Issues in the taxonomy of psychopathology in mental retardation

Neuropsychiatric consultation in mentally retarded patients: a clinical report

The present study describes the results of neuropsychiatric consultations in 70 institutionalized mentally retarded patients. On the basis of their major complaint, patients were assigned to eight overlapping categories. Diagnoses of a certain probability were established during multidisciplinary consensus meetings and classification was achieved according to ICD-10 criteria. In ten patients mental retardation was related to a specific syndrome; seizures or somatic comorbidity were present in 40 patients. The most frequent psychiatric diagnoses were: unspecified bipolar affective disorder (n = 14), depressive disorder (n = 6), impulse control disorder (n = 12), cycloid, transient, or schizoaffective psychotic disorder (n = 14), and (atypical) autism (n = 7). Recent history revealed a high occurrence of serious side effects of psychotropics or pharmacokinetic interactions. Appropriate pharmacological intervention resulted in an amelioration of the behavioural condition in about half of the patients. It is emphasized that psychiatric disorders frequently present with an atypical psychopathology and that stress- and anxiety-related disorders are most probably underdiagnosed.

Differences in profiles of emotional behavioral problems across instruments in verbal versus minimally verbal children with autism spectrum disorder

There has been increasing attention to the assessment of minimally verbal (MV) children with autism spectrum disorder (ASD). Previous research has begun to examine the relationship between verbal abilities and emotional and behavioral problems (EBP). The current study compared parent-reported EBP in children of differing language levels on two instruments commonly used in ASD research and clinical practice, the Child Behavior Checklist (CBCL) and Aberrant Behavior Checklist (ABC). The study consisted of 1,937 6-18 years old children with ASD from the Simons Simplex Collection. Children were divided into three language groups, by ADOS module (Module 1 = MV, 2 = phrase speech (PS), and 3 = verbally fluent (VF)) and then compared on CBCL and ABC subscales. The ABC and CBCL showed different patterns of elevations across the language groups. MV children were reported to have more impairment than VF children on the ABC irritability, lethargy, and hyperactivity scales. Children with less language (MV and PS) exhibited less impairment on the CBCL internalizing domain than VF children, but did not differ on the externalizing domain. Post hoc comparisons showed that internalizing differences were driven by fewer children with less language exhibiting clinically elevated anxious/depressed scores compared to VF children. The present study underscores the significance of considering language when assessing EBP. Results have implications for the psychiatric screening of children with ASD, particularly those with language impairments. Researchers should exercise caution when applying EBP instruments designed for use with different populations and purposes to broad samples of children. Autism Res 2019, 12: 1367-1375. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Some emotional and behavioral problem (EBP) scales include items that may be inappropriate for children with ASD and limited language. The present study found that there was a tendency for children with language impairment to have lower internalizing scores on the Child Behavior Checklist, but higher scores lethargy and irritability scores on the Aberrant Behavior Checklist, relative to verbally fluent children. This suggests that each of these instruments may underestimate EBPs in certain subsets of children.

Classification of psychiatric disorders in childhood and adolescence: building castles in the sand?

A classification system can benefit disturbed children enormously by bringing to bear a wealth of knowledge and experience. This can make all the difference between an inadequate consultation and a precise formulation of the nature and extent of a child's difficulties, their cause, the likely outcome and a realistic treatment plan. However, inappropriate application of a diagnostic label that has little validity could do more harm than good, and classification systems can be misused. This paper discusses, with examples, issues particular to childhood and adolescence that diagnostic systems need to address if they are to be useful. It considers different solutions applied by the two most widely used schemes, theInternational Classification of Diseases(ICD–10; World Heath Organization, 1992) and theDiagnostic and Statistical Manual of Mental Disorders(DSM–IV; American Psychiatric Association, 1994). Finally, the types of criteria used to validate categories are discussed.

ICD-10 and alternative diagnostic criteria for childhood autism among children with intellectual disability

OBJECTIVES

The diagnosis of Childhood Autism (CA) among children with Intellectual Disability (ID) based on clinical criteria validated for populations with average intelligence compromises it's diagnostic accuracy in this special population. This study documents the diagnostic accuracy of ICD-10 and alternative criteria for CA in ID population.

