus on specific disorders or more general aetiological factors for example,
and how they present and influence how a case presents and is managed.
How can you link this work both with in educational supervision and using
WPBAs?
Importantly, how can this research not only help you develop your current
understanding but identify areas you need to focus on in the future and how
you might incorporate them into future training experiences?
Task 3
Carry out some “research” into the basic science relating to the
differential diagnoses in the area of Anxiety Disorders.
Task 4
Carry out some “research” into the management of Anxiety Disorders?
Focus should be on acute and long term management and bio-psycho-
social approaches
24
Appendix 5
APPENDIX 5
Task 6) Consider the impact of excess alcohol use on the physical and
mental health of patients. What are the most common associated ill effects
and who are most vulnerable to such conditions? Discuss the impact of an
alcohol related harm with a patient.
25
Appendix 6
APPENDIX 6
Module
Module Handbook
26
Appendix 6
Contents
Historical Background
References
Appendices
1: Learning Disabilities. MRCPsych part B course week 1.
2: PowerPoint presentation Alzheimer’s disease – diagnosis and management
in PWLD.
27
Appendix 6
Learning Disability (LD) is the official term used in the UK and will be used in this
module. The term ‘Intellectual disability (ID)’ is synonymous to LD and recognised
worldwide. Other terms you may have heard are:
• Mental Retardation: The ‘official’ term used in North America and the ICD-10
When assessing and managing psychiatric and behavioural disorders in people with
learning disabilities (PWLD) you need to be aware of the differences in epidemiology
and range of psychopathology compared to the general population. Assessment
includes the developmental level of the PWLD, as well as, the usual physical,
psychological and social factors. PWLD often have more complex needs than the
general population and there are more people (multidisciplinary professionals and
carers) involved in their care. You need to consider everybody’s opinion and needs
when making a management plan.
This module builds on previous modules. You should have a good working
knowledge of other areas of psychiatry to enable you to translate your knowledge,
skills and attitude to managing psychiatric and behavioural problems in PWLD.
28
Appendix 6
Aims
At the end of the LD module you will have begun to:
• Relate the other areas of psychiatry to LD.
• Develop knowledge, skills, attitude and behaviour, specific to managing health
problems in PWLD.
Objectives
At the end of the LD module you should be able to:
1. Explain the term learning disability.
2. Comprehend how human development and ageing differs in PWLD.
3. Describe common genotypes and phenotypes associated with LD, explaining their
relevance when assessing and managing PWLD.
4. Describe the main features of autistic spectrum disorder (ASD), including the
differences between autism and Asperger’s syndrome. Explain how ASD may
affect the assessment, diagnosis and management of problems.
5. Demonstrate the classification of health problems in PWLD.
6. Apply the epidemiological differences in psychiatric illness in PWLD to the case
problems.
7. Differentiate between the assessment and management of psychiatric illness and
behavioural disorders in PWLD compared to the general population including:
• History taking,
• Diagnosis,
• Investigations,
• Treatment,
• Psychological theories and methods,
• Carers/families needs,
• Legislation,
• Provision of specialist services compared to mainstream services.
8. Assess and manage problems experienced by PWLD with a creative and
professional attitude.
29
Appendix 6
Areas of the MRCPsych Syllabus Covered (but may not be specifically taught!)
Basic Psychology
• Clinical applications of learning theory, memory, motivation, emotion and stress.
Social Psychology
• Clinical applications of self psychology, social behaviour in social interactions,
Theory of Mind, social identity and intergroup behaviour and altruism.
Basic Neurosciences
Molecular Genetics
• Conditions associated with chromosome abnormalities.
• Principle inherited conditions encountered in psychiatric practice and the genetic
contribution to specific psychiatric disorders.
Clinical Psychopharmacology
• The general principles will need to be applied to the clinical practice of
prescribing for PWLD.
Learning Disability
Developmental
30
Appendix 6
Clinical
Other
31
Appendix 6
Suggested Resources
• http://www.intellectualdisability.info/home.htm
• hebw.uwcm.ac.uk/learningdisabilities/index.htm
• http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/learnin
gdisabilities.aspx
• www.learningdisabilities.org.uk
• www.downs-syndrome.org.uk
Information for living successfully with Down's Syndrome. Facts and reassurance
for parents, a members group with news, literature and research.
