GENETIC AND BEHAVIOURAL ASPECTS OF PRADER-WILLI SYNDROME: A REVIEW WITH A TRANSLATION OF THE ORIGINAL PAPER

Enabling carers to access specialist training in breakaway techniques: a case study

The British Paediatric Association (1994) has estimated that in an 'average' population of 250 000 people, there will be 200 children with severe learning disabilities. Of these children, the number with behaviour difficulties has been estimated to be higher than that of the rest of the population (Saxby & Morgan I993). Behaviour difficulties are considered a major source of stress for parents and carers (Quine & Pahl I985; Quine I986). The effect upon the family, the carers and the child are considered complex and bi-directional (Dyson I993; I996).

This paper explores the experience of one family, whose child had Prader-Willi Syndrome and severe behaviour difficulties, and the process undertaken to access specialist training in 'Breakaway' training. Prader-Willi Syndrome has been associated with a range of behaviour difficulties including hyperphagia and food preoccupation, temper tantrums, stubbornness, lability, impulsivity, arguementativeness, depression, anxiety and repetitive behaviours (Dykens & Kasari I997). An escalation of the child's aggressive outbursts had necessitated intervention and the traditional methods of behaviour management had proven insufficient during episodes of crisis. To ensure the safety of both the parents and the child, access to training in 'Breakaway techniques' for the carers was procured, at the carers request. This paper concentrates upon the difficulties encountered during this process, both for the family and the professionals involved.

All names and locations identified in this paper have been changed to protect the anonymity of the individuals involved.

Cognitive and behavioural aspects of Prader-Willi syndrome

PURPOSE OF REVIEW

To provide a review of the recent advances in the diagnosis and treatment of psychiatric disorders in Prader-Willi syndrome (PWS).

RECENT FINDINGS

Research in the last 12 months has provided a descriptive prognosis of psychosis in PWS and highlighted the possible genes associated with the increased risk of psychosis for those with maternal uniparental disomy (mUPD). Several studies investigating social and communication skills have shown people with PWS to have difficulty with core, receptive and expressive language skills, interpreting emotional valence in faces, playing with children of their own age, understanding personal space and a developmental delay in the theory of mind. These social and communication deficits are often more pronounced in those with mUPD. Two recent clinical trials of oxytocin provide mixed results and highlight the need for an improved understanding of the neurobiological characteristics of the PWS brain. A recent pilot study suggests N-acetylcysteine may be a viable treatment for skin picking.

SUMMARY

Recent advances have contributed to our understanding of the emotional and behavioural problems associated with PWS, and provided directions for further research.

Functional Analysis of the Early Development of Self-Injurious Behavior: Incorporating Gene–Environment Interactions

The analysis of the early development of self-injurious behavior (SIB) has, to date, reflected the wider distinction between nature and nurture. Despite the status of genetic factors as risk markers for the later development of SIB, a model that accounts for their influence on early behavior–environment relations is lacking. In the current paper we argue that the investigation of gene–environment interactions (GxE) and other forms of gene–environment interplay could potentially enhance current approaches to the study of self-injury. A conceptual model of the early development of SIB based explicitly on such relations is presented. The model is consistent with the basic tenets of functional analysis. Implications for research and the assessment, treatment, and prevention of SIB are discussed.

Prader-Willi syndrome: an update and review for the primary pediatrician

Prader-Willi syndrome, the first known human genomic imprinting disorder, is one of the most common micro-deletion syndromes. Prader-Willi syndrome is caused by the absence of certain paternally inherited genes on the long arm of chromosome 15, resulting in a complete absence of the active copy of the genetic information in this region. It is most commonly known for its food-related characteristics of hyperphagia, food-seeking behavior, and consequent obesity. Primary care physicians play an important role in the care of children with Prader-Willi syndrome, from recognizing the presenting signs and symptoms at its various stages to understanding their unique medical, developmental, behavioral, and dietary issues. They can also serve as a valuable source of support and advocacy for the family. This article reviews the current state of knowledge about Prader-Willi syndrome and discusses up-to-date understanding of the management of this condition.

The expression of pain in infants with developmental delays

OBJECTIVE

To explore how infants with developmental delays express pain, we analysed facial expressions of infants receiving their routine immunization at around 4-6 months developmental age. The sample included eight infants with developmental disabilities (mean developmental age 4.8 months) and 30 typically developing infants (mean age 4 months). The Maximally Discriminative Facial Movement Coding system was used to code infant facial expressions during immunization.

RESULTS

The pain expression was by far the most common of all facial expressions following immunization for both groups of infants. Those with disabilities produced significantly fewer discrete high-intensity expressions of pain, and significantly more blended expressions than typically developing infants. Expressions of fear, sadness and anger were relatively infrequent in both groups. Infants with disabilities used their upper face less often than typically developing infants, and their mid face was uncodeable more often.

CONCLUSION

Infants with developmental delays were likely to show pain in facial expressions less clearly than typically developing infants. It is important for health care professionals to be aware that this may be the case when considering the administration of analgesia for such children.

Affective psychosis and Prader-Willi syndrome

Previous studies have demonstrated that maladaptive behaviours are common amongst adults with Prader-Willi syndrome (PWS). Case reports have also previously demonstrated that psychosis can occur amongst adults with PWS. The present study was undertaken in order to gain a better understanding of the psychopathology of the psychosis of PWS. Twenty-three out of 25 adults identified with PWS living in Northamptonshire, UK, agreed to participate. Comprehensive psychiatric assessments (using the PPS-LD), and measures of adaptive and maladaptive behaviours (using the AAMR-ABS) were completed. Comparisons were made for the prevalence of psychiatric disorders against those from a previous epidemiological study of adults with intellectual disability of other aetiologies from a neighbouring county. The PWS group was found to have higher rates of affective disorders (a point prevalence of 17.4%), in which psychotic symptoms were common, but similar rates of schizophrenia/delusional disorders (4.3%) compared with the comparison group. Behaviour disorders were also common. Surprisingly, none of the PWS group was found to have generalized anxiety or phobic disorders. The diagnostic criteria for the episodes including psychotic symptoms are explored. The high rates of affective disorders is of clinical (i.e. treatment) importance as well as being of academic interest with regard to the genetics of psychiatric disorders.

People with learning disabilities who also have mental health problems: practice issues and directions for learning disability nursing

The plight of people with learning disabilities who have mental health problems has become an issue of contemporary importance in the provision of health services to this section of the population. This paper will argue that learning disability nursing has a central role to play in the promotion of mental health for this client group (Department of Health 1995a). However, learning disability nursing presently operates without a clear model of mental health. Therefore, before this potential can be realized there is a need to establish the common ground between the discourses of learning disability nursing and those of psychiatric nursing which might be related to this client group. This paper begins by identifying the background issues relating to the problems of meeting the mental health needs of people with learning disabilities. It then proposes that an applied behavioural approach has the potential to provide a coherent theory that can link the discourses of normalization, developmental psychiatry and mental health nursing, whilst also establishing the applied behavioural approach as a powerful technology upon which meaningful interventions can be designed.