METHODS

Consensus clinical diagnosis of autism made by a multi-disciplinary team as the reference data were extracted from the case notes and psychological tests details by two trainee psychologists, and ICD-10 based clinical diagnosis, demographics, ID, CA related data documented independently of the psychiatrist. The appropriate statistical analyses were completed.

RESULTS

Repetitive behaviors formed the most common symptom cluster. The high internal consistency (κ = 0.75) among the three groups of ICD-10 symptoms indicate their usefulness in the diagnosis of CA among children with ID, but significantly more children with ID failed to meet the ICD-10 criteria for CA. The fourth alternative criteria had the highest concordance with the reference standard (100%) and the first alternative criteria had the highest agreement with the reference standard (κ = 0.88) in identifying CA among ID. The diagnostic accuracy of all the alternative criteria was significantly better than that of ICD-10 with the first alternative criteria having the best diagnostic accuracy (Sn = 98%; Sp = 100%; PPV = 1; NPV =0.83) closest to the reference standard.

CONCLUSIONS

The symptom clusters in ICD-10 for CA should be retained, however reorganising the diagnostic criteria is required for diagnosing CA accurately among children with ID. The first alternative criteria can significantly improve the case identifying ability and diagnostic accuracy altering there by the epidemiological data on Childhood Autism among children with Intellectual Disability.

The longitudinal course of attention deficit/hyperactivity disorder in velo-cardio-facial syndrome

OBJECTIVE

To evaluate predictors of persistence of attention deficit/hyperactivity disorder (ADHD) in a large sample of children with velo-cardio-facial syndrome (VCFS) with and without ADHD followed prospectively into adolescence.

STUDY DESIGN

Children with VCFS with (n = 37) and without (n = 35) ADHD who were on average 11 years old at the baseline assessment and 15 years old at the follow-up assessment were comprehensively assessed with structured diagnostic interviews and assessments of behavioral, cognitive, social, school, and family functioning. Control participants both with and without ADHD were also followed prospectively.

RESULTS

In adolescence, 65% of children with VCFS continued to have findings consistent with ADHD. Childhood predictors of persistence were higher rates of familial ADHD, having childhood depression, having higher levels of hyperactivity, and a larger number of intrusion errors on a verbal list learning test at baseline. Approximately 15% of children with VCFS who did not have ADHD at Time 1 met diagnostic criteria for ADHD at Time 2. All of these children had subthreshold ADHD symptoms at Time 1.

CONCLUSIONS

These findings prospectively confirm that persistence of ADHD into adolescence in VCFS is predicted by childhood variables that have been previously documented in the non-VCFS ADHD literature.

Prevalence of Depression and Dementia among Adults with Developmental Disabilities in Manitoba, Canada

Study Objective. To estimate and compare the prevalence of dementia and depression among adults with and without developmental disabilities (DDs). Methods. We linked data from several provincial administrative databases to identify persons with DDs. We matched cases with DD with persons without DD as to sex, age, and place of residence. We estimated the prevalence of dementia and depression and compared the two groups using the Generalized Estimating Equations (GEEs) technique. Results. The estimated prevalence of depression and dementia among younger adults (20-54) and older adults (50+) with DD was significantly higher than the estimated rates for the matched non-DD group (Depression: younger adults: RR = 2.96 (95% CI 2.59-3.39); older adults: RR = 2.65 (95% CI 1.84-3.81)), (Dementia: younger adults: RR = 4.01 (95% CI 2.72-5.92); older adults: RR = 4.80 (95% CI 2.48-9.31)). Conclusion. Significant disparities exist in mental health between persons with and without DDs.

Comorbidity of intellectual disability and mental disorder in children and adolescents: a systematic review

BACKGROUND

Mental disorder and intellectual disability each accounts for substantial burden of disease. However, the extent of this co-occurrence varies substantially between reports. We sought to determine whether studies in children and/or adolescents with acceptably rigorous methods can be distinguished from existing reports, and whether key risk factors could be ascertained.

