‘The role of Psychiatry in the care of people with Intellectual Disability’ Professor Emily Simonoff

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Professor Emily Simonoff on ‘The role of Psychiatry in the care of people with Intellectual Disability’.

This was recorded on 6 June 2018 at the Jack Tizard Memorial Lecture and National Conference 2018 on Intellectual Disability, and Autism.

ACAMH members can now receive a CPD certificate for watching this recorded lecture. Simply email membership@acamh.org with the day and time you watch it, so we can check the analytics, and we’ll email you your certificate.

Professor Emily Simonoff
Professor Emily Simonoff

I am Professor of Child and Adolescent Psychiatry in the Department of Child and Adolescent Psychiatry where I am also head of the Department and Academic Lead for the CAMHS Clinical Academic Group in King’s Health Partners. I am a Senior Investigator in the National Institute of Health Research and a Theme Lead for Child Mental and Neurodevelopmental Disorders in the Maudsley Biomedical Research Centre.

Research Interests; Autism, ADHD, Intellectual Disability, Antisocial behaviour, Genetics, Epidemiology.

My external roles include: Chair of the European ADHD Guidelines Group, member of the Steering Committee for Eunethydis (the European Hyperkinetic Disorder Network), Chair of the Mental Health Study Group for Autistica and past Senior Clinical Advisor to the National Institute of Health and Clinical Excellence (NICE).

Bio via KCL

Transcript

Great. Well, thanks very much for that introduction. I should say one of the benefits or adverse effects of having an office very near Steven Scott’s is that when you haven’t given your title to ACAMH, he pops down for a half day and says, have you got a couple of titles yet?  So I came up with this title and like many people who want to prevaricate, I would slightly change it now to be the role of the psychiatrist within the multidisciplinary team in the care of people with intellectual disability, because I think I don’t want anyone to take away the idea that the psychiatrist works as a semi-autonomous individual in caring for this very important group of children, adolescents and adults, but rather that virtually all of our practice must be within the multidisciplinary sector.

And really, it’s the fact that isn’t happening that led me to come up with that particular title, and it’s a reflection really of what’s going on in the NHS, particularly in CAMH services at the moment. I think, I’ve been around long enough that I can remember first when virtually all CAMH services excluded children and young people with intellectual disability from the services and then NHS, it was before NHS England, it was actually the Department of Health said that one of the ways in which they were going to judge whether CAMH services were comprehensive was the demonstration that there were services for children and young people with intellectual disability.

What that led to in some places was excellent multidisciplinary services, but in other areas really [inaudible 00:02:14] disciplinary services or certainly not comprehensive multidisciplinary services. So, for example, there are so many services for children and young people with intellectual disability.

And we’re sadly at another stage in the incarnation of NHS cuts, whereby there is increasing pressure on CAMH services. Our own local services in South London have been cut 30% to 40% over the last five to eight years, and although it’s not being stated over in many places, that means the children and young people with intellectual disability are being excluded in a rather more subtle way where clinicians are saying we don’t have the skills to care for this group of children.

And by the fact that you’re here today, I’m almost certainly preaching to the converted, but what I hope you’ll come away from is, so this talk with the idea that actually this is an important and common group of children and young people who have mental health problems and that we absolutely have to embrace their care in our services at every level. It’s always daunting to follow from Chris Oliver because it was such a beautiful talk and highlights such a structured and detailed work in relation to identifying syndromes and single gene disorders, but largely speaking, I’m going to be focussing on a much wider group of children and adolescents with intellectual disability, many of whom we don’t know the cause and sometimes we don’t even recognise the fact that they have an intellectual disability.

So going onto really a different group of children, and I really wanted to start by highlighting the many different labels of course that we’ve used   over the last 30 years when we talk about what we now call in the UK intellectual disability. One consequence, of course, for a researcher when you’re trying to systematically review the literature in the areas it’s almost impossible to do a literature review because there’s so many different terms that are being used. You don’t have a single [inaudible 00:04:40] that you can reliably use when you want to search the research literature, but I also argue that this has had an impact on the identity of specialist services for children with intellectual disability as well. [inaudible 00:05:06] of that intellectual developmental disorder, but I think at least with DSM five, it’s been the norm, and the fact that we don’t have a single term that’s well recognised in society over many years causes us difficulties in face recognition and the way in which we can easily promote the issues and needs of this group of individuals. That isn’t of course driven by us. Just too just wake you up after lunch, these were the terms used to define mild, moderate and severe intellectual disability no more than 50 to 60 years ago.

