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MRCPsych

Course

HANDBOOK
For
MODULE
DEVELOPERS

Wessex Deanery
School of Psychiatry
Contents

Page

Introduction 3

Overall concept of the Course 4

Organisation and management of the Course 4

Basic structure of the Course 5


− The parts 5
− The modules 5
− Module leads 6
− Learning sets 6
− Learning set mentors 7
− Topics 7
− Setting tasks 7
− Facilitators 10
− Masterclasses 10

Varieties of Module design 12

A Suggested Design Template for Modules 14

Appendices
− Appendix 1: The basic course structure 15

− Appendix 2: Topic timetable 16

− Appendix 3: Topic example - Old Age Psychiatry ‘Memory’ 19

− Appendix 4: Tasks example - Topic: Anxiety Disorders 23

− Appendix 5: Tasks example - Substance Misuse 25

− Appendix 6: Handbook example - Learning Disability 26

Edition 1 15 July 2010

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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

Purpose of a Module Handbook

Module Developers need to write a module handbook. Module handbooks are


very important for trainees to understand what the module is intending to
cover and how it goes about doing it. They also help those who teach the
module and act as facilitators to see what the course is attempting to do and
how it is going about that. One that is well written:
• Sets out the module’s aims and objectives
• Says how this is to be achieved (states what the tutors, facilitators and
trainees need to be doing)
• Declares the principles underpinning the module (reinforces the
educational basis of the course as a whole)

In other words, a good module handbook is more than a list of content to be


covered and a time-table for what is happening and when and who is
involved. It translates the aims of the module into action.

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

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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.

The Course is based on the following educational principles:


• helping trainees to link together the various elements of their Core
Training, including helping them see the inter-connections between
- their clinical practice
- their weekly discussion with their educational supervisors
- ongoing personal study
- exam preparation and revision
• encouraging trainees to take personal responsibility for their learning
through:
- group work with fellow trainees in ‘learning sets’
- personal assignments, including ‘writing for learning’ (‘reflective
writing’)
- facilitated active learning (rather than ‘being lectured at’!)
- input from ‘experts’ (through ‘masterclasses’)
- guided access to web-based learning resources and the use of
advanced IT facilities
• providing trainees with a broad overview of psychiatry whilst also
attending to the details they need for their current practice and for
passing their exams
• offering long-term mentorship for their broader postgraduate education
in Psychiatry, including career development support.

Organisation and management of the Course


The Course has been devised and developed by a steering group (see
website) that sets the strategic direction and establishes the guiding
educational principles. This group is responsible for the basic structure of the
Course, module development, and facilitator development. It works closely
with Sue Wilkins, Postgraduate Education Coordinator in Southampton, who
is responsible for the organisation and running of the Course, and who
advises the steering group on how best to formulate their plans and to
translate them into action.

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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

• Part B1 modules (for CT2 or 3 trainees, run bi-annually)


- General Adult
- Old Age
- Addiction
- Psychotherapy
- Forensic

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• 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 generally are responsible for:


• developing their module, normally with a team of colleagues, within the
general principles of the Course shown above
• the detailed organisation required for it to run smoothly
• allocating and briefing the weekly facilitators
• organising special activities such as ‘masterclasses’ (see below).

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).

Trainees are allocated to a learning set usually on a ‘geographical’ basis –


that is, in relation to where they live. Changes to allocation are discouraged
(though allowed under special circumstances). It is anticipated that Learning
Sets will remain together for Part A and Part B of the Course.

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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).

Learning Set ‘Mentors’

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-

1. Provides guidance to module developers to help address some of the


difficulties module developers have experienced at this stage of
developing their modules
2. Recognises that each module will have its own specific challenges and
therefore requires a balance between flexibility for those designing the
tasks so as to allow them to introduce their own ideas, on the one hand,
and the need to provide some consistency and links between each of the
modules, on the other.

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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.

What Makes a ‘Good’ Task?

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

1. Tasks should be allocated in a way that acknowledges what tasks each


Learning Set has already done. This should enable each group to have a
broader experience over the whole module as appropriate.
2. Learning sets may be given a selection of tasks and allowed to choose the
most appropriate/educationally worthwhile for each group.
3. Tasks may even be more skeletal in framework with trainees being helped
to ‘design’ their own tasks with facilitator input in the task setting sessions.