METHOD

Published studies investigating the prevalence of mental disorders in children and/or adolescents with intellectual disability were reviewed.

RESULTS

Nine studies with acceptable methods were identified, 4 which compared the prevalence of mental disorder in populations of those with and without intellectual disability, and a further 5 studies that estimated the rates of mental disorder in those with intellectual disability were identified. Collectively, these studies demonstrate rates of comorbidity for children and adolescents between 30 and 50% with a relative risk of mental disorder associated with intellectual disability ranging from 2.8-4.5. The risks for this comorbidity associated with age, gender, severity of intellectual disability, and socioeconomic status remain uncertain.

CONCLUSIONS

Appreciation of this comorbidity needs to be a fundamental component of both mental health and intellectual disability services.

Attachment behaviour towards support staff in young people with intellectual disabilities: associations with challenging behaviour

BACKGROUND

Attachment research has shown the importance of attachment behaviour for the prevention of dysregulated behaviour due to emotional distress. The support of an attachment figure may be especially important for people with intellectual disability (ID), because they are less adept in dealing with stressful situations on their own. Our purpose was to examine the role of support staff as targets of attachment behaviour for young people with ID by testing the hypothesis that young people who more often engage in attachment interactions with group care staff are less at risk for challenging behaviours. The study design included professional caregivers' report of young persons' attachment behaviour across different relationships to address the relationship-specific nature of attachment behaviour in a group care context.

METHODS

Support staff rated attachment behaviour of 156 young participants with moderate to severe ID who were attending a group care setting. For each participant, we asked two members of the classroom support staff to fill out the Secure Base Safe Haven Observation list. One of them also rated challenging behaviour (Abberant Behavior Checklist).

RESULTS

Young people who showed more secure attachment behaviour towards professional caregivers were less irritable, less lethargic and less stereotypic in their behaviour, even if we controlled for developmental age and Autism Spectrum Disorders. Two results point in the direction of relationship-specific attachment behaviour: the absence of high consistency in a person's attachment behaviour towards two different caregivers and the independent contribution of each of these relationships to explaining differences in lethargy and stereotypies. A certain preference in attachment behaviour towards specific caregivers was not associated with challenging behaviour.

CONCLUSIONS

Findings suggest that attachment behaviour may be part of young persons' adaptation to the stresses and challenges of group care. Furthermore, adaptation may be determined by the integration of relationships with support staff, because each relationship with a care staff member bears uniquely on challenging behaviour.

Development of the Children's Scale of Hostility and Aggression: Reactive/Proactive (C-SHARP)

Whereas some scales exist for assessing aggression in typically developing children, they do not give a detailed analysis, and none is available for populations with developmental disabilities (DD). Parents of 365 children with DD completed the Children's Scale of Hostility and Aggression: Reactive/Proactive (C-SHARP), which surveys the severity of aggressive and hostile behaviors (Problem Scale) in addition to their proactive or reactive qualities (the Provocation Scale). Factor analysis yielded a 5-factor solution: I. Verbal Aggression (12 items), II. Bullying (12 items), III. Covert Aggression (11 items), IV. Hostility (9 items), and V. Physical Aggression (8 items). Coefficient alpha ranged from moderate (0.74, Physical Aggression) to high (0.92, Verbal Aggression). General validity was supported by expected differences between age and gender groups. Preliminary normative data were presented. The C-SHARP appears to be a promising tool for assessing aggression and hostility in children with DD.

Correlated and coupled within-person change in emotional and behavioral disturbance in individuals with intellectual disability

Individual change and variation in emotional/behavioral disturbance in children and adolescents with intellectual disability has received little empirical investigation. Based on 11 years of longitudinal data from the Australian Child to Adult Development Study, we report associations among individual differences in level, rate of change, and occasion-specific variation across subscales of the Developmental Behavior Checklist (DBC) with 506 participants who had intellectual disability and were ages 5 to 19 years at study entry. Correlations among the five DBC subscales ranged from .43 to .66 for level, .43 to .88 for rate of change, and .31 to .61 for occasion-specific variation, with the highest correlations observed consistently between disruptive, self-absorbed, and communication disturbance behaviors. These interdependencies among dimensions of emotional/behavioral disturbance provide insight into the developmental dynamics of psychopathology from childhood through young adulthood.

