Psychopathology in young people with intellectual disability

Change in autism symptoms and maladaptive behaviors in adolescence and adulthood: the role of positive family processes

Little is known about outcomes for individuals with autism spectrum disorders (ASD) into adulthood. Several characteristics of individuals with ASD predict long-term outcomes, and the family environment may also play a role. The present study uses a prospective, longitudinal design to describe and predict trajectories of autism symptoms and maladaptive behaviors over 8.5 years in a large, community-based sample of adolescents and adults with ASD. Overall, autism symptoms and maladaptive behaviors were observed to improve over the study period. Above and beyond the adult's gender, age, and level of intellectual disability, greater improvements were associated with higher levels of maternal praise (based on maternal speech samples) and higher quality mother-child relationships. Implications for future research and intervention are discussed.

Psychopathology and cognitive performance in individuals with membrane-associated guanylate kinase mutations: a functional network phenotyping study

BACKGROUND

Rare pathogenic variants in membrane-associated guanylate kinase (MAGUK) genes cause intellectual disability (ID) and have recently been associated with neuropsychiatric risk in the non-ID population. However, it is not known whether risk for psychiatric symptoms amongst individuals with ID due to MAGUK gene mutations is higher than expected for the degree of general intellectual impairment, nor whether specific cognitive differences are associated with disruption to this gene functional network.

METHODS

This study addresses these two questions via behavioural questionnaires and cognitive testing, applying quantitative methods previously validated in populations with ID. We compared males with X-linked ID caused by mutations in three MAGUK genes (PAK3, DLG3, OPHN1; n = 9) to males with ID caused by mutations in other X chromosome genes (n = 17). Non-parametric and parametric analyses were applied as appropriate to data.

RESULTS

Groups did not differ in age, global cognitive impairment, adaptive function or epilepsy prevalence. However, individuals with MAGUK gene mutations demonstrated significantly higher psychopathology risks, comprising elevated total problem behaviours, prominent hyperactivity and elevated scores on an autism screening checklist. Despite these overt difficulties, individuals in the MAGUK group performed more accurately than expected for age and intelligence quotient (IQ) on computerised tests of visual attention, convergent with mouse models of MAGUK loss-of-function.

CONCLUSIONS

Our findings support a role for MAGUK genes in influencing cognitive parameters relevant to psychiatric risk. In addition to establishing clear patterns of impairment for this group, our findings highlight the importance of careful phenotyping after genetic diagnosis, showing that gene functional network disruptions can be associated with specific psychopathological risks and cognitive differences within the context of ID.

Environmental risk factors associated with the persistence of conduct difficulties in children with intellectual disabilities and autistic spectrum disorders

We investigated the association between exposure to environmental risks in early childhood and the prevalence and persistence of conduct difficulties (CD) in children with intellectual disability (ID) who did not have autistic spectrum disorder (ASD), children with ASD and typically developing (TD) children. Results indicated that: (1) exposure to risk was associated with elevated prevalence of CD at age three and, for TD children and children with ID, increased risk of CD persisting to ages five and seven; (2) at all levels of risk, children with ASD were more likely to show persistent CD than other children; (3) children with ID were no more likely to show persistent CD than TD children at low levels of exposure to environmental risk.

The effectiveness of Stepping Stones Triple P parenting support in parents of children with borderline to mild intellectual disability and psychosocial problems: a randomized controlled trial

BACKGROUND

Children with borderline to mild intellectual disability (BMID) have been shown to be at increased risk for psychosocial problems. The presence of these psychosocial problems leads to parenting stress. Stepping Stones Triple P (SSTP) is a parenting support program to support parents with children with BMID and psychosocial problems. The aim of this study was to evaluate the effectiveness of SSTP compared to Care as Usual (CAU) in reducing psychosocial problems in children with BMID.

METHOD

We conducted a randomized controlled trial in the Northern provinces of the Netherlands. Parents of children aged 5 to 12 with borderline (IQ 70 to 85) or mild (IQ 70 to 50) ID and psychosocial problems were invited. Psychosocial problems were identified using the Strengths and Difficulties Questionnaire (SDQ) parent report (≥14). Measurements were assessed before the intervention (T0), immediately after the intervention (T1) and after a follow-up of six months (T2). SSTP takes 8 to 10 individual sessions of 40-90 minutes, provided over 10 to 12 weeks. CAU concerned any service, except SSTP. Primary outcomes were the child's psychosocial problems (SDQ parent and teacher forms and the Eyberg Child Behavior Inventory, ECBI). Secondary outcomes were parenting stress (Parenting Stress Index, PSI) and parenting skills (Alabama Parenting Questionnaire, APQ).

RESULTS

In total 209 parents of children aged 5 to 12 with BMID were allocated blindly to either SSTP (n =111) or CAU (n =98). In the intention to treat analyses, SSTP achieved no significantly better effect than CAU for the SDQ parent report, the ECBI and the APQ on the short- and long- term. In the short term, SSTP was significantly more effective than CAU for the SDQ teacher report (B = -2.25, 95% CI -3.79 to -0.71) and the PSI (B = -7.06, 95% CI -12.11 to -2.01). For both SDQ teacher report and PSI, there was no statistically significant effect in the long term. Dropout from SSTP was considerable (49%), with the effects being solely found in the adherent SSTP subgroup.

CONCLUSIONS

SSTP had some short-term advantages over CAU, but not in the longer term.

TRIAL REGISTRATION

Dutch Trial Register NTR2624. Registered 26 November 2010.

Parental and practitioner perspectives on raising an adolescent with a disability: a focus group study

PURPOSE

To examine the challenges faced by parents of teenagers with a disability to determine the need for a tailored parenting program for this population.

METHOD

Focus groups were conducted with six parents and nine practitioners with experience supporting parents of teenagers with a disability.

RESULTS

An inductive thematic analysis revealed close agreement between parents and practitioners and eight understandable and relevant themes. The results indicated that parents have difficulty planning and facilitating transitions for their adolescent children, managing behavioural problems due to these problems being unique to this developmental period and because some of the parenting strategies that were useful when their children were younger were no longer applicable. High levels of stress and feelings of grief were also described.