They were the technical terms for those categories and of course now words of, you know, they’re epithets used against individuals and this is the challenge that we have. So we do constantly change the terminology, but I think it also causes us difficulties. So why am I worrying about the psychiatry of intellectual disability? Well, I hope this slide makes the point for you. These are epidemiological studies and you’ll all be well used to the idea that we do epidemiological studies, because if we do clinical studies, we’re likely to pick up higher rates of disorder, higher rates of comorbidity.

I would actually argue that for intellectual disability the opposite applies. When we look at clinical samples we under-detect intellectual disability in our populations with mental health problems. So these epidemiological studies and the ones on the left hand side with a controlled comparison group of average IQ and those on the right hand side just looking at people with intellectual disability or children with intellectual disability show remarkable consistency in the rates of psychiatric or mental health disorders amongst children and adolescents, and for an epidemiologist this is remarkably consistent, both in the rates of disorder, those with ID, but also the odds ratios which are anywhere between three to eight-fold increase for those with intellectual disability.

So just to also focus on how striking it is that two studies done in the UK more than four decades apart, Anderson, which is based on the [background noise 00:07:50] children and young people, and Roger [inaudible 00:07:55] are both strikingly similar rates, but also differences in rates. So I hope I don’t need to persuade you that we have considerably increased rates. Now, what are the disorders that we see? These are expressed odds ratios, and I’m sure I don’t need to tell you.

But just to remind you because the slide is perhaps not totally ideal. The odds ratio of one means that there’s no difference between people with intellectual disability and those of average ability. So anything above one is increased risk of having that condition if you have intellectual disability, and there’s one disorder that’s strikingly been left off this slide and I’m sure people can be very slightly drowsy after lunch, and it’s autism spectrum disorder and the reason for that is if I put it on the same slide, everything else would be dropped.

So the odds ratio for autism in this study was 74. A huge increase in people with intellectual disability. So what you can pick up is really right across the whole spectrum of mental health or psychiatric conditions we have increased rates in people with intellectual disability. This is just to remind you that we think of intellectual disability as individuals with an IQ below 70. So extremely low end of the normal distribution. The important thing to bear in mind for clinical practise, is that not only do we need to define intellectual disability in terms of IQ but also about the function.

So the idea that your everyday functioning, whether it’s communication or your living skills, independence, that those are also compromised. In clinical settings it’s usually the case that that is so that adaptive function is also compromised, not necessarily the case when you’re doing research studies and that would be a logical step, and just as a sort of clinical play at this point, the measuring of that dysfunction is often extremely helpful as part of the clinical process. We have two main measures that we use in the UK. Define them which is an interview based measure and the [inaudible 00:10:11].  So that would be behaviour assessment schedule, which is the questionnaire completed by parents.

So it really requires relatively little comprehension, and it can be quite revealing in terms of areas of function that have real meaning, everyday life of the family. People with autism typically, whatever they are typically have a discrepancy of at least several years of functioning, whether adaptive function is considerably lower than you would expect on the basis of their IQ alone. In terms of managing individuals clinically the function is likely to be at least as important in thinking about how you organise interventions and the advice you give to family, schools and other people involved with that child. But having said that, so when we’re talking about disorders for individuals whose IQ is in the lowest 2% to 3% of the population, but given those increased prevalence rates, they actually account for 15% of individuals with mental health problems and psychiatric disorders. And therefore, I would argue that the care of people with intellectual disability, mental health problems is part of the role not only of every psychiatrist, but of every CAMHS service, and we can’t exclude from our care and consideration.

Okay, back to [inaudible 00:11:49] and I wanted to really highlight that it may be helpful to think about two broad groups of individuals with intellectual disability and they tend to relate to the IQ level, but there is considerable overlap. First of all, the group where we can identify the cause of intellectual disability and a large and important part of those are the conditions that Chris was talking about before launching the genetic conditions with Mendelian inheritance, chromosomal conditions such as Down’s syndrome, but also what we call CMVs a combination of areas which are genetic abnormalities, so we can now reliably identify with sequencing, genomic sequencing that should be part of every genetic service that people that people move into. So undertaking genetic analysis is really part and parcel of the diagnostic assessment of people with intellectual disability.

It’s also important to remind you of the acquired causes of intellectual disability, many of which will be more prevalent in lower and middle income countries for which we often neglect in the armed services. So things like the alcohol syndrome. We often forget to ask about intake of alcohol or indeed other recreational drugs. Although alcohol in fact is the one that’s most clearly associated with intellectual disability. What we have here is the group who represent 50% to 75% of individuals with intellectual disability for whom we cannot currently identify a single cause and because of where they occur on that normal distribution.

