Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables

Clinical predictors of severe behavioural problems in people with intellectual disabilities referred to a specialist mental health service

Associations between demographic and clinical variables and severe behavioural problems in people with intellectual disabilities were examined in a cross-sectional survey of 408 adults consecutively referred to a specialist mental health service. Severe behavioural problems were present in 136 (33.3%) of the sample. The demographic and clinical predictors of severe behavioural problems in this sample were identified by logistic regression. Age and gender were not associated with severe behavioural problems. The presence of severe ID independently predicted the presence of severe behavioural problems. Schizophrenia spectrum disorders and personality disorders independently predicted the presence of severe behavioural problems, whereas the presence of an anxiety disorder independently predicted their absence. There is an increasing evidence base of relationships between mental disorders and behavioural problems in people with ID although the pattern of these relationships remains unclear.

Diagnosis and treatment of aggression in individuals with developmental disabilities

Aggressive behavior is a common referral problem for individuals with developmental disabilities (DD), placing them at risk for institutionalization, social isolation, physical restraint, over-use of medication to treat behavior problems, exclusion from services, and becoming a victim of abuse. Aggression strains relationships between individuals being supported and their caregivers, whether professionals or family members. The treatment of aggression is persons with DD, with or without comorbid mental illness, remains a controversial area and changes in practice have been slow to come. The evidence related to pharmacotherapy and psychological treatment is, in general, either lacking or poor. This does not suggest that these treatments are necessarily ineffective but that there is not enough good quality evidence to support their usefulness. This review considers the prevalence and correlates of aggression, as well as possible causative factors. The relationship between mental illness, intellectual disability and aggression is explored. The psychopharmacological and psychological treatment literature is reviewed with implications for clinical care and future research.

Prevalence of, and factors associated with, problem behaviors in adults with intellectual disabilities

This study aimed to determine the prevalence of problem behaviors in adults with intellectual disabilities and to investigate which factors are independently associated with problem behaviors. A population-based cohort (n = 1023) had comprehensive individual assessments. Data were examined using multivariate logistic regression. The prevalence of problem behaviors was 22.5% (psychiatrists' opinion) or 18.7% (DC-LD criteria). Factors independently associated with problem behaviors were lower ability level, female gender, living in a congregate care setting or with paid carer support (rather than living with a family carer), having urinary incontinence; visual impairment, not having Down syndrome, and not having severe physical disabilities. Further studies focusing on the etiology, course, and treatment of problem behaviors are required.

A general practice-based prevalence study of epilepsy among adults with intellectual disabilities and of its association with psychiatric disorder, behaviour disturbance and carer stress

BACKGROUND

Although the elevated occurrence of epilepsy in people with intellectual disabilities (ID) is well recognized, the nature of seizures and their association with psychopathology and carer strain are less clearly understood. The aims were to determine the prevalence and features of epilepsy in a community-based population of adults with ID, and to explore whether the presence of epilepsy was associated with greater psychopathology or carer strain.

METHODS

Data were collected on the age, gender, place of residence, adaptive and challenging behaviour, social abilities and psychiatric status of 318 adults from 40 general practices, together with the degree of malaise and strain of family carers. For participants with epilepsy, a nurse collected information on seizures, investigations, treatment and carer concerns by interview. Association between epilepsy and psychiatric morbidity, challenging behaviour and caregiver malaise or strain, was explored by comparing those with epilepsy with a comparison group matched on adaptive behaviour.

RESULTS

Fifty-eight participants (18%) had epilepsy: 26% were seizure free, but 34% had extremely poorly controlled seizures. Earlier onset and seizure frequency were associated with adaptive behaviour. Carer concerns were related to seizure frequency and a history of injury. There were no significant differences in psychopathology, carer malaise or caregiver strain between the matched epilepsy and non-epilepsy groups.

CONCLUSIONS

This study supports the high occurrence and chronicity of epilepsy among people with ID. While psychopathology and carer strain is common within this population, underlying disability-related factors appear to be more important than the presence of epilepsy per se.

Psychopathology in children and adolescents with epilepsy: an investigation of predictive variables

This epidemiological study was aimed at determining the prevalence of behavioral and emotional problems in a UK community-based population of children and adolescents with epilepsy aged 4-17 using a postal questionnaire survey. The intent was to identify, through this survey, those epilepsy-related and demographic factors predictive of the presence of psychopathology and diminished health-related quality of life, and to distinguish whether such factors differ for differing types of psychopathology. Outcomes were measured using the Strengths and Difficulties Questionnaire (SDQ), Moods and Feelings Questionnaire (MFQ), Impact of Paediatric Epilepsy Scale (IPES), and Quality of Life in Epilepsy Inventory for Adolescents (QOLIE-AD-48). Information was obtained from main carers for 56 children (25 males and 31 females, mean age=12 years, SD=3 years 9 months, range=5-17). Parent report identified that 23 (47.9%, 95% confidence interval [CI] 34.5-61.7%) children met psychiatric caseness criteria and 32 (61.5%, 95% CI 48-73.5%) had chronic distress and social impairment. Regression analyses identified seizure severity as a risk factor for emotional problems and depression (odds ratio [OR]=1.09, P<0.05), whereas cognitive impairment was associated with behavioral problems, specifically conduct problems (OR=14.0, P<0.05), hyperactivity/inattention (OR=9.4, P<0.01), and peer problems (OR=28.5, P<0.01). Cognitive impairment and high seizure frequency were significantly related to increased IPES scores (R(2)=0.33, P<0.001) and diminished QOLIE-AD-48 scores (R(2)=0.39, P<0.01). In conclusion, children with epilepsy experience considerable psychopathology and reduced quality of life. Epilepsy-related factors appear more closely associated with emotional well-being, and cognitive factors with behavior problems.