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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

Tasks should not:

• be viewed as needing to cover the entire curriculum. Trainees will have


their attention directed to the College curriculum, and to see how each
topic ‘maps onto’ it. But no module, nor the whole course, will be able to
cover ‘everything’. Trainees will be told that they will have to do extra work
to do that!
• be viewed as ‘set in stone’ and can be adapted and altered as a module
proceeds in response to the trainees interpretation and feedback.

Module developers should:

• 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

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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.

Each week, there needs to be a Lead Facilitator – normally an experienced


clinician – appointed by the Module Lead, who:
• has been fully briefed by the Module Lead about the Module
• contacts the week’s Facilitators (where possible in advance)
• fully briefs them about the week’s work
• supports them on the day
• gives trainees a brief but concise introduction to the week’s topic at the
start of the session (this will have been covered by the Module Lead at
the first session of the Module)
• outlines the tasks for the Learning Sets to work on
• helps Facilitators to monitor the work of the Learning Sets and offers
guidance on their tasks as necessary
• receives from Learning Sets their agreed work plan at the end of the
first afternoon of the topic
• introduces the masterclass contributor and chairs the discussion (e.g.
where the masterclass is a presentation)
• reconnects to the topic, recaps the tasks and clarifies the processes of
the session at the beginning of the second morning of the topic
• chairs the plenary session, leads the discussion, time-keeps, validates
and corrects and gives feedback to trainees
• summarises the topic at the end of the second morning of the topic
• allows time before the close of the session for trainees to write
summaries of their learning from the topic.

Masterclasses

The Course Steering Group encourages Module Developers to include a


session which ‘goes beyond’ the topic of the week called a ‘Masterclass’. The
purpose of a masterclass is to provide:
• an overview of the topic
• ‘the bigger picture’
• ‘added value’

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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)

Module Developers are encouraged to be inventive and creative in devising


masterclasses for their module. The Steering Group recognises that it might
be ‘easier’ to arrange a ‘lecture’ to be given by an ‘outside speaker’, and on
occasions this might be entirely appropriate. However, other possibilities such
as the examples given above are likely to be more valuable educationally for
trainees. Also, the Steering Group wishes to reiterate the shift of emphasis in
the new Course away from ‘spoon feeding’ trainees towards engaging them
much more fully in their own learning. Masterclasses are perfect opportunities
to contribute towards (and to reinforce) this.

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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.

Old Age Psychiatry

Appendix 3 shows some preliminary thinking regarding the Old Age


Psychiatry module for Part A of the Course particularly concerning the briefing
for Trainees in their Learning Sets.

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.

This example elaborates on (and reinforces) the principles of the Course,


particularly regarding:
• trainees taking responsibility for their own learning.
• relating work on the Course to their current clinical experience
• bringing in self study from a variety of sources
• linking to their workplace based assessment
• prompting them to discuss the topic with their Educational Supervisor
• encouraging them to write up their findings in their portfolio.

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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.

Whilst the module developers insist it is still ‘work in progress’, it closely


reflects how the Steering Group hopes module handbooks will look in the
future. Developers of other modules might find it useful to review this draft.
We draw below from it a template for what might be included in module
handbooks generally.

Interestingly, the module developers plan to include a visiting theatre group,


and are devising some creative masterclasses.

As the module developers approach commencement of module they will add


further to their document, particularly including the names of the people
involve, the Facilitators and the weekly Lead Facilitator.

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A Suggested Design Template for Modules

The new Wessex MRCPsych Course is at a relatively early stage of its


development. In this Handbook for Module Developers we have said that it is
the hope of the Steering Group that the people devising modules will plan
creatively and flexibly to design a module that fits with the educational needs
of Trainees and the constraints of their specialty, within the overall educational
principles of the course as a whole.

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

Edition 1 15 July 2010

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Appendix 1

APPENDIX 1:

The Basic Course Structure


NOTES:
1. The table below shows the two parallel courses of the programme – Course A for
CT1 trainees (un-shaded), the Course B for CT2 (B1) & CT3 (B2) trainees (shaded) –
which run on alternate weeks.
2. Topics on both courses run from one lunchtime to the next lunchtime a fortnight later
(e.g. yellow shaded area for Topic 1 of Course A, blue for Course B1/2).
3. Details of the modules for the two courses are given in separate module handbooks.
4. Much of the timetabled time is spent working in small groups (Learning sets).
5. The time between the fortnightly sessions involves trainees working on a particular
topic in a way discussed and agreed by their Learning set, by: reading, discussion
with their educational supervisor, making links with their clinical practice, portfolio
writing.
Programme week 1 Programme week 2 Programme week 3 Programme week 4
Course A: CT1 Course B1: CT2 & B2: Course A: CT1 Course B1: CT2 & B2: CT3
CT3
Introduction to course Introduction to course Work in Learning sets: Work in Learning sets: discus
How it works How it works discus work carried out work carried out since last
Allocation to learning set Allocation to learning set since last meeting. Prepare meeting. Prepare
presentation of findings and presentation of findings and
conclusions. conclusions.