Best clinical and research practice in adults with an intellectual disability

Though the prevalence of epilepsies is substantially higher in people with intellectual disability (ID) compared with the general population, little is known of the psychosocial burden of epilepsy and adjustment and their respective determinants in this important population. In most modern societies, adult life with an ID is characterized by diminished self-determination, autonomous function, and life choices. These factors alone are known to be critically linked to the individual's overall quality of life. The task is to identify additional burdens attributable to coexisting epilepsy. This article addresses the significance, for people with ID who have epilepsy, of the many different factors, including seizure or epilepsy-related parameters, antiepileptic medication, coexisting motor and sensory impairments, and psychopathological and behavioral disorders, that can impact their quality of life. Discussion also covers the methodological difficulties in published studies, and, finally, proposals are outlined for future research in this field.

Validation of the mood and anxiety semi-structured (MASS) interview for patients with intellectual disabilities

BACKGROUND

When assessing people with intellectual disabilities (ID), using the DSM-IV-TR can be challenging. Frequently, significant clinical data must be obtained from interviews with key informants. A new semi-structured interview tool was developed including behavioural descriptions of each DSM-IV-TR symptom criterion for a number of mood and anxiety disorders. A goal was to provide mental health clinicians with an instrument easy to use in clinical practice that would increase reliable identification of diagnostically important mood and anxiety symptoms. This is especially important given the fact that many experts believe these 'internalizing' clinical syndromes may often be missed in this population, because of characteristic limitations in expressive language skills.

METHOD

To establish validity, the Mood and Anxiety Semi-structured (MASS) Interview-derived diagnoses were compared with clinical DSM-IV diagnoses derived from an extensive inpatient evaluation and classifications based on the Hamilton Depression Rating Scale for 93 psychiatric inpatients served on a specialized unit for people with ID and major mental health disorders.

RESULTS

Agreement with the MASS Interview was high yielding significant kappa coefficients ranging from 0.42 to 0.78.

CONCLUSIONS

The MASS Interview, a semi-structured interview containing behavioural descriptions of DSM-IV symptom criteria, shows promise as a potentially helpful tool in the psychiatric diagnostic evaluation of persons with ID and limited expressive language skills, in the detection of mood and anxiety disorders. The tool also yields a wide breadth of clinical information and is easy for mental health clinicians to use.

Dimensions of behavior of toddlers entering early intervention: Child and family correlates

This study examined the nature and correlates of the behavioral characteristics of a nationally representative sample of 1612 toddlers 18-31 months of age entering Part C early intervention services in the U.S. Factor analysis of 15 items describing child behavior collected as part of an extensive telephone interview of parents yielded four dimensions of behavior: difficult behaviors, lack of persistence, distractible, and withdrawn. Demographic and personal characteristics of the child and family were found to be related to the four behavioral dimensions. Parent reports of behavior of toddlers with fair or poor health or those with communication difficulties were less positive for all behavioral dimensions, suggesting the development of toddler behavioral characteristics is influencing or being influenced by other facets of development.

Psychische Störungen bei behinderten Kindern und Jugendlichen - Übersicht und Schlussfolgerungen für die Psychodiagnostik

Zusammenfassung: Es wird eine Übersicht über die Studien zur Prävalenz psychischer Störungen bei Hörschädigung, Blindheit, körperlicher oder intellektueller Behinderung gegeben. Neben Entwicklungseinschränkungen in Folge von organischen oder genetischen Bedingungen tragen Belastungen der Eltern-Kind-Beziehung und der Entwicklung sozialer Kompetenzen sowie der sozialen Partizipation zu einem deutlich erhöhten Risiko für die Ausbildung emotionaler oder sozialer Störungen bei. Probleme der psychopathologischen Beurteilung sowie der Differenzierung zwischen Auswirkungen der Behinderung und psychischer Störung werden diskutiert und Schlussfolgerungen für die Praxis gezogen.