32
Appendix 6
• Smiley, E., Cooper, S-A., Finlayson, J., Jackson, A., Allan, L., Mantry, D.,
McGrother , C. McGrother, C., McConnachies, A. and Morrison, J. (2007).
Incidence and predictors of mental ill-health in adults with intellectual
disabilities: Prospective study. The British Journal of Psychiatry. 191: 313 - 319.
• Cooper, S-A., Smiley, E., Morrison, J., Williamson, A. and Allan, L. (2007).
Mental ill-health in adults with intellectual disabilities: prevalence and associated
factors. The British Journal of Psychiatry. 190: 27 - 35.
http://www.rcpsych.ac.uk/publications/booksbeyondwords.aspx
Prescribing
Bhaumik, A. and Branford, D. (eds.) (2005). The Frith Prescribing Guidelines for
Adults with Learning Disability. London: Taylor and Francis. ISBN 1-84184-581-7
Autism
• Holt, G. and Bouras, N. (eds). (2002). Autism and related disorders. The basic
handbook for mental health, primary care and other professionals. London:
Royal College of Psychiatrists.
• Wing, L. (1996). The Autistic Spectrum. A guide for parents and professionals.
London: Constable. ISBN: 0 09 475160 9.
• The National Autistic Society. (1989). Autism: Behind the Invisible Wall. (Video).
• www.autisticsociety.org
An excellent and easily navigable site providing lots of information about most
aspects of autism and Asperger's syndrome, including legal issues. There are links
to current medical research, news updates, and medications.
• www.nas.org.uk
The National Autistic society is the largest UK charity working for people with
autistic spectrum disorders. Useful list of publications, information and
comprehensive set of links to autism sites. Content for professionals as well as
those with such disorders and their families.
33
Appendix 6
Timetable
Week 1: Learning Disability and Week 2: Older Adults with a Week 3: Autistic spectrum Week 4: Forensic issues in
Psychiatric Disorders Learning Disability disorders Learning Disability
34
Appendix 6
Historical Background
In the thirteenth century Arabic countries used asylums to provide benevolent care for
PWLD. However, it was a Select Committee’s recommendations in 1807 that set up
asylums in each county for lunatics (this term included PWLD, mental illness or
epilepsy). In 1886, The Idiots Act addressed the needs of PWLD by introducing
registration, inspection and admission to specialised asylums, separate to people with
mental illness or epilepsy.
Briefly, in the early nineteenth century, a few people believed that the LD was able to
be modified and some residential schools and institutions were created.
Unfortunately, this approach waned in the second half of the nineteenth and the early
twentieth centuries with the increasing concern that PWLD had limited economic
usefulness for the wider community. This reflected a belief that they were one of a
number of causes for the social ills within the population and that procreation would
result in the spread of social ills. This is thought to have paved the way for the
eugenics movement which was only discredited in the UK when the Nazi regime
interned and annihilated thousands of people, including PWLD.
The Mental Deficiency Act (1913) legalised the detention of PWLD and set up
colonies for ‘mental defectives’ with a superintendent and visiting medical officer
(usually a general practitioner). Britain’s present unusual position of having a Faculty
of the Psychiatry of LD within the Royal College of Psychiatrists arose as a result of
the superintendents usually being trained in mental asylum work.
Following the First World War the formation of colonies was accelerated when the
Report of the Mental Deficiency Committee (1929) recommended that 100,000
PWLD be immediately institutionalised. Most of the colonies were in rural settings,
away from towns and run as self-sufficient enclosed communities where people
remained for life, as this was considered in their best interests.
When the NHS was launched in 1948 the ‘mental defective’ colonies were transferred
from local authority care to the NHS, with a change of name to hospitals. Free
treatment became available and all, including those in colonies, were entitled to the
services of a general practitioner. However, the old colonies remained isolated from
mainstream developments in healthcare and little was invested into community
services.
By the 1950’s it was clear that institutional care was not the answer for PWLD.
Several reports identified the impoverished and squalid living conditions, lack of
privacy, emphasis on predominantly physical care and the custodial attitudes of the
staff. The 1959 Mental Health Act ended compulsory detention of PWLD because of
a LD alone, enabling the discharge of many back into the community.