CONCLUSIONS

These results suggest that parents of adolescents with a developmental disability could benefit from a parenting program and that an existing evidence-based parenting program should be modified. Implications for program design for this population are discussed.

IMPLICATIONS FOR REHABILITATION

Parents have difficulty supporting their teenagers' behaviour. Some parenting strategies that were useful for young children are no longer applicable. Parents may benefit from a parenting program tailored for teenagers.

Day occupation is associated with psychopathology for adolescents and young adults with Down syndrome

BACKGROUND

Young adults with Down syndrome experience increased rates of emotional and behavioural problems compared with the general population. Most adolescents with Down syndrome living in Western Australia participate in sheltered employment as their main day occupation. Relationship between day occupation and changes in behaviour has not been examined. Therefore, the aim of this research was to explore any relationship between post school day occupations and changes in the young person's behaviour.

METHODS

The Down syndrome Needs Opinion Wishes database was used for case ascertainment of young adults aged 15 to 32 years with Down syndrome. Families of 118 young people in this population-based database completed questionnaires in 2004, 2009 and 2011. The questionnaires addressed both young person characteristics such as age, gender, presence of impairments, behaviour, functioning in activities of daily living, and family characteristics such as income and family functioning. Post-school day occupations in which the young people were participating included open and sheltered employment, training and day recreation programs. Change in behaviour of young adults who remained in the same post-school day occupation from 2009 to 2011 (n = 103) were examined in a linear regression model adjusting for confounding variables including age, gender, prior functioning and behaviour in 2004 and family income.

RESULTS

In comparison to those young adults attending open employment from 2009 to 2011, those attending day recreation programs were reported to experience worsening in behaviour both in the unadjusted (effect size -0.14, 95% CI -0.24, -0.05) and adjusted models (effect size -0.15, 95% CI -0.29, -0.01).

CONCLUSIONS

We found that the behaviour of those participating in open employment improved compared to those attending other day occupations. Further examination of the direction of this association is required.

Impact of county disadvantage on behavior problems among US children with cognitive delay

OBJECTIVES

We investigated relationships among cognitive delay, community factors, and behavior problems over 2 years in early childhood with a national sample of US families.

METHODS

Data were from 3 waves of the Early Childhood Longitudinal Study, Birth Cohort (2001-2005; n = 7650). We defined cognitive delay as the lowest 10% of mental scores from the Bayley Short Form-Research Edition, administered at 9 and 24 months. At 24 months, we classified children as typically developing or as having resolved, newly developed, or persistent cognitive delays. Behavior was measured at age 4 years with the Preschool and Kindergarten Behavior Scales (range = 0-36). Community factors included perceived neighborhood safety and an index of county disadvantage.

RESULTS

Behavior scores at age 4 years (mean = 12.4; SD = 4.9) were higher among children with resolved (Β = 0.70; SE = 0.20), newly developed (Β = 1.92; SE = 0.25), and persistent (Β = 2.96; SE = 0.41) cognitive delays than for typically developing children. The interaction between county disadvantage and cognitive delay status was statistically significant (P < .01), suggesting that county disadvantage was particularly detrimental for children with persistent delays.

CONCLUSIONS

The community context may provide an opportunity for public health interventions to improve the behavioral health of children with cognitive delays.

Cognitive delay and behavior problems prior to school age

OBJECTIVE

To investigate the relationship between cognitive delay (CD) and behavior problems between ages 9 months and 5 years, while adjusting for covariates related to CD.

METHODS

Data were from 4 waves of the Early Childhood Longitudinal Study, Birth Cohort (n = 8000). Children were classified as typically developing (TD) or as having resolved, newly developed, or persistent CD between 9 and 24 months, based on scores from the Bayley Short Form-Research Edition below or above the 10th percentile. Child behavior was measured by using the Infant/Toddler Symptom Checklist (ages 9 and 24 months) and the Preschool and Kindergarten Behavior Scales (ages 4 and 5 years); children in the top 10th percentile were considered to have a behavior problem. Hierarchical linear modeling estimated the effect of CD status on children's behavioral trajectories, adjusted for confounders.

RESULTS

CD resolved for 80.3% of children between 9 and 24 months. Behavior problems at 24 months were detected in 19.3%, 21.8%, and 35.5% of children with resolved, newly developed, and persistent CD, respectively, versus 13.0% of TD children. Behavior problems increased among children with CD over time, and more so among children with persistent CD. By age 5, children with persistent CD had behavior scores moderately (0.59 SD) higher than TD children.

CONCLUSIONS

Behavior problems among children with CD are slightly higher at 9 months, clearly evident by 24 months, and increase as children move toward school age. Efforts to promote the earliest identification, evaluation, and service referral may be necessary to improve outcomes for these children.

Relationship between family quality of life and day occupations of young people with Down syndrome

PURPOSE

To explore relationships between family quality of life, day occupations and activities of daily living (ADL) of young persons with Down syndrome.

METHOD

Data were collected from 150 families with a young person with Down syndrome aged 16-30 years participating in the Down syndrome "Needs Opinions Wishes" database. Data described the young person's characteristics (including functional abilities, behaviour and day occupations) and family characteristics (including income, family and community supports and quality of life).

RESULTS

Compared to families of young people attending open employment, families of young people participating in sheltered employment tended to report poorer family quality of life, after adjusting for personal characteristics, behaviour and income (coeff -6.78, 95 % CI -14.38, 0.81). Family supports reduced this relationship (coeff -6.00, 95 % CI -12.76, 0.76). Families of young people with greater functioning in ADL reported better family quality of life regardless of personal and environmental factors (coeff 0.45, 95 % CI 0.05, 0.85) and inclusion of family factors such as family supports reduced this association (coeff 0.29, 95 % CI -0.10, 0.67).

CONCLUSIONS

Participation of young people with Down syndrome in open employment may positively influence family quality of life. Services that facilitate functioning in ADL and assist the families in accessing suitable family supports have the potential to positively influence family quality of life.

Outcomes in young adulthood: are we achieving community participation and inclusion?

BACKGROUND

Despite recognition of the importance of integrated community living and support, there is evidence that parents remain the primary caregivers of young adults with intellectual disability (ID). In addition, employment rates remain low in this population. This study aimed to investigate the changes in living arrangements and participation in daytime activities over time in a community population of young people with ID.