Feedback and discussion: Feedback and discussion:


Each Learning set presents Each Learning set presents
findings and conclusions to findings and conclusions to
whole year group. whole year group.
Mid morning break
Course objectives. Course objectives. Discussion continues, Discussion continues, ending
How the programme fits How the programme fits ending in summary and in summary and conclusion
with the College curriculum with the College conclusion by Lead by Lead Facilitator.
and examination. curriculum and Facilitator.
examination. Time allowed for Trainees to
Time allowed for Trainees to write up own portfolio notes
write up own portfolio notes on their learning from this
on their learning from this module.
module.
Topic 1 ends.
Topic 1 ends.
Lunch break
Topic 1 begins. General Topic 1 begins. General Topic 2 begins. Topic 2 begins.
introduction followed by introduction followed by
allocation of allocation of
tasks/scenarios to Learning tasks/scenarios to
sets, which meet and begin Learning sets, which meet
discussion of how they will and begin discussion of
tackle the task. how they will tackle the
task.
Masterclass session
relating to Topic. Masterclass session
relating to Topic.
Mid afternoon break
Communications for 6 Exam preparation As for Week 1. As for Week 2.
months, followed by including CASC
MRCPsych Exam overview
and preparation
Appendix 2

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.

Time Activity People involved Tasks


11:30 Plenary session in progress Trainees Conclude feeding back findings on previous topic
(for previous topic) Previous topic lead and topic Topic lead and facilitators comment on findings
Arrival of topic lead and facilitators Next topic lead and facilitators observe: ‘catch the mood’ of the day,
facilitators for next topic Next topic lead and facilitators hear the issues being raised
Postgrad Education Coordinator Liaises with new topic lead and facilitators, reports progress

12:00 Conclusion of previous topic Trainees Write reflections on topic and complete topic feedback sheet

12:15 Lunch Trainees Have lunch


Leads and facilitators for both Meet to discuss how the previous topic went, issues arising, etc, and to
previous and next topics, Postgrad discuss next topic, detailed planning, aims, clarifying learning sets’
Education Coordinator tasks, activities, roles, timings.
Previous topic lead and facilitators leave (12:45)

13:00 Plenary session, start of new Trainees Attend plenary session


topic, introduction New topic lead Topic lead (or Modular Lead who would give introduction at least at start
of a new Module):
1. Sets the scene for new topic: introduces self and facilitators,
introduces topic, gives links to previous topic(s), plus place of topic: in
the module; the course; the curriculum, relation of topic to the exam.
2. Reiterates and reinforces the educational model – how it will work in
this topic, role of facilitators
3. Presents clear plan for the new topic: details (ideally handout) of the
process for this topic, describes and explains learning sets’ tasks,
explicit about possible reading and other resources, indicates
suggestions for homework – what trainees might bring back.
New topic facilitators Support topic lead, offer suggestions.

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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).

14:15 Masterclass (format to be Topic lead Introduce masterclass speaker/service user/activity


decided by Module Lead and Masterclass leader Runs the Masterclass
described to Trainees during Topic facilitators Attend, contribute to discussion
introduction) Trainees Attend, consolidate topic learning/task

15:00 Afternoon break Trainees Break


Topic Lead and facilitators, Meet to discuss observations on afternoon’s work, share any concerns,
Postgrad Education Coordinator review learning sets’ plans. Postgrad copies plans.

15:15 Communications skills/ Exam Trainees Plenary session


preparation session Session lead Introduces session
Topic Lead and facilitators (if Attend exam session (if required), contributing to discussion and
required) MCQ/CASC practice.
17:00 Close

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

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Appendix 2

08:45 Arrive All Coffee/Tea on arrival and available all morning.

09:00 Plenary session Trainees Be punctual


Topic Lead and facilitators Topic lead ‘reconnects’ to the topic and module, recaps on topic and
tasks, clarifies processes for rest of the topic (morning session)

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.