I hope it’s intuitive that they actually are the majority of individuals with intellectual disability. Much of what I’m going to talk about in the next few slides will apply to them. What we know about individuals is that genetic factors are important, but they’re largely polygenic, and the research today on the inheritance of IQ, which is anywhere between 60% to 80% heritable, suggests that each gene accounts for 0.05% of the variance. So genes with tiny effects as individuals and therefore we’re really talking about many genes acting together, but also importantly were environmental factors.

We’re talking about heritability. So 68%, that means environmentalities. It’s not a correct word but we’ll use it for the moment, of 20% to 40% and those factors are important, and we’ll see how they’re important in psychiatric conditions and their correlates, and there’s no evidence currently to suggest that the role of genes and the environment for this group of individuals is any different from that for the rest of this current year. Paula [inaudible 00:15:05] studies nothing to suggest the difference. So sometimes at the extreme low end of ability, but that comes with all sorts of adverse consequences.

Okay, so we looked at the odds ratios for individual disorders, but what I wanted to do is turn that slightly on its head and look at the proportion of individuals with intellectual disability compared to those who have different disorders, and the point that I wanted to make is that although we think, for example, of ticks and ADHD has been most strongly associated with intellectual disability in terms of odds ratios. In fact they account for really a much smaller proportion of those who should be attending clinical services.

And what you should expect them to see in CAMH services, once again the common disorders that we recognise, and when I talk about contacts throughout this talk I’m talking about both oppositional, defiant and conduct disorder of any type and the emotion disorder will be anxiety and depression the emotion. So largely speaking the common things occur commonly in individuals with intellectual disability and we need, therefore, to focus as much on good and effective interventions and diagnostic strategies for those groups of individuals if we are going to make an impact in serving this population.

Okay, so we talked a bit about the role of environmental adversity and again, I’m referring to the work of [inaudible 00:16:52] I think really beautifully has taken some of the cohort studies that have been done both and we’ve talked about the British household study but also the millennium cohort and some of the Australian cohort studies and looked at that in relation to individuals, children and adolescents with intellectual disability, and this slide talks again about odds ratios, different psycho social adversity factors and the odds ratios for those in intellectual disability compared to average IQ. Well, I want to take away is that every single one of these is increased in the families of children with intellectual disability, mostly in mental health, but every single one of them and these aren’t adjusted. So in aggregate there will really be quite a significant impact.

And this slide is showing us on your X-axis, the number of psycho-social adversity factors for individual children and the percentage you have conduct emotional or ADHD, and I want you to take away two things from the slide. The first is that even with no factors identified the intellectual disability group have higher rates of disorder, but secondly, that those plots rise significantly more steeply in children with intellectual disability. So we might have had the thought that, oh, well, it’s just part and parcel of intellectual disability.

They come from families where these issues are more common. We don’t really need to take that into account, but actually what we’re seeing is greater sensitivity rather than blunted or no sensitivity to the psycho-social adversities and I think for many of us in CAMH services this plays to some of the strengths that we have which are to identify factors that may play a role in promoting or maintaining mental health problems and identifying ways of intervening. So we need to be particularly aware of those in children with intellectual disability, and I also think of this as the conserve to studies which show that having relatively higher IQ is a protective factor against psychosocial adversities. That’s been well-known fact for many years, perhaps first promulgated by Michael Rutter.

But this is really showing at the other end we have greater sensitivity. Okay, and as an example, Eriston [s.l. 19:46] showed that children with intellectual disability were twice as likely if they’re presented with conduct disorder have persistent symptoms some two years later and he looked at the factors that were associated with that, not all of which are psychosocial. [Inaudible 00:20:06] and language problems will come as no surprise, nor will perhaps the psychosocial adversity, but in that epidemiological studies showing that when those were accounted for there was no persistence in the intellectually disability group.

Now, that’s quite different from saying that if we do treat those problems, we know that the psychosocial adversity if we had a vaccine for psychosocial adversity, all their conduct problems would go away, because this has never been a logical study, we’re looking at associations rather than causality, but nevertheless, it’s giving us some ideas of where we might want to look and where we might want to test whether the differences, because we’re dealing with different types of children, those with and without psychosocial adversity or whether the psychosocial adversity is playing an active role in the maintenance of [inaudible 00:21:07] problems over time.