METHOD

The sample consisted of 536 participants aged 4.0-18.9 years at Wave 1, followed up at Wave 5 when aged 20.5-37.6 years. Information was collected on their living arrangements and daytime activities at both time points, along with living skills and information on community social inclusion at Wave 5. For parents still caring for their adult child with ID, information was also collected on parental ratings of their own mental and physical health, and their satisfaction with the long-term care arrangements for their adult child.

RESULTS

A significant proportion of young people were still living with their parents at Wave 5. A greater proportion of those with a severe-profound degree of ID were living in residential care. Parents caring for their adult child reported high levels of mental health problems and dissatisfaction with the long-term care arrangements for their child. A small proportion of young people were in paid employment, and the majority was engaged in structured activities provided for those with an ID. Over one-third of the sample participated in a structured daytime activity for 10 or fewer hours per week, and 7% were not engaged in any structured daytime activity.

CONCLUSIONS

These results suggest that adequate provision of accommodation and employment services for young adults with an ID is lacking. In many cases the responsibility of care continues to reside with parents as their children transition from childhood to adulthood. Greater attention is needed to address these issues and facilitate social inclusion and integration for young people with ID.

The association between behavioural and emotional problems and age in adults with Down syndrome without dementia: Examining a wide spectrum of behavioural and emotional problems

The literature on the association between behavioural and emotional problems and ageing in adults with Down syndrome (DS) without dementia is limited and has generally not reported on a wide range of behavioural and emotional problems. This research aimed to extend the field by examining the associations between age and a wide spectrum of behavioural and emotional problems in adults with DS without dementia. A preliminary analysis of the association between potential covariates and behavioural and emotional problems was also undertaken. Parents and caregivers completed a questionnaire on behavioural and emotional problems for 53 adults with DS aged between 16 and 56 years. Twenty-eight adults with DS and their caregivers were part of a longitudinal sample, which provided two time points of data approximately four years apart. Additionally, 25 participants with DS and their caregivers were from a cross sectional sample, which provided one time point of data. Random effects regression analyses were used to examine the patterns in item scores for behavioural and emotional problems associated with age. No significant associations between age and the range or severity of any behavioural and emotional items were found. This suggested a more positive pattern for ageing adults with DS than has been previously described. Given that behavioural and emotional problems were not associated with age, investigation into other factors that may be associated with the behavioural and emotional difficulties for adults with DS is discussed.

Longitudinal design considerations to optimize power to detect variances and covariances among rates of change: simulation results based on actual longitudinal studies

We investigated the power to detect variances and covariances in rates of change in the context of existing longitudinal studies using linear bivariate growth curve models. Power was estimated by means of Monte Carlo simulations. Our findings show that typical longitudinal study designs have substantial power to detect both variances and covariances among rates of change in a variety of cognitive, physical functioning, and mental health outcomes. We performed simulations to investigate the interplay among number and spacing of occasions, total duration of the study, effect size, and error variance on power and required sample size. The relation between growth rate reliability (GRR) and effect size to the sample size required to detect power greater than or equal to .80 was nonlinear, with rapidly decreasing sample sizes needed as GRR increases. The results presented here stand in contrast to previous simulation results and recommendations (Hertzog, Lindenberger, Ghisletta, & von Oertzen, 2006; Hertzog, von Oertzen, Ghisletta, & Lindenberger, 2008; von Oertzen, Ghisletta, & Lindenberger, 2010), which are limited due to confounds between study length and number of waves, error variance with growth curve reliability, and parameter values that are largely out of bounds of actual study values. Power to detect change is generally low in the early phases (i.e., first years) of longitudinal studies but can substantially increase if the design is optimized. We recommend additional assessments, including embedded intensive measurement designs, to improve power in the early phases of long-term longitudinal studies.

Training of child and adolescent psychiatry fellows in autism and intellectual disability

Patients with autism spectrum disorders and intellectual disability can be clinically complex and often have limited access to psychiatric care. Because little is known about post-graduate clinical education in autism spectrum disorder and intellectual disability, we surveyed training directors of child and adolescent psychiatry fellowship programs. On average, child and adolescent psychiatry directors reported lectures of 3 and 4 h per year in autism spectrum disorder and intellectual disability, respectively. Training directors commonly reported that trainees see 1-5 patients with autism spectrum disorder or intellectual disability per year for outpatient pharmacological management and inpatient treatment. Overall, 43% of directors endorsed the need for additional resources for training in autism spectrum disorder and intellectual disability, which, coupled with low didactic and clinical exposure, suggests that current training is inadequate.

Co-occurring mental disorder and intellectual disability in a large sample of Australian prisoners

OBJECTIVE

Prisoners with intellectual disability who have a coexisting mental health issue often have unmet health needs and are more likely to reoffend than those with intellectual disability alone. The aims of this study were to estimate the prevalence of co-occurring mental disorder among prisoners with intellectual disability and to explore the association between intellectual disability and mental disorder.

METHODS

Cross-sectional study of adult prisoners within 6 weeks of release from custody in seven prisons in Queensland, Australia between August 2008 and July 2010. Intellectual disability was assessed using a practical composite screening tool. Prisoners who scored <85 on the Hayes Ability Screening Index and reported either having attended a special school or having been diagnosed with intellectual disability were identified as having an intellectual disability. Mental health was assessed using self-reported psychiatric diagnoses, the Kessler Psychological Distress Scale (K-10), and the Mental Component Summary score of the Short-Form-36 health survey version 2. The association between intellectual disability and mental health was assessed using univariate and multivariate logistic regression.

RESULTS

Overall, 1279 prisoners completed the HASI: 316 (24%) scored below the recommended cut off for further diagnostic assessment of intellectual disability, 181 (14%) reported attending a special school, and 56 (4%) reported that they had been diagnosed with an intellectual disability. On our composite measure, 115 (9%) participants were identified as having an intellectual disability. Among prisoners with intellectual disability, the estimated lifetime and current prevalence of co-occurring mental disorders was 52.5% (95% CI 43.3-61.5) and 37.2% (95% CI 28.8-46.5), respectively. Of those with intellectual disability, 13.5% (95% CI 8.3-21.1) reported very high psychological distress, as measured by the K10. Prisoners with intellectual disability were significantly more likely than their non-disabled peers to report a current diagnosis of depression [adjusted odds ratio (AOR) 1.8, 95% CI 1.1-3.2] or substance dependence (AOR 3.7, 95% CI 1.6-8.4], after adjusting for potentially confounding variables. Prisoners with intellectual disability were also significantly more likely than their non-disabled peers to use antipsychotic medication (AOR 1.7, 95% CI 1.0-2.8).