11:30 Plenary presentations contd. Trainees Continue as above for 10:00


(arrival of lead and facilitators Topic lead and facilitators Continue as above for 10:00
for next topic) Next topic lead and facilitators Join plenary session to observe: ‘catch the mood’ of the day, hear the
issues being raised

12:00 Conclusion of topic Trainees Trainees write reflections on topic and complete topic feedback sheet

12:15 Lunch Trainees Have lunch


Leads and facilitators for both Meet to discuss how the concluding topic went, issues arising, etc, and
concluding and next topics, to discuss next topic, detailed planning, aims, tasks, activities, roles,
Postgrad Education Coordinator timings. Out-going lead and facilitators leave (12:45)

13:00 Next topic begins


Revised 27 January 2010

18
Appendix 3

APPENDIX 3

Module: Old Age Psychiatry (Part A of the Course)

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.

Background notes for all Learning Sets

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?

[The following task might be given to a Learning Set]

Task for Learning Set 1

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.]

Work Plan for Learning Set 1

Learning Set member 1: is currently working in Older Person’s Mental


Health. Has a number of inpatients with dementia mainly Alzheimer’s Disease
and Vascular Dementia.

Agrees to ‘research’ Alzheimer’s Disease and Vascular Dementia.

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

• In educational supervision will discuss the clinical features of each


condition and do some further reading on areas highlighted.
• Following on from this will prepare a written piece, possibly a table,
comparing and contrasting the clinical features of both to be shared
with the group at next session.

Learning Set member 2: is currently working in Adult Mental Health. Has


recently seen a patient in the outpatient clinic with memory impairment and
depression.

Agrees to do some book work on this topic

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.

Learning Set member 3: is currently working in Older Person’s Mental


Health. Is due to do a Case Presentation at their local education session the
following week, and was planning to present a case of Lewy Body Dementia.

Agrees to modify case presentation for the Group Task.

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.

Learning Set member 4: is currently working in Adult Mental Health. Has no


patients at present with memory impairment.

Agrees to do some book work

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

Learning Set member 5: is currently working in Adult Mental Health. Has


recently admitted a patient whist on call with alcohol dependence and
cognitive impairment.

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

Topic - Anxiety Disorders


Aimed at Part A

The resources in the handbook and reference to the College Curriculum


should help to guide you on what you might focus on. How you tackle this and
divide up the task is largely up to you as a group and will of course be
influenced by individual’s previous experience and current practice, as well as
personal interest and preferences.
Your facilitator can also help you to decide on what to focus on.
Please remember that each topic and often each task can potentially cover a
vast area. It is not feasible or expected that you cover the entire topic in detail.
The intention might be to use this task to focus your learning but also as
importantly to help you plan your future (short and longer term) learning.

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.

You might want to consider-


How you might go about making the diagnosis?
What challenges might you face at your stage?
How might you begin to address these challenges at your stage of training?
What reading/resources might you need to look at or think about addressing
at this point in your training?
What elements of your everyday clinical practice might help you develop this
area of learning?
Are there experiences available to you in your current job that you might want
to do or plan to do in the upcoming months? Alternatively do you need to think
about how future jobs might also provide these?
Are there opportunities available currently to explore your current
understanding through WPBAs? If so, how did doing this help you think about
your own future learning?

Task 2
“Research” important aetiological factors in the development of Anxiety
Disorders and consider what epidemiological and prognostic factors
might be important.

You might want to consider-


What diagnoses to focus on and how you might divide the work up as a
group?
How you might use cases you come across in your current clinical practice
which help to make the links and demonstrate these factors?
What other resources/reading preparation might be useful?

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.

You might want to focus on areas such as genetics, neurochemistry,


neuroanatomy?
Remember this list may well be exhaustive and require a degree of distillation
of what work you as a group and individuals might reasonably do.
Consider finding out what other resources might be helpful for future
preparation - e.g. literature, seminal and recent studies, textbooks and other
media.
Wherever possible can you use clinical examples as a basis for developing
your understanding and relevance of some of these factors? This may well be
limited due to the nature of the topic but be creative!

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

You may want to focus on specific disorders or specific treatment modalities.


How you tackle this as a group is for you to decide.
You may want to use cases from clinical practice as a basis for looking at
basic pharmacological strategies used and how they relate to practice more
generally
You might want to think about how you can use other experiences, clinicians,
non medical members of your team to help you understand non medical
approaches e.g. psychologists, OTs
It is important to remember that this task should not only help to guide your
current learning but also, perhaps through discussion with your educational
supervisor and by doing WBPAs, help you devise a plan of how you continue
to develop learning in this area through future training in this current job and
others.