And this is really just to remind us again, as for those of us who are psychiatrists that we need to keep our medical skills up to date because individuals, including children and adolescents with intellectual disability have much increased rates of general health problems, including sensory problems, hearing and vision problems which often go undetected and are good for at risk of missing their appointments for screening, of obesity, of starting to smoke and future varied rates of epilepsy dependent on the study group, but certainly somewhere in the middle of that.

So we’re dealing with a group where we actually need to ensure that they’re getting good general and specific medical services and that is one of the reasons why we need to have psychiatrists as well as a good functioning multidisciplinary team caring for them.

Okay, parents and we’ve highlighted the role of psychosocial adversity as an important in both initiating and maintaining the psychiatric problems in individuals with intellectual disability.

This is looking at parents who have intellectual disability and the problems in their children, and again, we’re on odds ratios and remember one is no difference. So what you can see is overall very much higher rates of development of speech, language problems, behavioural difficulties and accidents, but once we have first for the social adversity and then for mental health problems in the parents, those alterations are massively reduced, getting close to if not actually at one. So hugely important to think about the context in which these children are growing up and just we show that very high rates over the high rate of parental mental disorders, and we need to think about whether our parents of children with intellectual disability also have an intellectual disability or a low IQ themselves. Have a heritability, so 60% to 80%.

And we often [inaudible 00:23:39] difficulties themselves. Parents who have intellectual disability are also, not surprisingly, at increased risk of mental health problems. So we have a vicious circle of familial and environmental adversity. So all that leads us to think about well, you know, it’s absolutely essential that we have effective and robust interventions for children with intellectual disability. What is the evidence base for that? And we’ll turn in a minute to the broader evidence base, but perhaps the area where it’s been best delineated is in relation to ADHD.

And this slide shows the effect sizes where bigger is better reflecting in standard deviation units and the red column is the effect size of stimulant treatment in [inaudible 00:24:41] populations, which is between point seven and point eight in aggregate studies. So that’s a really clear message now, and the aggregate intellectual disability studies showed rates of roughly half that, which led us to do a study where we really do the best possible stimulant intervention we could think children with intellectual disability, so optimising the intervention for the individual child looking carefully for adverse effects and measuring carefully over time.

And what you can see is our effect sizes are absolutely the same as those of the earlier studies. There’s maybe be more robust exercises, but we could go to questions and answers. So we’re really only getting half the magnitude of benefit for children with intellectual disability. It is a significant benefit and the point you should take away, is it’s always worth considering whether medication is appropriate because it clearly is better than nothing, but why was it showing such poor outcomes compared to [inaudible 00:26:01] children?

And I think there are at least several different reasons and I’ve put a different disorder, I should really say misclassification. So are we calling children who we’ve diagnosed as having ADHD, should they really have another diagnosis? Are we, for example, misinterpreting mannerisms and stereopathies? There’s fidgeting. Autistic like a preference for attention [inaudible 00:26:30]. There’s global inattention. So we’re mislabelling children as having ADHD. I would argue that in general, the evidence is that we tend to miss ADHD in children with low IQ and intellectual disability.

You tend to think that their level… that these problems are due to their intellectual disability, and therefore don’t [inaudible 00:26:58].  So we then need to think about different brain mechanisms, [inaudible 00:27:05], impulsivity may look at surface level very similar, but the underpinning mechanisms may be very different and that’s absolutely crucial to think about. We also need to consider whether the effect sizes we identified are real or whether they’re swamped by the general effects of having intellectual disability.

Certainly my experience of doing clinical [inaudible 00:27:29] and with parents is they might give and say ADHD it’s much better at concentrating. He doesn’t move around so much. No, it’s really not better overall and the question of whether the intellectual disability are given the global mass scale, but we also need to bear in mind that adverse effects may limit the way in which we can intervene, and therefore, for example, the population had twice the rate of adverse effects leading to stop improvement than we would have expected average IQ kids.

So I think this is where medication or any intervention has been well looked at. We still have many questions. What do we know, otherwise? Well, [inaudible 00:28:20] undertook a review of treatment for people with intellectual disability, both children and adults, and in terms of psychological interventions they found ten RCTs for psychological interventions directed at individuals’ intellectual disability. In some of those trials actually have multiple [inaudible 00:28:44].

So what you’ll see is there is a small evidence base, but if you look at those five RCTs for anxiety, they only include roughly 150 individuals. So very small trials each [inaudible 00:29:01] that they couldn’t meta-analyse the results.