CONCLUSIONS

Prisoners with an intellectual disability were more likely than their non-disabled peers to have elevated rates of psychiatric comorbidity and unmet treatment needs. There is a need for enhanced collaboration between specialist intellectual disability psychiatric services and mainstream prison mental health services, to ensure coordinated service delivery for this dually disadvantaged group.

A controlled clinical evaluation of the Parents Plus Children's Programme for parents of children aged 6-12 with mild intellectual disability in a school setting

The aim of this study was to evaluate the effectiveness of the parent training, Parents Plus Children's Programme (PPCP) as an intervention for parents of children with mild intellectual disabilities. Participants were parents of children, aged six to 12, attending a special school for children with mild general learning disability (n = 29). Minor programme adaptations were made. Pre and post-assessment included the Strengths and Difficulties Questionnaire, the Parenting Stress Index, the Kansas Parent Satisfaction Scale and parent identified personal and child-related goals. A significant reduction in clinical range scores for treatment group participants (n = 16) was observed. Conversely, clinical range scores for control group participants (n = 13) increased, or remained elevated. These preliminary results suggest that PPCP may be successfully delivered as a routine community-based intervention and aid to prevent and reduce behavioural problems, reduce parent stress and increase parent confidence and satisfaction. Further investigation of programme effectiveness for parents of children with developmental disability is warranted.

Psychometric evaluation of a Dutch version of the Mini PAS-ADD for assessing psychiatric disorders in adults with different levels of intellectual disability

BACKGROUND

People with intellectual disabilities (ID) have an increased vulnerability to develop psychiatric problems. Moreover, the early recognition and the accurate diagnosis of psychiatric disorders in the population of persons with ID are challenging.

METHOD

A Dutch version of the Mini PAS-ADD, which is a screening instrument for identification of mental health problems in people with ID, was evaluated in terms of internal consistency, interinformant reliability, item grouping and criterion validity based on a large-scale random sample (n = 377) and a clinical sample (n = 99) of adults with ID.

RESULTS

The Dutch version of the Mini PAS-ADD showed moderate internal consistency, and moderate concordance among informants. Both aspects of the reliability were comparable for different levels of ID. A factor analysis largely confirmed the scale structure. Concurrent validity with the Reiss Screen for Maladaptive Behavior was high for the Depression, Psychosis and Autism scale. The outcome of the criterion-validity analysis indicated high specificity. The sensitivity for specific psychiatric disorders by the corresponding scales was moderate, but the general sensitivity for the presence of psychopathology on the basis of any of the scales was satisfying.

CONCLUSIONS

The present research reconfirmed the use of the Mini PAS-ADD as a primary screening device for the identification of mental health problems among people with ID.

Competency based advanced training in Intellectual Disability Psychiatry: a NSW prototype

OBJECTIVE

This paper describes a competency based advanced training year in adult Intellectual Disability Psychiatry enabled through a partnership between disability and mental health sectors. This training experience could be viewed as a prototype for further specialised training schemes in Intellectual Disability Psychiatry, and has relevance for the implementation of competency based psychiatric training schemes in Australia.

CONCLUSIONS

The need for a specific training curriculum in Intellectual Disability Psychiatry is outlined with reference to epidemiological evidence and human rights. The formulation of the training programme and the training experience itself is described and evaluated. Conclusions on the implications of this experience for the future competency based training schemes are drawn. Building a skilled workforce is necessary to address the significant inequalities in mental health experienced by people with intellectual and developmental disabilities. A significant initial step for this would be the development of a specialised training curriculum. Service provision for this population is scattered across many disciplines and organisations with historically little mutual cooperation. Additionally, proposed competency-based training schemes stipulate that a medical expert develops a wide skill set across multiple domains. Thus, formal cross sector collaboration is fundamental for any competency based training scheme to be feasible.

The role of coping strategies in predicting change in parenting efficacy and depressive symptoms among mothers of adolescents with developmental disabilities

BACKGROUND

Parents of children with developmental disabilities (DD) face greater caregiving demands than parents of children without DD. There is considerable variability in parents' adjustment to raising a child with DD, however. In line with a strengths-based approach, this study explores coping strategies as potential mechanisms of resilience among mothers of adolescents with DD. This study examines the frequency with which mothers use various coping strategies and the extent to which those strategies moderate the relationship between adolescent behaviour problems and aspects of maternal well-being. Both positive and negative dimensions of well-being are explored, with maternal depressive symptoms and perceived parenting efficacy examined as outcomes cross-sectionally and longitudinally.

METHODS

The present study focuses on 92 mothers and their adolescents with DD. The adolescents had a wide range of diagnoses, all with continuing special needs. Data were collected from mothers through interviews and self-administered questionnaires when their adolescents were aged 15 and aged 18. A structured assessment of the adolescent was completed during home visits at age 15.

RESULTS

Mothers reported frequently using strategies of denial and planning but rarely using strategies of mental and behavioural disengagement to cope with recent stressful situations. Adolescent behaviour problems were found to contribute to greater symptoms of depression and lower feelings of parenting efficacy as well as increases in depressive symptoms over time. Mothers of sons, but not daughters, reported increases in parenting efficacy across their child's adolescent period. Above and beyond adolescent factors, several coping strategies emerged as significant predictors of mothers' symptoms of depression and perceived parenting efficacy. Moreover, use of Active Coping/Planning, Positive Reinterpretation/Growth, and Behavioural/Mental Disengagement as coping strategies moderated the impact of adolescent behaviour problems on maternal depressive symptoms.