In 1971, the White Paper, ‘Better Services for the Mentally Handicapped,’
(Department of Health and Social Security Welsh Office, 1971) was developed
because of concerns about the adverse effects of institutionalisation and segregation,
and recognition that most PWLD did not need to live in a hospital in order to have
their health needs met. The Jay Report (1979) re-emphasised the need for local
authority-led care and a service philosophy based on the principles of normalisation,
35
Appendix 6
With the availability of funds for social services and community learning disability
team provision, the entire responsibility of community care was slowly transferred
back to local authorities, who would provide the necessary support structures to
enable (where possible) people to remain in their own homes, reducing the demand
for long-term care. The Government’s White Paper, ‘Valuing People: A New
Strategy for Learning Disability for the 21st Century,’ (DH, 2001) was the first policy
that signalled a new approach to the delivery of care for PWLD. It set out the vision
that,
‘All people with LD are people first with the right to lead their lives like any
others, with the same opportunities and responsibilities, and to be treated with
the same dignity and respect. They and their families and carers are entitled
to the same aspirations and life chances as other citizens.’
By 2008, all long stay hospitals, except one had closed and their residents, where
appropriate, moved into supported living rather than residential care. Unfortunately,
‘Healthcare for All,’ (Michael, 2008) an independent inquiry into access to healthcare
for PWLD found ongoing, significant inequalities in access to healthcare services and
in the quality of services (Valuing People Now, 2009).
Some specific strategies/ government documents about PWLD have already been
mentioned. In addition, you may find it helpful to read and understand the following
as you work through this module:
36
Appendix 6
• Crews et al. (1994) point prevalence rate of diagnosis based on DSM-III-R criteria
was 15.6%.
• Prasher (1995) 28.9% point prevalence in people with Down Syndrome.
• Cooper and Bailey (2001) 40.9% point prevalence.
• Smiley et al. (2007) 16.3% 2 yr incidence of mental ill health.
• The population:
o Different definitions for the term ‘LD.’
o Heterogeneity. People with mild LD have different needs and problems to
those with severe. People may have more or less problems due to the
aetiology of their LD, for example, hypothyroidism, sensory difficulties,
depression and Alzheimer’s Dementia are increased in Down Syndrome.
• The logistical difficulty of identifying the LD population for surveying. There
are few formal registers of PWLD for research or other purposes. Research
undertaken on PWLD who resided in institutions will be biased towards more
health problems, as this population was usually more disabled.
• The classification system employed. For example is behavioural disturbance a
psychiatric disorder? It depends on the classification system used. How
applicable are standardised criteria, which often require verbal reporting and a
degree of insight that symptoms are not normal, for PWLD?
PWLD experience higher rates of psychiatric disorders because they usually have the
same risk factors as the general population plus their own risk factors.
Objectives
The case this week introduces you to psychiatric and behavioural disorders in PWLD.
Whilst undertaking your personal and group research for the case problem be mindful
that by the end of week 1 you should be able to:
37
Appendix 6
Case Problem
Background
Petra is an 18yr old woman with moderate LD and velo-cardio-facial syndrome. She
lived at home until two months ago. Mum was Petra’s main carer until her death from
cancer two years ago. At this point her father and younger sister became her carers.
Petra moved into a 10 bedded residential home for people with moderate/severe
learning disabilities as dad and sister were finding supporting Petra increasingly
difficult.
Petra is not known to psychiatric services but is known to both the LD and children
and families teams (social services).
Petra enjoyed school. She needed 1:1 support in order to maintain her concentration,
enthusiasm and stop her becoming distracted. She especially enjoyed physical
activities and computer work. The school and Petra communicated using Makaton.
Concerns/Problems
The home is requesting a Mental Health Act assessment for the following reasons:
The home have been intermittently restraining Petra over the last week. Two staff
members have left and four others have gone off sick because of Petra’s behaviour.
38
Appendix 6
Issues to be considered
What is the role for the CLDT (as a team and individual
professionals) in assessment of Petra?
4+8 Management What is the role for the CLDT (as a team and individual
professionals) in the management of Petra?
39
Appendix 6
http://www.intellectualdisability.info/home.htm
Smiley, E., Cooper, S-A., Finlayson, J., Jackson, A., Allan, L., Mantry, D.,
McGrother, C. McGrother, C., McConnachies, A. and Morrison, J. (2007).
Incidence and predictors of mental ill-health in adults with intellectual disabilities:
Prospective study. The British Journal of Psychiatry. 191: 313 - 319.
40
Appendix 6
Introduction
The research difficulties into the proportion of the older population with LD and the
health needs of older PWLD are similar to those discussed in week 1’s introduction.