24
Appendix 5

APPENDIX 5

Substance Misuse Tasks

Understanding and managing alcohol use disorders

Task 1) Explore the psychology of addictive behaviour – consider the


cycle of change and other models. Debate the use of motivational interview
techniques. Talk to a patient with alcohol dependence and consider the
impact of their use on their carers. Find a piece of literature, artwork or
cinematography that explores issues around alcohol use.

Task 2) What is the current public health agenda around alcohol


consumption in the United Kingdom? How common are alcohol related
problems and what factors influence consumption? How has alcohol use
changed in younger people and what is the impact of legal initiatives?
Propose a model of a legal framework to reduce the negative impact of
alcohol on society and the individual.

Task 3) What is the history behind benzodiazepine treatment for anxiety


and depression - when was it regularly established in the UK? Explore the
issues around dependency of benzodiazepines and how practice of
prescribing has changed in the last few decades. Discuss compulsion to use
and other dependence factors in a patient with benzodiazepine use.

Task 4) Explore the neurochemistry in relation to alcohol/benzodiazepine


use – how does this lead to physiological dependence and associated
withdrawal syndromes? What is the pharmacology behind abstinence based
medical treatments and what is the evidence base of this treatment? How is
the alcohol dependent person vulnerable to thiamine deficiency and how
should this be managed and for how long?

Task 5) Describe a model for alcohol use treatment services – what is


the role of primary care and when should secondary care services be
involved? Consider the role of community alcohol services and residential
detoxification and rehabilitation centres. Consider psychosocial models of
intervention to enable patients to maintain abstinence.

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

Wessex MRCPsych Course Part B

Module: Learning Disability

Module
Module Handbook

26
Appendix 6

Contents

Introduction to the module


Aims
Objectives
Areas of the MRCPsych Syllabus Covered
Suggested Resources
Timetable

Historical Background

Week 1: Learning Disability and Psychiatric Disorders


Introduction
Objectives
Case problem
Issues to be considered
Resources

Week 2: Older Adults with a Learning Disability


Introduction
Objectives
Case problem
Issues to be considered
Resources

Week 3: Autistic Spectrum Disorders


Introduction
Objectives
Case problem
Issues to be considered
Resources

Week 4: Forensic issues in Learning Disability

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

Introduction to the module


module
Learning Disability is (RCPsych, 2001):

• Intelligence Quotient (IQ) <70 and


• Continued impairment in adaptive behaviour and social functioning with
• Onset during the developmental period (i.e. <18yrs old).

‘Learning Disability’ is assessed by intellectual criteria which measure the learning


process; impairment is global.

‘Learning difficulty’ is a measure of learning achievement, is assessed using


educational criteria, and is about specific problems (e.g. dyslexia) rather than global
impairment (Bhaumik and Branford, 2005).

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

• Mental Handicap: A term used historically in the UK

• Mental Subnormality and Feeble-mindedness: Now seriously outdated

• Mental Impairment and Severe Mental Impairment: used in the original UK


1983 Mental Health Act.

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!)

Behavioural Science and Socio-cultural Psychiatry

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.

Social science and socio-cultural psychiatry


• Life events and their subjective, contextual evaluation.
• The sociology of residential institutions.
• Stigma and Prejudice.

Basic Neurosciences

Neuroanatomy, Neurophysiology, Neurochemistry


• As applied clinically to the case problems.

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

a) The neurobiology of brain development and the effects of genetic and


environmental factors.

b) More common learning disability disorders. For example, Down’s Syndrome,


fragile-X syndrome, foetal alcohol syndrome and the developmental problems
of very low birth weight babies.

c) Specific disorders of development including autism and Asperger’s syndrome.

d) The influence of social factors on intellectual and emotional development.

Classification and Epidemiology

b) Modern systems of classification including ICD-10 and the WHO


classification of impairments, disabilities and handicaps.

30
Appendix 6

c) The prevalence of intellectual impairment in the general population. The


prevalence of superadded behavioural, psychiatric and other impairments
within this group. The factors which might account to the observed high rates
of psychiatric behavioural disorders in this group.