CONCLUSIONS

This study extends previous findings by focusing on both positive and negative dimensions of parent well-being during their child's adolescent period. Adolescence can be a stressful time for parents, with typical developmental tasks entailing additional strains for parents of adolescents with DD. The present findings point to several coping strategies that may reduce the impact of challenging behaviours during this period on mothers' symptoms of depression and feelings of parenting efficacy. Certain coping strategies were found to exert a greater impact on maternal well-being for parents of adolescents with higher levels of behaviour problems, suggesting that interventions may benefit from an increased focus on this group of mothers with heightened caregiving demands.

Prevention and early intervention for behaviour problems in children with developmental disabilities

PURPOSE OF REVIEW

To review the recent evidence regarding early intervention and prevention studies for children with developmental disabilities and behaviour problems from 2011 to 2013. Recent advances in the field are discussed and important areas for future research are highlighted.

RECENT FINDINGS

Recent reviews and studies highlight the utility of antecedent interventions and skills training interventions for reducing behaviour problems. There is preliminary evidence for the effectiveness of parent training interventions when delivered in minimally sufficient formats or in clinical settings. Two recent studies have demonstrated the utility of behavioural interventions for children with genetic causes of disability.

SUMMARY

Various forms of behavioural and parent training interventions are effective at reducing the behaviour problems in children with developmental disabilities. However, research on prevention and early intervention continues to be relatively scarce. Further large-scale dissemination studies and effectiveness studies in clinical or applied settings are needed.

Stepping Stones Triple P-Positive Parenting Program for children with disability: a systematic review and meta-analysis

This systematic review and meta-analysis evaluated the treatment effects of a behavioral family intervention, Stepping Stones Triple P (SSTP) for parents of children with disabilities. SSTP is a system of five intervention levels of increasing intensity and narrowing population reach. Twelve studies, including a total of 659 families, met eligibility criteria. Studies needed to have evaluated SSTP, be written in English or German, contribute original data, and have sufficient data for analyses. No restrictions were placed on study design. A series of meta-analyses were performed for seven different outcome categories. Analyses were conducted on the combination of all four levels of SSTP for which evidence exists (Levels 2-5), and were also conducted separately for each level of SSTP. Significant moderate effect sizes were found for all levels of SSTP for reducing child problems, the primary outcome of interest. On secondary outcomes, significant overall effect sizes were found for parenting styles, parenting satisfaction and efficacy, parental adjustment, parental relationship, and observed child behaviors. No significant treatment effects were found for observed parenting behaviors. Moderator analyses showed no significant differences in effect sizes across the levels of SSTP intervention, with the exception of child observations. Risk of bias within and across studies was assessed. Analyses suggested that publication bias and selective reporting bias were not likely to have heavily influenced the findings. The overall evidence base supported the effectiveness of SSTP as an intervention for improving child and parent outcomes in families of children with disabilities. Limitations and future research directions are discussed.

Factor analysis of the self-report version of the strengths and difficulties questionnaire in a sample of children with intellectual disability

The rate of emotional and behavioural disturbance in children with intellectual disability (ID) is up to four times higher than that of their typically developing peers. It is important to identify these difficulties in children with ID as early as possible to prevent the chronic co-morbidity of ID and psychopathology. Children with ID have traditionally been assessed via proxy reporting, but appropriate and psychometrically rigorous instruments are needed so that children can report on their own emotions and behaviours. In this study, the factor structure of the self-report version of the Strengths and Difficulties Questionnaire (SDQ) was examined in a population of 128 children with ID (mean age=12 years). Exploratory and Confirmatory Factor Analysis showed a three factor model (comprising Positive Relationships, Negative Behaviour and Emotional Competence) to be a better measure than the original five factor SDQ model in this population.

Prevalence of negative life events and chronic adversities in European pre- and primary-school children: results from the IDEFICS study

Background

Children are not always recognized as being susceptible to stress, although childhood stressors may originate from multiple events in their everyday surroundings with negative effects on children’s health.

Methods

As there is a lack of large-scale, European prevalence data on childhood adversities, this study presents the prevalence of (1) negative life events and (2) familial and social adversities in 4637 European pre- and primary-school children (4–11 years old), using a parentally-reported questionnaire embedded in the IDEFICS project (‘Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS’).

Results

The following findings were observed: (1) Certain adversities occur only rarely, while others are very regular (i.e. parental divorce); (2) A large percentage of children is shielded from stressors, while a small group of children is exposed to multiple, accumulating adversities; (3) The prevalence of childhood adversity is influenced by geographical location (e.g. north versus south), age group and sex; (4) Childhood adversities are associated and co-occur, resulting in potential cumulative childhood stress.

Conclusions

This study demonstrated the importance of not only studying traumatic events but also of focusing on the early familial and social environment in childhood stress research and indicated the importance of recording or monitoring childhood adversities.

Service development for intellectual disability mental health: a human rights approach

BACKGROUND

People with intellectual disability (ID) experience higher rates of major mental disorders than their non-ID peers, but in many countries have difficulty accessing appropriate mental health services. The aim of this paper is to review the current state of mental health services for people with ID using Australia as a case example, and critically appraise whether such services currently meet the standards set by the Convention on the Rights of Persons with Disabilities.

METHODS

The literature regarding the current state of mental health services for people with ID was reviewed, with a particular focus on Australia.

RESULTS

The review highlighted a number of issues to be addressed to meet the mental health needs of people with ID to ensure that their human rights are upheld like those of all other citizens. Many of the barriers to service provision encountered in Australia are likely also to be relevant to other nations, including the culture of division between disability and mental health services, the inadequate training of both disability and mental health workers in ID mental health, and the lack of relevant epidemiological data. None of these barriers are insurmountable.

CONCLUSIONS

Recommendations are made for adopting a human rights-based approach towards the development and provision of mental health services for people with ID. These include improved policy with measurable outcomes, improved service access via clear referral pathways and the sharing of resources across disability and mental health services, and improved service delivery through training and education initiatives for both the mental health and disability workforce.

The mental health needs of children and adolescents with learning disabilities

PURPOSE OF REVIEW

To provide an update on the mental health needs of children and adolescents with learning disabilities, by examining salient studies published predominantly in the last 12-18 months.