An additional factor is the criteria used to define ‘older.’ Should this be 65 years, as
used for the non LD population, or lowered as PWLD appear to ‘age’ quicker?
Older PWLD can suffer with all the same psychiatric disorders as the older general
population. Throughout the lifespan bereavement disorders are underdiagnosed in
PWLD because the person does not necessarily either express their grief, or express it
in the way we would expect. Finally, Alzheimer’s dementia is much more prevalent
in PWLD because of its association with Down Syndrome. As the MMSE is
unsuitable for determining diagnosis, or monitoring disease progression, due to the
higher level of cognitive functioning needed to complete before disease onset, the LD
services use a variety of other multidisciplinary assessments.
41
Appendix 6
Epilepsy 22-30% 1%
Disorder
Nutrition <10% PWLD have balanced diet
↑Malnourishment
↑Obesity
The case this week builds on the work you undertook for week 1. You need to ensure
you have completed week 1’s objectives before moving onto this case. Whilst
undertaking your personal and group research for the case problem be mindful that by
the end of week 2 you should be able to:
42
Appendix 6
Case Problem
Background
Pat is a 45 yr old woman with Down Syndrome. She lived at home with her parents,
in Gloucester, until six months ago when they died. They were both in their 80’s.
Her father had a heart attack at home, having suffered with deteriorating health for
several years. Her mother died in her sleep a month later.
Pat has one sister, Jane, aged 55 yrs, who is her only family and lives in Southampton.
After their parents’ death Jane moved Pat into a residential home in Southampton. Pat
did not attend the funerals. Prior to their parents’ death Jane visited Pat and her
parents on a bimonthly basis to check everything was okay. Pat was always neatly
dressed and liked to wear make-up. She enjoyed telling Jane what had been
happening in-between visits.
Concerns/Problems
The home staff have not noticed any of Jane’s concerns. They report:
• Pat likes to be left alone and chooses not to join in with organised activities in the
home.
• Pat becomes upset if washed, pushing staff away. If they continue she will hit
them.
• Pat states she does not like the food, or will fill up with sweets brought to her by
Jane, in-between meals.
The staff believe it would be abuse if they made Pat have a wash or join in with
activities. There are 29 other residents in the home and they cannot spend all day
looking after Pat.
43
Appendix 6
Issues to be considered
What could you do to test Do you need to gather more information, and if so,
your working hypotheses? from whom?
What management might you Would the MCA be applicable in helping you to
suggest? assess and manage Pat? If so, how?
44
Appendix 6
• What are the limitations to using assessments validated in the general population
in PWLD?
• How often is the MCA referred to in your current psychiatric placement when
managing clients?
• How does the ability of an individual to choose their own life circumstances affect
their mental wellness?
http://www.intellectualdisability.info/home.htm
In particular the webpages on grief, dementia, Down Syndrome and physical
health.
http://www.downs-syndrome.org.uk/images/stories/DSA-
documents/Publications/health/ageing_and_consequences.pdf
45
Appendix 6
.
Objectives
Case Problem
Background
Concerns/Problems
Issues to be considered
Week 4 - Forensic LD
46
Appendix 6
References
Bhaumik, A. and Branford, D. (eds.) (2005). The Frith Prescribing Guidelines for
Adults with Learning Disability. London: Taylor and Francis.
Department of Health (DH) (2001). Valuing People. A New Strategy for Learning
Disability for the 21st Century. A White Paper. London: HMSO.
Department of Health (DH) (2009). Valuing People Now: a new three year
strategy for people with learning disabilities. London: DH.
Department of Health and Social Security Welsh Office (1971). Better Services
for the Mentally Handicapped. London: HMSO.
Jay Report. (1979). Report of the Jay Committee. London: Department of Health
and Social Security.
Michael, J. (2008). Healthcare for all. Report of the independent inquiry into
access to healthcare for people with learning disabilities.
http://www.iahpld.org.uk/Healthcare_final.pdf. Accessed 03/02/2009.
Smiley, E., Cooper, S-A., Finlayson, J., Jackson, A., Allan, L., Mantry, D.,
McGrother, C., McGrother, C., McConnachies, A. and Morrison, J. (2007). Incidence
and predictors of mental ill-health in adults with intellectual disabilities: Prospective
study. The British Journal of Psychiatry. 191: 313 - 319.
47