Clinical

a) The characteristics of learning disability and mental handicap.

b) The presentation, diagnosis and treatment of psychiatric illness and


behavioural disorder in people with a learning disability (mental handicap).

c) Psychological methods of assessment and an understanding of psychological


theories as to the cause of problem behaviours. An understanding of relevant
behavioural modification techniques.

d) The application of psychiatric methods of treatment in learning disability


(mental handicap) including psychotherapy, drug treatments, behaviour
therapy and cognitive therapy.

e) Specific syndromes and their association with particular psychiatric or


behavioural disorders (behavioural phenotypes).

f) The impact of disability on the family and the psychological consequences of


having a child with a disability.

g) The assessment, management and treatment of offenders with a learning


disability (mental handicap).

Other

a) A broad understanding of legislation which may be of importance, for


example relating to common law, mental health, sexual offenders, community
care etc. General principles rather than details would be required.

b) Normalisation and service development for people with a learning disability


(mental handicap). The change from an institutional to an individualised,
needs led approach.

c) The provision of specialist psychiatric services for people with a learning


disability (mental handicap).

31
Appendix 6

Suggested Resources

Adapted from the RCPsych website www.rcpsych.ac.uk.

General information on Learning Disability and Psychiatry of Learning


Disability

• Fraser, W. and Kerr, M. (eds.). (2003). Seminars in the Psychiatry of Learning


Disabilities (second edition). London: RCPsych. ISBN-13: 9781901242935

An informative and readable textbook that provides a comprehensive overview of


the field in one volume.

• Royal College of Psychiatrists (2001). DC-LD (Diagnostic criteria for psychiatric


disorders for use with adults with learning disabilities/mental retardation).
(Occasional Paper OP48). London: Gaskell. ISBN-13: 9781901242614

A classification system providing operationalised diagnostic criteria for


psychiatric disorders, for use with adults with moderate to profound learning
disabilities. It may also be used in conjunction with the ICD-10 and DSM-IV
manuals, when working with adults with mild learning disabilities.

• http://www.intellectualdisability.info/home.htm

Information about various aspects of Learning Disabilities, for all people.

• hebw.uwcm.ac.uk/learningdisabilities/index.htm

Thorough review of evidence on various aspects of the management of people


with LD.

• http://www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/learnin
gdisabilities.aspx

Extremely informative leaflets for anyone who is worried about themselves, a


friend or a relative. Titles include, ‘Depression in people with learning
disabilities’ and ‘Learning disability and mental health.’

• www.learningdisabilities.org.uk

Research organisation working with people with Learning Disabilities to improve


their quality of life. Site has a variety of information and research findings, mainly
on services and support systems.

• 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. (2005). Epidemiology of mental health problems in adults with


learning disability: an update. Advances in Psychiatric Treatment. 11:214-222.

• 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.

Books beyond words

http://www.rcpsych.ac.uk/publications/booksbeyondwords.aspx

A series of picture books developed to make communicating easier with PWLD.

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

• Attwood, T. (1998). Asperger’s Syndrome. A guide for parents and professionals.


London: Jessica Kingsley Publishers. ISBN: 1 85302 577 1.

• 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

Introduction to module. Introduction to the day. Introduction to the day.


Small group work. Small group work. Multiprofessional
masterclasses

Coffee break Coffee break Coffee break Coffee break

Group work feedback. Case presentation. Multiprofessional


Presentation: Blue Apple Theatre Seminar: Diagnosing and managing masterclasses.
dementia in PWLD. Small group work.

Lunch Lunch Lunch Lunch

Group summary. Group summary. Group work feedback.


Week 2 case preparation. Week 3 case preparation. Group summary.
Week 4 preparation.

Tea break Tea break Tea break Tea break

Exam Practice Exam Practice Exam Practice Exam Practice

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

‘[utilisation] of means which are as culturally normative as possible in order


to establish and/or maintain personal behaviours and characteristics which
are as culturally normative as possible.’

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:

Foundation for People with Learning Disabilities (2002). Include Us Too.


ISBN: 0-9541586-5-2.

Mencap (2004). Treat me Right.


http://www.mencap.org.uk/displaypagedoc.asp?id=316. Accessed 16/02/3009.

Mencap (2007). Death by Indifference.


http://www.mencap.org.uk/document.asp?id=284. Accessed 16/02/2009.

36
Appendix 6

Week 1 – Learning Disability and Psychiatric Disorders


Introduction

PWLD more commonly experience psychiatric disorders. However, as you will


discover, in most research related to PWLD, the exact incidence or prevalence varies:

• 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 difficulties with research in the LD population include:

• 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:

 Explain the term ‘learning disabilities.’