RECENT FINDINGS

There have been further articles published supporting the findings of earlier landmark studies demonstrating an increased prevalence of mental health disorders in young people with learning disabilities. These articles suggest higher rates of comorbidity than were previously recognized. There are few published studies pertaining to the effectiveness of psychological and pharmacological treatments, although there is a recognition that the latter are more routinely and perhaps inappropriately administered. Antipsychotics are the most commonly prescribed group of medications and, despite a lack of evidence, continue to be prescribed more to address challenging behaviours rather than in the treatment of an identified psychiatric disorder. Reviews examining services and policies in other countries further highlight that the health and social care needs of individuals with learning disabilities are receiving more attention, with a shared vision that services should be inclusive and preferably community based.

SUMMARY

Although there is improved knowledge of the rates of mental health disorders in young people with learning disabilities, in clinical practice these mental health needs continue to be underrecognized and untreated.

Work-ability assessment in young adults with disabilities applying for disability benefits

PURPOSE

To investigate the impact of diagnosis, co-morbidity, secondary conditions (e.g. learning problems, subclinical mental and somatic complaints, addictions, and socio-emotional and behavioral problems) and problems in social context on work ability as assessed by Insurance Physicians (IPs) in young adults applying for a disability benefit.

METHOD

IPs of the Social Security Institute assessed young adults with disabilities (aged 15-27) applying for a disability benefit (n = 1755). Data were analyzed with multilevel ordinal regression techniques.

RESULTS

Primary diagnosis, co-morbidity and subclinical mental complaints were associated with IP-assessed work ability. Persons with mental health conditions as primary diagnosis were less likely to reach a higher work ability than persons with somatic diseases. Young adults with two or more co-morbid conditions and those with psychiatric or developmental co-morbidity were less likely to reach a higher work ability level than persons without co-morbidity. Young adults with subclinical mental complaints were half as likely to reach a higher IP-assessed work ability than young adults without this condition.

CONCLUSION

Primary diagnosis, type and number of co-morbid conditions and subclinical mental complaints are associated with IP-assessed work ability. Work-ability assessments among adolescents with disabilities applying for disability benefits still focus mainly on medical factors.

Prevalence of psychosomatic and emotional symptoms in European school-aged children and its relationship with childhood adversities: results from the IDEFICS study

The prevalence of childhood stress and psychosomatic and emotional symptoms (PES) has increased in parallel, indicating that adverse, stressful circumstances and PES in children might be associated. This study describes the prevalence of PES in European children, aged 4-11 years old, and examines the relationship among PES, negative life events (NLE) and familial or social adversities in the child's life. Parent-reported data on childhood adversities and PES was collected for 4,066 children from 8 European countries, who participated in the follow-up survey of IDEFICS (2009-2010), by means of the 'IDEFICS parental questionnaire'. A modified version of the 'Social Readjustment Rating Scale', the 'KINDL Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents' and the 'Strengths and Difficulties Questionnaire' were incorporated in this questionnaire, as well as questions on socio-demographics, family lifestyle and health of the child. Chi-square analyses were performed to investigate the prevalence of PES among survey centres, age groups and sex of the child. Odds ratios were calculated to examine the childhood adversity exposure between PES groups and logistic regression analyses were conducted to investigate: (a) the contribution of the number and (b) the specific types of experienced adversities on the occurrence of PES. 45.7% of the children experienced at least one PES, with low emotional well-being during the last week being most frequently reported (38.2%). No sex differences were shown for the prevalence of PES (P = 0.282), but prevalence proportions rose with increasing age (P < 0.001). Children with PES were more frequently exposed to childhood adversities compared to children without PES (e.g. 13.3 and 3.9% of peer problems and 25.4 and 17.4% of non-traditional family structure in the PES vs. no PES group, respectively, P < 0.001). An increasing number of adversities (regardless of their nature) was found to gradually amplify the risk for PES (OR = 2.85, 95% CI = 1.98-4.12 for a number of ≥3 NLE), indicating the effect of cumulative stress. Finally, a number of specified adversities were identified as apparent risk factors for the occurrence of PES, such as living in a non-traditional family structure (OR = 1.52, 95% CI = 1.30-1.79) or experiencing peer problems (OR = 3.55, 95% CI = 2.73-4.61). Childhood adversities were significantly related to PES prevalence, both quantitatively (i.e. the number of adversities) and qualitatively (i.e. the type of adversity). This study demonstrates the importance and the impact of the child's family and social context on the occurrence of PES in children younger than 12 years old.

Trajectory of behavior and emotional problems in autism

High rates of behavior and emotional problems have been consistently reported in children and adolescents with autism. Elevated rates of mental health problems have also been reported in adults with autism. Little is known, however, about the longitudinal development of behavior and emotional problems in autism. This study followed a cohort of children and adolescents over 18 years. Outcomes were evaluated in terms of behavior and emotional problems and autism symptomatology. The role of childhood factors (age, gender, IQ, behavior, and emotional problems) and the environment (socioeconomic disadvantage) were considered in terms of adult outcomes. Overall, improvements in comorbid behavior and emotional problems and autism symptomatology were observed. However, rates of comorbid behavior and emotional problems in adulthood remained high.

Scaling methods to measure psychopathology in persons with intellectual disabilities

Psychopathology prior to the last four decades was generally viewed as a set of problems and disorders that did not occur in persons with intellectual disabilities (ID). That notion now seems very antiquated. In no small part, a revolutionary development of scales worldwide has occurred for the assessment of emotional problems in persons with ID. The first standardized test to emerge was the Psychopathology Instrument for Mentally Retarded Adults (PIMRA) in 1984. Since that time, an impressive number of measures of general psychopathology have emerged for adults and children as well as for persons across the full range of levels of ID. The purpose of this review was to provide a description of available measures, to review papers published on these measures, and to discuss emerging trends in test development. The trends in this body of information for enhancing differential diagnosis of psychopathology in persons with ID are discussed.