Psychiatric syndromes comorbid with mental retardation: differences in cognitive and adaptive skills

The study concerns the specific cognitive and adaptive skills of persons dually diagnosed with mental retardation (MR) and comorbid pathologies, as schizophrenia, personality and mood disorders, pervasive developmental disorders, epilepsy and ADHD. The sample was composed of 182 subjects, diagnosed as mild or moderate MR level, age range from 6 years 8 months to 50 years 2 months, mean age 17.1 (standard deviation 7.9). All the subjects were inpatients in a specialized structure for the diagnosis and the treatment of MR. The instruments of the study were Wechsler Intelligence Scale (WAIS-R or WISC-R according to the chronological age of subjects) and Vineland Adaptive Behavior Scale (VABS). Results confirm that comorbidity is a factor differentiating among mentally retarded subjects. Both verbal processes requiring memory retrieval and visuo-spatial processes are involved as differentiating features. ADHD strongly increases the impairment of cognitive skills, while behavioral disorders are less damaging in MR performance. In adult samples, the differentiating role of comorbid syndromes in MR individuals is reduced for cognitive skills, and limited to some basic verbal abilities, more impaired in mood disorder, less in schizophrenic disorder. The areas of adaptation and socialization, motor and daily living skills, are impaired more in generalized development disturbances than in comorbid schizophrenic and personality and mood disorders. An accurate psychological assessment of dual diagnoses is useful in detecting the specific underlying processes differentiating the comorbid syndromes, and in planning an appropriate rehabilitative treatment.

Interactions between seizure frequency, psychopathology, and severity of intellectual disability in a population with epilepsy and a learning disability

Despite observations associating lower IQ and psychopathology in epilepsy, the possible differential effects of varying severity of learning (intellectual) disability (LD) on the manifestation of psychopathology in people with LD and epilepsy have not been clarified. In this study of retrospectively collected data describing the epilepsy, learning disability, and psychopathology of 175 patients with epilepsy and LD over a 3-month period, we observed that 65 patients had no recent seizures, whereas 110 had experienced at least one seizure in the preceding 3 months. We found that depression and psychoses were more common in those with no seizures in the preceding 3 months, but that which of these psychiatric states was manifest was related to the severity of LD. Psychosis rates were higher in those with mild LD, whereas depression rates were higher in those with severe LD.

Epilepsy, intellectual disability, and living environment: a critical review

Epilepsy occurs at a higher incidence and is more prevalent in people with an intellectual disability than in the general population. Nonetheless, we have insufficient knowledge of the extra needs of people with epilepsy and intellectual disability, of their families, and of the living environment. The lack of information about specific needs of the living environment may, in particular, be important. A Medline search revealed that scant attention has been paid to the specific needs for patients with epilepsy and intellectual disability, and only a few studies have focused specifically on this topic. The majority of studies have been focused on medical treatment issues and the organization and availability of health and social services. There is an indication that people with epilepsy and intellectual disability lack skills training appropriate to their intellectual potential. And although several reviews have emphasized the need for information on living environment and quality of life, we did not find such studies in our search.

Development of a measure to assess the impact of epilepsy on people with an intellectual disability: the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C)

BACKGROUND

Epilepsy is common in people with intellectual disability, yet clinicians and researchers seldom obtain information directly from the client. The development and preliminary validation of a novel measure for use with people with mild to moderate intellectual disabilities is described.

METHODS

Focus group methods (6 groups; 24 participants) identified issues of concern, and qualitative analysis (NUD*IST) was applied to derive items and themes for a draft scale. Psychometric scale development techniques were then used in a pilot study and subsequent field-testing to investigate validity and reliability (n = 46).

RESULTS

A total of 148 issues of concern was reduced initially to 52 and then to 42 items using these methods. The derived scale comprised sub-scales reflecting (1) concerns about having seizures; (2) about injury; (3) about issues during; and (4) after seizures; (5) about medication; (6) about what people think; and (7) about daily life. Cronbach alpha for the Glasgow Epilepsy Outcome Scale - Client version (GEOS-C) was 0.92, and ranged from 0.64-0.81 for the sub-scales. Relatively weak associations (r <or= 0.40), between client and family carer, staff carer or clinician views, suggests that proxy reports are not good predictors of how people with epilepsy themselves are feeling. Preliminary validation suggests that the GEOS-C can discriminate on variables of clinical importance.

CONCLUSIONS

The GEOS-C complements existing GEOS measures, can be completed in 5-15 min depending upon the level of support required, and may provide a valuable clinical and research tool. Further validational work and appraisal of sensitivity are required.