 Describe the epidemiology and aetiology of psychiatric and behavioural problems
in PWLD, including common associated genotypes and phenotypes.
 Classify health problems in PWLD.
 Describe how the presentation of psychopathology in PWLD compares to the
presentation of psychopathology in the general population.
 Know how to undertake a thorough assessment of problems in PWLD.
 Know how to manage psychiatric problems in PWLD.
 Ask for help, appropriately, from the community learning disability team (CLDT).

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:

• Petra is being physically aggressive to staff and other service users.


• Petra is running off in public places.
• Petra is being physically destructive to property, e.g. pulling down curtains,
kicking holes in walls and doors, throwing TV out of the window.
• Petra is not complying with staff’s requests or the home’s rules.

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

Groups Task Heading Stop and Think Questions


1 +5 Differential What is the differential diagnosis?
Diagnosis
How could you classify the problems and differential
diagnosis?

Which parts of Petra’s presentation is psychopathological


and which parts could be normal behaviour considering
her social circumstances, learning disability and
diagnoses?

How do PWLD present differently to the general


population when mentally unwell?
2+6 Aetiology What is the epidemiology of mental health problems in
PWLD and which aspects apply to Petra?

What do you think are the aetiological factors for Petra’s


presentation?

What are the common genotypes and phenotypes in LD?

Does Petra have a specific genotype or phenotype and if


so how does it influence your aetiological hypothesis?

Is Petra’s age an important factor when considering her


presentation?
3+7 Assessment What questions would you be asking as part of your
history?

What might you be looking out for when undertaking a


mental state and physical examination, taking into account
Petra’s known diagnoses?

What other information would you like and why?

Who do you want to talk to and why?

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?

What are the psychological, biological and social factors


to be considered in the management of Petra’s
presentation?

Do you need to consider any legislation?

39
Appendix 6

Suggestions for discussion in your weekly supervision

• The group’s and your individual stop and think questions?


• What are the similarities between Petra’s case and the clients in your current
psychiatric placement?
• What are the differences between Petra’s case and the clients in your current
psychiatric placement?

Essential resources for this week

 Fraser, W. and Kerr, M. (eds.). (2003). Seminars in the Psychiatry of Learning


Disabilities (second edition). London: RCPsych. ISBN-13: 9781901242935

 http://www.intellectualdisability.info/home.htm

 Royal College of Psychiatrists (2001). DC-LD (Diagnostic criteria for psychiatric


disorders for use with adults with learning disabilities/mental retardation).
(Occasional Paper OP48). London: Gaskell.

 Smiley, E.(2005). Epidemiology of mental health problems in adults with learning


disability: an update. Advances in Psychiatric Treatment. 11:214-222.

 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

Week 2 – Older Adults with a Learning Disability

Introduction

The proportion of the older population with LD is increasing, probably reflected by


the better survival rates at a younger age. Since early mortality is higher in the more
severe LD population, it is the people with a milder degree of LD who are more likely
to have a life expectancy closer to that found in the general population.

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?

As always it is important to exclude physical health problems when assessing PWLD


who have been referred to you. The morbidity and mortality rates in PWLD are higher
than the general population at all ages, due to a combination of risk factors including:
• The underlying disorder,
• Communication difficulties,
• Symptoms presenting in an unusual manner,
• The person’s lack of understanding that the symptom/ sign is not normal,
• Diagnostic overshadowing (the symptom/sign is mistakenly attributed to the
person’s LD).

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

Physical Health Problems in PWLD compared to the general population

Disorder LD Gen. pop.


Mortality ↑
Coronary Heart 2nd cause death Leading cause
Disease death

GI disorders Ca 48-58% Ca 25%


50% GORD
↑H. Pylori

Respiratory disease Leading cause death 46-52% 15-17%


↑Aspiration and infections

Epilepsy 22-30% 1%

Disorder
Nutrition <10% PWLD have balanced diet
↑Malnourishment
↑Obesity

Oral Health 36.5% of PWLD have problems


Screening Cervical smear 24% of all PWLD cf. 82% gen pop.
Sensory impairment PWLD have 200 x Visual problems cf. gen. pop.
40% of PWLD have hearing problems

Musculoskeletal ↓Bone density


↑Fractures/falls

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:

 Comprehend how human development and ageing differs in PWLD.