Behavioural equivalents of anxiety in children with fragile X syndrome: parent and teacher report

BACKGROUND

Identifying many of the diagnostic criteria for anxiety and depression in individuals with intellectual disability (ID) can be challenging because they may be unable to recognize and communicate their emotional experiences accurately. The purpose of this study is to identify behavioural equivalents of anxiety in children with fragile X syndrome (FXS), the leading inherited cause of ID.

METHODS

Parents and teachers of 43 children (aged 6-14 years) with full mutation FXS completed two standardized questionnaires on children's problem behaviour and psychiatric symptoms. Items from the questionnaires thought to be possible behavioural equivalents of anxiety were identified and grouped into four domains: Avoidance Behaviours - Confrontational; Avoidance Behaviours - Non-confrontational; Anxiety Continuum Behaviours; and Behavioural Dysregulation. The mean rating for the four groups of items was used to predict the children's status for exhibiting significant problems with anxiety as defined by the Diagnostic and Statistical Manual of Mental Disorders-oriented Anxiety Subscale from the problem behaviour scale.

RESULTS

The predictor variables classified 81% (parent rating) and 86% (teacher rating) of the children correctly. Avoidance Behaviours - Confrontational and Avoidance Behaviours - Non-confrontational (teacher rating) and Anxiety Continuum Behaviours (parent and teacher rating) made unique contributions to the models.

CONCLUSIONS

Children who are unable to identify and communicate that they worry about general day-to-day events may exhibit more observable behaviours resembling active and passive avoidance (e.g. arguing, avoiding difficult tasks, staring off) or have specific phobias and compulsions. These findings suggest that there are behavioural equivalents for anxiety disorder in children with FXS and, more generally, support the notion of behavioural equivalents in ID.

Psychopathology in tuberous sclerosis: an overview and findings in a population-based sample of adults with tuberous sclerosis

BACKGROUND

Tuberous sclerosis (TS) is a multi- system disorder with complex genetics. The neurodevelopmental manifestations of TS are responsible for considerable morbidity. The prevalence of epilepsy and intellectual disabilities among individuals with TS have been well described. Ours is the first study that explores the prevalence and pattern of psychopathology in a population-based sample of adults with TS.

METHODS

Sixty subjects were identified through a capture-recapture analysis of TS. Information was gathered as to seizure history, cognitive functioning (WISC-III) and psychopathology (SADS-L, SAPPA). Lifetime psychopathology was categorized according to Research Diagnostic Criteria. The overall pattern of mental illness (MI) was examined as well as how this varied with IQ and seizure history.

RESULTS

Twenty-four (40.0%) subjects had a history of MI. The most common diagnosis was that of an affective disorder [18 (30.0%)], the majority of which were major depressive episodes. Alcoholism [4 (6.7%)] and anxiety disorders [3 (5.0%)] were the next most common diagnoses. Two (3.3%) subjects had had a tic disorder. Only one individual had a diagnosis of schizophrenia. MI was found in 75.0% of those with a history of epilepsy and 37.5% of those without epilepsy. MI was significantly more prevalent in those with a full-scale IQ above 70.

CONCLUSIONS

A significant proportion of adult with TS experience MI. MI was significantly more [corrected] prevalent in subjects with a full-scale IQ above 70. Reasons for such a finding are explored, and related methodological considerations for future research outlined.

Is ADHD a valid disorder in children with intellectual delays?

To assess the validity of ADHD in children with mental retardation, we applied Robins and Guze's [Robins, E., and Guze, S.B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126, 983-987.] criteria for determining the validity of a psychiatric disorder. We review the literature describing clinical correlates, family history, treatment response, laboratory studies, course, and outcome of children with ADHD and mental retardation. Although clearly an area in need of further research, there is preliminary evidence to suggest that ADHD is a valid psychiatric condition in children with mental retardation. Nevertheless, without knowing the base rates of ADHD symptoms in the mental retardation population, the positive predictive power and negative predictive power of ADHD symptoms in this population remain an open question. In addition to assessment of base rate symptoms, future research should consider what diagnostic algorithm may best be applied to the diagnosis of ADHD in mental retardation.