The behavioral phenotype of Mowat-Wilson syndrome

Mowat-Wilson syndrome (MWS) is caused by a heterozygous mutation or deletion of the ZEB2 gene. It is characterized by a distinctive facial appearance in association with intellectual disability (ID) and variable other features including agenesis of the corpus callosum, seizures, congenital heart defects, microcephaly, short stature, hypotonia, and Hirschsprung disease. The current study investigated the behavioral phenotype of MWS. Parents and carers of 61 individuals with MWS completed the Developmental Behavior Checklist. Data were compared with those for individuals selected from an epidemiological sample of people with ID from other causes. The behaviors associated with MWS included a high rate of oral behaviors, an increased rate of repetitive behaviors, and an under-reaction to pain. Other aspects of the MWS behavioral phenotype are suggestive of a happy affect and sociable demeanor. Despite this, those with MWS displayed similarly high levels of behavioral problems as those with intellectual disabilities from other causes, with over 30% showing clinically significant levels of behavioral or emotional disturbance. These findings have the potential to expand our knowledge of the role of the ZEB2 gene during neurodevelopment. Furthermore, they are a foundation for informing interventions and management options to enhance the independence and quality of life for persons with MWS.

College students' conceptualizations of deficits involved in mild intellectual disability

Precedential rulings in recent capital murder trials may, in some cases, leave it up to a jury to determine whether or not an individual meets criteria for an intellectual disability (ID) and should be spared from the death penalty. Despite the potential for misconceptions about ID to bias decisions, few empirical studies have examined the public's conceptualizations of individuals with ID. This study sought to examine 890 college students' conceptualizations of the deficits involved in mild ID. Students were asked to respond to two online surveys about the cognitive and adaptive behavior deficits that people with mild ID may experience. While most students were correct about basic facts, such as ID is not contagious and not curable, there was no clear consensus regarding beliefs about individuals with ID getting married, having children, or engaging in other mainstream activities of adult living. Students' responses are examined in light of results of studies that identify and examine bona fide deficits and areas of successful mainstreaming among persons with ID. Implications of misconceptions are discussed.

Psychometric properties and norms of the German ABC-Community and PAS-ADD Checklist

AIM

The aim of the present study was to standardize and generate psychometric evidence of the German language versions of two well-established English language mental health instruments: the Aberrant Behavior Checklist-Community (ABC-C) and the Psychiatric Assessment Schedule for Adults with Developmental Disabilities (PAS-ADD) Checklist. New methods in this field were introduced: a simulation method for testing the factor structure and an exploration of long-term stability over two years.

METHODS

The checklists were both administered to a representative sample of 270 individuals with intellectual disability (ID) and, two years later in a second data collection, to 128 participants of the original sample. Principal component analysis and parallel analysis were performed. Reliability measures, long-term stability, subscale intercorrelations, as well as standardized norms were generated. Prevalence of mental health problems was examined.

RESULTS

Psychometric properties were mostly excellent, with long-term stability showing moderate to strong effects. The original factor structure of the ABC-C was replicated. PAS-ADD Checklist produced a similar, but still different structure compared with findings from the English language area. The overall prevalence rate of mental health problems in the sample was about 20%.

CONCLUSION

Considering the good results on the measured psychometric properties, the two checklists are recommended for the early detection of mental health problems in persons with ID.

Stepping Stones Triple P seminars for parents of a child with a disability: a randomized controlled trial

Parents of children with a developmental disability require tailored parenting support, as their families have special needs and are at risk of increased burden. The aim of this study was to evaluate the efficacy of the Stepping Stones Triple P seminars, a brief group intervention for parents of a child with a disability. There were two seminars that presented parenting strategies to improve both child behavior and parenting variables implicated in the development and maintenance of child problem behavior. Fifty-three parents participated in this randomized controlled trial. Each had a child, aged two to ten, with a disability. The results indicated significant reductions in child behavior problems, the use of dysfunctional parenting styles, and parental conflict reported by parents in the intervention group compared to a waitlist group. The results were maintained at 3-month follow-up and there was evidence of a sleeper effect for parenting confidence. This study demonstrated that the seminars provide a promising intervention for parents of children with a disability. Limitations and implications for future research are also discussed.

Preventing behavioural and emotional problems in children who have a developmental disability: a public health approach

Children with developmental disabilities are at substantially greater risk of developing emotional and behavioural problems compared to their typically developing peers. While the quality of parenting that children receive has a major effect on their development, empirically supported parenting programs reach relatively few parents. A recent trend in parenting intervention research has been the adoption of a public health approach to improve the quality of parenting at a population level. This has involved delivering parenting interventions on a large scale and in a cost-effective manner. Such trials have been demonstrated to reduce negative parenting practices, prevent child maltreatment, and reduce child behavioural and emotional problems. However, these trials have been restricted to parents of children who are developing typically. This paper explores the rational for the extension of a population health approach to parenting interventions for children with developmental disabilities. It is argued that a population-based implementation and evaluation trial of an empirically supported system of interventions is needed to determine whether this approach is viable and can have a positive impact on parents and their children in a disability context. The Stepping Stones Triple P--Positive Parenting Program is presented as an example of a parenting intervention that satisfies the requirements for such a trial. Tasks and challenges of such a trial are discussed.

[Psychopathology in youths with intellectual disabilities--prevalence and prevention]

A survey of epidemiological findings suggests a significantly increased level of emotional and behavioural problems in children and youth with intellectual disabilities. Some biological and social factors are presented which contribute to this elevated risk for psychopathology. Assessment and intervention planning needs to acknowledge genetic dispositions, and limitations of the capacity of information processing which characterise children with intellectual disabilities. Early intervention may help to prevent emotional and behavioural problems by supporting a positive parent-child relationship, increasing the parents' educational competence and assisting preschool teachers in supporting positive relationships with peers, and promoting social competence.

Gait adaptation during obstacle crossing reveals impairments in the visual control of locomotion in Williams syndrome

Recent evidence indicates that individuals with Williams syndrome (WS), a rare genetically based neurodevelopmental disorder, show abnormalities of parietal and cerebellar regions of the brain that may be involved in the visual control of locomotion. Here we examined whether parietal and cerebellar abnormalities contribute to deficits in spatiotemporal characteristics and foot placement variability during obstacle crossing in adults with WS, when compared with an IQ-matched group of adults with Down syndrome (DS) and typically developing adult controls. We used the GAITRite walkway to examine the spatiotemporal characteristics and foot placement variability relative to a small ground-based obstacle in the travel path. We found that adults with WS showed late adjustments to spatiotemporal gait characteristics alongside an exaggerated and more spatially constrained visual guidance of foot positioning in the final steps prior to stepping over the obstacle. In contrast, the adults with DS showed longer step duration and more variable step length and step duration during the crossing and recovery steps after the obstacle, suggestive of cerebellar dysfunction. Although the controls were able to reduce the variability of foot placement across the obstacle crossing trials, both the WS and DS groups did not become more consistent with practice. These findings indicate a less flexible and overly constrained visuomotor system in WS, which is consistent with more widespread and diffuse abnormalities in parietal and cerebellar regions.