 Describe the physical and mental health problems associated with Down
Syndrome.
 Apply your understanding of physical health problems in PWLD when
undertaking assessments.
 Describe the presentation of psychopathology in PWLD compared to the general
population.
 Utilise the skills of the CLDT effectively.
 Apply the MCA to PWLD.

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

Jane is now worried about Pat because:


• At times Pat does not appear to recognise Jane.
• Pat is often in dirty clothes and does not wear make-up. She has lost a
considerable amount of weight (although was obese before the move). Jane has to
initiate conversation and then Pat usually replies ‘don’t know.’ If Pat initiates
conversation it will be to ask when she can go home to her parents.
• Pat used to enjoy knitting but this now sits by her bed untouched.

Report by the Residential Home Staff

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

Use the following prompts to present, as a group, a formulation of Pat’s case,


including differential diagnosis, aetiology, investigations and treatment.

Stop and Think Questions


What is your working What is the differential diagnosis?
hypotheses?
What is Pat’s level of learning disability?

What is the phenotype of Down Syndrome?

How significant is Pat’s change of social


circumstances to her presentation?

From what physical problems could Pat be


suffering?

From what psychiatric problems could Pat be


suffering?

What could you do to test Do you need to gather more information, and if so,
your working hypotheses? from whom?

What other questions do you want to ask?

Does the GP have a role in assessing Pat? If so,


what would you recommend?

What members of the CLDT could be involved in


assessing Pat and what specific assessments could
they undertake?

What basic annual health checks should Pat receive?


(Don’t forget to take into account her level of LD
and genotype!)

What management might you Would the MCA be applicable in helping you to
suggest? assess and manage Pat? If so, how?

What members of the CLDT could be involved in


helping the home to support Pat and what specific
work may they undertake?

What is the local authority’s role?

How would you approach the Would the MCA be applicable?


staff’s concerns re physical
abuse? How would it help the residential home staff to
support Pat?

44
Appendix 6

Suggestions for discussion in your weekly supervision

• 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?

Essential resources for this week

 Fraser, W. and Kerr, M. (eds.). (2003). Seminars in the Psychiatry of Learning


Disabilities (second edition). London: RCPsych. ISBN-13: 9781901242935

 http://www.intellectualdisability.info/home.htm
In particular the webpages on grief, dementia, Down Syndrome and physical
health.

 Royal College of Psychiatrists (2001). DC-LD (Diagnostic criteria for psychiatric


disorders for use with adults with learning disabilities/mental retardation).
(Occasional Paper OP48). London: Gaskell.

 http://www.downs-syndrome.org.uk/images/stories/DSA-
documents/Publications/health/ageing_and_consequences.pdf

45
Appendix 6

Week 3 – Autistic Spectrum Disorders


Introduction

.
Objectives

Case Problem
Background
Concerns/Problems

Issues to be considered

Questions Stop and Think Questions

Essential resources for this week

Week 4 - Forensic LD

9- 3.30 Forensic LD day. Combination of multidisciplinary teaching using small


groups and case problems given on the day.

46
Appendix 6

References
Bhaumik, A. and Branford, D. (eds.) (2005). The Frith Prescribing Guidelines for
Adults with Learning Disability. London: Taylor and Francis.

Cooper, S-A, Bailey, N. M. (2001). Psychiatric disorders amongst adults with


learning disabilities - prevalence and relationship to ability level.
Irish Journal of Psychological Medicine. 18: 45-53.

Crews, W. D., Bonaventura, S. and Rowe, F. (1994). Dual diagnosis: prevalence


of psychiatric disorders in a large state residential facility for individuals with
mental retardation. American Journal on Mental Retardation. 98: 688-731.

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.

Idiots Act (1886). (49&50 Vict., c.25).

Jay Report. (1979). Report of the Jay Committee. London: Department of Health
and Social Security.

Mental Deficiency Act (1913). (3&4 Geo. V., c.12).

Mental Health Act (1959). (7&8 Eliz. ІІ, c.72).

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.

Prasher, V. P. (1995). Prevalence of psychiatric disorders in adults with Down's


syndrome. European Journal of Psychiatry. 9: 77-82.

Report of the Mental Deficiency Committee (Wood Report) (1929). London:


HMSO.

Royal College of Psychiatrists (2001). DC-LD (Diagnostic criteria for psychiatric


disorders for use with adults with learning disabilities/mental retardation).
(Occasional Paper OP48). London: Gaskell.

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

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