Preschool children with and without developmental delay: behaviour problems, parents' optimism and well-being

BACKGROUND

Children with intellectual disability are at heightened risk for behaviour problems, and these are known to increase parenting stress. This study explored the relation of behaviour problems to less child-related domains of parent well-being (depression and marital adjustment), as well as the moderating effect of a personality trait, dispositional optimism.

METHOD

Participating children (N = 214) were classified as developmentally delayed, borderline, or nondelayed. Mothers' and fathers' well-being and child behaviour problems were assessed at child ages 3 and 4 years.

RESULTS

Parents of delayed and nondelayed preschoolers generally did not differ on depression or marital adjustment, but child behaviour problems were strongly related to scores on both measures. Optimism moderated this relationship, primarily for mothers. When child behaviour problems were high, mothers who were less optimistic reported lower scores on measures of well-being than did mothers who were more optimistic.

CONCLUSIONS

Interventions for parents that aim to enhance both parenting skills and psychological well-being should be available in preschool. It may be beneficial for such programmes to focus not only on behaviour management strategies aimed at child behaviour change, but also on parents' belief systems, with the aim of increasing dispositional optimism.

Pharmacotherapy of disruptive behavior and item changes on a standardized rating scale: pooled analysis of risperidone effects in children with subaverage IQ

BACKGROUND

Disruptive behavior disorders (DBDs), excluding attention deficit/hyperactivity disorder (ADHD), are characterized by a repetitive pattern of antisocial, aggressive, and defiant behavior involving major violations of age-appropriate norms, resulting in significant functional impairment. Risperidone is licensed for the treatment of DBDs in children, adolescents, and adults in several countries. The aim of this study was to determine the effect of risperidone in a clinical setting on the symptom items of the Nisonger Child Behavior Rating Form (N-CBRF), used for the assessment of DBD patients.

METHOD

Data from two 6-week, randomized, double-blind, placebo-controlled trials of risperidone oral solution (0.02-0.06 mg/kg/day) in children with DBDs and subaverage IQ (mild, moderate mental retardation and borderline IQ) were pooled for analysis.

RESULTS

Risperidone produced improvement in both the Social Competence and the Problem Behavior N-CBRF subscales. Risperidone reduced symptoms in the Problem Behavior subscales (e.g., Conduct Problem, Insecure/Anxious) but also improved positive behaviors on the Social Competence subscales. Unlike most problem-behavior items, certain items reflecting "Affective insecurity" (e.g., shy, timid; clings to adults; crying, tearful episodes) failed to improve. This was also true of social disinterest and certain rituals. No items showed any worsening of symptoms with active medication.

CONCLUSION

Whereas most categories of problem behavior improved with risperidone, items reflecting "affective insecurity" and some infrequently endorsed items were unaffected in these children with DBDs and subaverage IQ. These data may provide a more refined knowledge of risperidone's therapeutic effects in such children.

Psychosocial Theories of Depression for Individuals With Intellectual and Developmental Disabilities: A Historicist Perspective

The mental health care system has historically marginalized individuals with intellectual and developmental disabilities (I/DD). Until the mid-1980s, many clinicians doubted that individuals with I/DD were capable of depression (Sovner & Pary, 1993). Although it is now generally accepted that individuals with I/DD do have depression, they may not be treated or may be inappropriately treated (Matson et al., 2000). A historicist perspective takes into account the effect of marginalization on science and practice. Depression has both biological and psychosocial aspects. Key groups of theories regarding the psychosocial aspects of depression include psychodynamic/psychoanalytic, behavioral, cognitive, and ecological/interpersonal theories (Clark, Beck, & Alford, 1999; Joiner, Coyne, & Blalock, 1999). The application of psychosocial theories of depression to individuals with I/DD continues to reflect their marginalization and oppression. Behavioral theories of depression are limited in their conceptions for research, identification, and treatment of depression but continue to be used widely with individuals with I/DD. Cognitive theories of depression are widely used in research and treatment of depression in the general population, but have limited usage among individuals with I/DD. Interpersonal theories of depression are used in the general population and have many benefits, but are only now being investigated for use with individuals with I/DD. In this article, theories of depression as applied to individuals with I/DD are discussed from a historicist perspective.