The effectiveness of Stepping Stones Triple P: the design of a randomised controlled trial on a parenting programme regarding children with mild intellectual disability and psychosocial problems versus care as usual

BACKGROUND

Children with an intellectual disability are at increased risk of psychosocial problems. This leads to serious restrictions in the daily functioning of the children and to parental stress. Stepping Stones Triple P aims to prevent severe behavioural, emotional and developmental problems in children with a (intellectual) disability by enhancing parenting knowledge and skills, and the self-confidence of parents. This paper aims to describe the design of a study of the effectiveness of parenting counselling using Stepping Stones Triple P compared to Care as Usual.

METHODS/DESIGN

The effects of Stepping Stones Triple P will be studied in a Randomised Controlled Trial. Parents of children aged 5-12 years with an IQ of 50-85 will be recruited from schools. Prior to randomisation, parents complete a screening questionnaire about their child's psychosocial problems and their parenting skills. Subsequently, parents of children with increased levels of psychosocial problems (score on Strengths and Difficulties Questionnaire ≥ 14) will be invited to participate in the intervention study. After obtaining consent, parents will be randomised either to the experimental group (Stepping Stones Triple P) or to Care as Usual. The primary outcome is a change in the child's psychosocial problems according to parents and teachers. The secondary outcome is a change in parenting skills. Data will be collected before the start of the intervention, immediately after the intervention, and six months after.

DISCUSSION

This paper presents an outline of the background and design of a randomised controlled trial to investigate the effectiveness of Stepping Stones Triple P, which aims to decrease psychosocial problems in children with a mild intellectual disability. Stepping Stones Triple P seems promising, but evidence on its effectiveness for this population is still lacking. This study provides evidence about the effects of this intervention in a community-based population of children with a mild intellectual disability.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2624.

The longitudinal relationship between behavior and emotional disturbance in young people with intellectual disability and maternal mental health

Although elevated rates of parent psychosocial distress have been associated with child behavior and emotional problems, little is known about the nature of this relationship over time. This study followed an epidemiological cohort of children and adolescents over 11 years with 4 waves of data collection. Within this cohort, complete data were available on 238 mothers and their children. Behavior and emotional problems were assessed using the DBC, maternal mental health with the GHQ. Multivariate growth curve modelling was used to evaluate the commonality of individual change patterns. High levels of mental health problems were reported, which were stable over time. Higher scores on the DBC were associated with higher rates of mental health problems. Increases in child social relating problems were associated with increases mental health symptoms, particularly depression and anxiety.

Behavioural and emotional problems in people with severe and profound intellectual disability

BACKGROUND

People with severe and profound levels of intellectual disability (ID) are frequently examined as a single group in research. However, these two groups may be significantly different, particularly in the area of emotional and behavioural difficulties.

METHOD

The Developmental Behaviour Checklist (DBC) was completed by parents and caregivers of 107 people with severe ID and 22 people with profound ID at four time periods across 12 years. Regression analyses were used to examine trends in sub-scale scores across time and groups.

RESULTS

Significant differences between the groups of people with severe and profound ID were found. People with profound ID had significantly lower scores across all sub-scales except Social Relating. This was usually related to fewer items being selected as present for people with profound ID, as opposed to the scores being attributable to lower item severity scores.

CONCLUSIONS

There are significant differences between groups of people with severe and profound ID in scores on the DBC, indicating differences in behavioural and emotional problems. Caution should be exercised by researchers treating these two disparate groups as a single group, and by practitioners translating such findings into practice.

Cognitive-adaptive disabilities

Cognitive-adaptive disabilities (CADs) are not frequently seen in the general pediatric setting. Yet, given the high rates of comorbidity in that population, they commonly demand a lot of time and effort on the part of clinicians. One aspect of comorbidity is the degree to which psychiatric disorders occur in children, adolescents, and young adults with CADs. This article reviews the epidemiology, associated psychopathology, and pharmacologic treatment of selected CADs.

The mental health of young people with disabilities: impact of social conditions

BACKGROUND

Young people with disabilities have poorer mental health than their non-disabled peers. However, people with disabilities are more likely than others to experience financial hardship and low social support, both of which have been linked with poor mental health outcomes. This article explores the extent to which the relatively poor mental health of young people with disabilities is related to the social conditions in which they live.

METHODS

Secondary analysis was performed on Wave 6 (2006) of the survey of Household Income and Labour Dynamics in Australia (HILDA). This nationally representative sample included 3,392 young Australians, aged 15-29, of whom 475 reported having a long-term health condition, impairment or disability.

RESULTS

Young people with disabilities reported poorer mental health than their non-disabled peers. However, this relationship was moderated by both social adversity and social support, with minimal differences in mental health observed between the groups under conditions of high social support and low financial hardship.

DISCUSSION

The results suggest that disability represents a potential adversity that may be exacerbated or ameliorated by the effects of wealth/financial hardship and social support.

CONCLUSION

It may be possible to improve the mental health of disabled people by addressing their social exclusion.

Individual, life events, family and socio-economic factors associated with young people with intellectual disability and with and without behavioural/emotional problems

The aim of this study was to compare a range of individual, life events, family and socio-economic factors associated with young people with intellectual disabilities and with and without behavioural/emotional problems. Teachers in 16 schools in one region of the UK completed a postal questionnaire on 249 young people with intellectual disabilities aged between 11 and 19 years. There were two groups: 155 young people with behavioural/emotional issues, and 94 without. Using a binary logistic regression analysis, a number of individual, life events, family and socio-economic risk factors were found to be significantly associated with emotional/behavioural problems. The results are discussed alongside findings from other studies. The importance of a multidimensional assessment is highlighted, as well as the interdependent nature of the risk factors.