Furthermore, they raised the standard by which the quality of trials and quality of the overall evidence is evaluated [inaudible 00:29:14] low to very low. Steven will be particularly happy to see this, one bright and shiny exception to that was in parent training trials of intervention where there was a clear demonstration of efficacy and benefit of parent based interventions for younger children with emotional behavioural problems. It’s even worse when we look at pharmacological interventions. You know, just really very profound evidence or absence of evidence for that group and I really wanted to contrast the evidence for those with intellectual disability with a recent network meta-analysis that was done for depression in typically developing adults with average IQ, [inaudible 00:30:08].

And it’s a shame, and one of the roles of the psychiatrist, as well as the academic professional in the care of people with intellectual disability is to ensure that we develop evidence base for intervention and that we dealt with this shameful situation.

The last point I want to raise before drawing to a close is, I think, the enormous potential of bringing objective measurements into the assessment and monitoring of interventions for people with intellectual disability, and again, Chris, alluded to this to some extent but more perhaps in an experimental setting and what I want to leave you with, is where I’ve started to bring this in to people without intellectual disability, and there is absolutely no reason why we shouldn’t be looking at how we bring remote monitoring and objective measurement in for people with intellectual disability, and I hope that all of you will be early adopters. So we’re talking about remote monitoring via risk held devices. How many of you have a Fitbit on today that can measure your activity levels and heart rate? But we also have more sophisticated Fitbits that can also measure [inaudible 00:31:36] as well as just activity levels. So ironically what kind of activity?

So hopefully we can distinguish what type of fidgeting from mannerisms when dealing with the [inaudible 00:31:47] and also using Smart Phones to look at where we are. What’s the time of day when we get upset? What’s our tone of voice from which we’re going to be able to extract emotional tone? How do we communicate with others? So enormously rich opportunities for using remote monitoring, and I think we want to think about these in terms of both diagnostic interventions where we’re often limited in our assessments of people with intellectual disability who may have limited ability to communicate the [inaudible 00:32:23] of their symptoms.

So we rely on parents, carers to give us high quality accurate accounts, to be able to pick up subtle differences and to be able to read the differences between, for example, anxiety and anger, which may be better protected with objective measures and to look for very subtle changes that may not be obvious, for example, from facial expression or activity level. We also have problems, for example, getting routine information from schools and parents outside of the home and finding an intervention, I think because subjective measures can allow us to get data right throughout the day and measure changes over long periods of time, we can make more subtle differences and pick up early differences as well because the data will give us more power.

So I hope you all will be early adopters. This is just to give you a sense of what they might look like. This is actually comparing actigraphy data and social communication data from a normal control and someone with bipolar, and what you’re supposed to pick up is the more regularity across the time-course of activity levels and use of different kinds of social communication in a typically developing person.

A rather more random pattern for both of those and bipolar disorder. It’s early days but I think very exciting. So I want a wind up really by highlighting that psychiatric disorders are clearly increased in individuals with intellectual disability and they’re sort of marked by [inaudible 00:34:11] mobility and psychosocial adversity, but there’s very scant evidence for the effectiveness of interventions where it is we really know, we know very little about the brain mechanisms.

So finally, just to think about the way in which new technologies may help you in the future to build better care. Thanks.

Professor Emily Simonoff

It’s not very often that we get some extra five minutes for questions and answers. There’s five minutes, [inaudible 00:34:58]. So does anyone have any questions for [inaudible 00:35:01]?

Speaker 2

I’ve got one. So stimulants for ADHD and intellectual disability. Have you seen cases where it’s been inappropriately withheld, because we were hearing this morning about possible over-use [inaudible 00:35:36]?

Professor Emily Simonoff

[Inaudible 00:35:41]. Say that again.

Speaker 2

Sorry, do you see many cases where the stimulants have been withheld given the benefit when they have?

 

Professor Emily Simonoff

So absolutely, I think perhaps a more structured experience we had was in our clinical trial where we were mainly recruited from schools which have intellectual disability. I think there were a couple of things that happened. First of all, the behaviours were seen as well, you know, they’re developmentally disabled, so what do you expect? So that’s what we call diagnostic overshadowing. The intellectual disability seems cause of everything, but also the mislabelling of ADHD, for example, as the non-compliant behaviour.

And that’s common in children with intellectual disability, as it is in the general population. The take home message must be that a large number of children, around 40% shows good effects of medication when measured in the most stringent way. Compared to [inaudible 00:36:55] effect of 7%.

Speaker 3

I have a question relating to where, sort of,  behaviours challenge others fit within the research, because most researchers will have these high rates of conduct disorders that many of the children at lower levels of ability wouldn’t meet the criteria. So in terms of as you go through the 25 questions, essentially for [inaudible 00:37:21] and conduct , they’re not doing the breaking of laws or even necessarily the breaking of rules, but they are hitting the ball, and that is their main presentation perhaps, whether they’re fitting under emotion of conduct?

Professor Emily Simonoff

And so if I were given another [inaudible 00:37:40] and Chris has said some lovely things about changing behaviour and the need to think carefully about how we use that as a term, because the greatest risk of thinking about challenging behaviour is we identify Risperidone as an intervention for challenging behave, and the first point I would start is why is a child with intellectual disability engaging in challenging behaviours, whether it’s aggression directed at themselves in terms of self-injury or directed at others, in terms of hitting because very often those non-compliant maladaptive challenging behaviours can be masquerading, and Chris gave some wonderful examples, maybe masking underlying physical and physiological conditions, but it can also be masking other psychiatric facilities such as, for example, anxiety is the most common one, in my experience, but also depression and even traumatic experiences, and one should never in that group of children, and arguably many children take those behaviours at face value and thinking about the needs within the context of an overall comprehensive assessment.

Speaker 4

I’m Clare Walters, a community paediatrician from Cambridgeshire. I’ve got a question about identification of children with intellectual disability in current services as I feel historically, this has been partly the role of SEND services. It seems to be that formal assessment is very much out of fashion. So actually, we struggle to get a full assessment of children’s cognitive ability, other than the school reporting, and I suppose I’m interested in your advice or other people’s experience about how they manage that within their own services.

Professor Emily Simonoff

So it’s a really important issue and you might say, and when is it important that you do identify. This is certainly topic when we did like a master-class and it came up a lot? I think, my personal experience is schools are very good at reporting which children are achieving well below expected levels. We get reliable information from schools and the public. I would strongly advise [inaudible 00:40:15] to include the school report as part of routine assessment in which you ask them how a child is achieving academically as well as the way in which they present behaviourally and emotionally.

And then I think it becomes a clinical judgement at what point in achieving below standard we decide that a cognitive assessment needs to be done. I found it helpful to have a lower threshold that is assessed more frequently than less than [inaudible 00:40:48], but possibility to use a screening measure, something like vocabulary skill, which any member of a multidisciplinary team can administer and it only takes about 20 minutes to do as a sort of screening, but I think for everyone it’s a discussion with other services about the importance of identification because it may have implications both for that individual and the expectations of that individual, but also potentially we looked at CMVs. Also potentially for the wider family and before the break, Vicky [inaudible 00:41:25]  made a comment about the lack of desire for educational services to label children and of course, labelling them as having lower IQ is part of that. So it’s really a dialogue that CAMH services should be having with LAE and their schools because they are going to be LAE about how that identification is and where it’s been beneficial.

So I think if I’ve understood properly you’re saying IQ can fluctuate using functional assessment as well as or instead of IQ.

So I hope everyone took away that I was highlighting the importance of looking at adaptive function, as well as simply measuring IQ and that there are easily use in our clinical setting to do that and that they are extremely helpful in understanding how a child is functioning in everyday life. IQ is in fact, over time, we can talk about fluctuation in two ways.

One is fluctuation over time and obviously like any other person you get variation, but it’s a reasonably stable measure of [inaudible 00:43:52]. Unless you’re seeing a child on a particularly bad day, you’re likely to get something that is reasonably predictable over time. Variation across sub-test is often informative and in a world where we could do full assessments on every child that we’re concerned that would certainly be encouraging [inaudible 00:44:21], IQ tests. I’m trying to suggest that there may be some ways through for the busy CAMH service where people may feel if they can’t do a full or single [inaudible 00:44:37] assessment they can’t do anything.

They need to find ways of identifying children whose interventions may [inaudible 00:44:47] because of their learning. The number of children I see referred to me because they didn’t respond to treatment [inaudible 00:44:59] four or five years to find out that they had an IQ of 50 and no one had actually queried whether they had intellectual disability because they’re chatty.

So I think there’s a balance there.

I think that is the world that we live in currently, and we both need to take that on board and work with our local services, education services, but also think how we can close that gap, because some of the implications are for us as CAMH services and if we don’t identify intellectual disability and design our assessments and interventions accordingly we will be the ones who are potentially [inaudible 00:45:53] care of that child.

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