Psychiatric disorders in adolescents with developmental disabilities: longitudinal data on diagnostic disagreement in 150 clients

The current paper describes the prevalence of psychiatric diagnoses in a large sample (n = 150) of adolescents with developmental disabilities who were hospitalized for inpatient psychiatric treatment. Differential diagnoses made during their inpatient stay in a specialty unit for the assessment and treatment of dually diagnosed adolescents are presented and contrasted with longitudinal/historical data on these same patients' diagnoses prior to admission. Results indicate that these individuals received a wide spectrum of diagnoses during their adolescent years. The paper offers indirect support that correctly diagnosing psychiatric conditions is often challenging in adolescents with developmental disabilities. Factors related to diagnostic complexity and misdiagnoses (false positives and false negatives) are discussed. Longitudinal data on psychotropic medication usage for these individuals are also presented.

Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) and psychiatric phenotypes

BACKGROUND

The concept of behavioural phenotypes is reviewed, with emphasis on the need to research reasons for heterogeneity.

METHODS/RESULTS

The classification of emotional, behavioural, linguistic and cognitive abnormalities associated with genetic disorders may be improved through the use of the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation.

CONCLUSIONS

Examples of such abnormalities are discussed, showing how more accurate descriptions can result in improved diagnosis and treatment.

Psychiatric diagnosis, intellectual disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD)

BACKGROUND

Classification of psychopathology using operationalized diagnostic criteria is one component of psychiatric assessment. Previous literature has demonstrated that there are limitations in the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual-IV (DSM-IV) when used with adults with intellectual disabilities.

METHODS

A literature search using Medline, PsychLIT and hand searching of key journals identified the existing literature, which was reviewed by the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) Development Working Group. Key findings are integrated into this paper. This, together with expert consensus led to the development of DC-LD, a new psychiatric classificatory system devised specifically for use with adults with intellectual disabilities. The new diagnostic criteria and classification within DC-LD were piloted with 52 field investigators drawing on 709 clinical cases. Validity of DC-LD classification was measured by comparison between the criteria providing DC-LD diagnosis and the gold standard of learning disabilities psychiatric assessment.

RESULTS

In 96.3% of cases, the DC-LD diagnosis was fully concordant with that of clinical opinion. The few discrepancies related to level of detail.

CONCLUSION

DC-LD accommodates the pathoplastic effect of intellectual disabilities on psychopathology. Its use will hopefully improve clinical practice and facilitate research, but further work to determine its usefulness and limitations is required.

Intellectual disabilities, depressive episode, diagnostic criteria and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD)

BACKGROUND

Depressive episode is one of the most common types of psychiatric illness that occurs in adults with intellectual disabilities.

METHODS

A comprehensive literature search was undertaken using Medline, PsychLIT and hand-searching of key journals. This paper reviews the evidence and integrates findings, to report how evidence relates to the development of the new Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation[DC-LD] depressive episode criteria.

RESULTS

This area is better researched than many others, providing evidence on clinical symptomatology and presentation. In view of the lack of utility of standard diagnostic criteria developed for use with the general population, and set within the historical context, there are clearly identified reasons for the introduction of DC-LD. The depressive episode category has been informed by the evidence, and field trials showed excellent validity compared with the gold standard of learning disabilities psychiatric assessment.

CONCLUSIONS

The DC-LD depressive episode category may improve clinical diagnosis and facilitate research. Its usefulness and limitations are yet to be determined in detail.

Beyond the disability: recognizing mental health issues among persons with intellectual and developmental disabilities

Current societal changes mean increased possibilities for individuals with I/DD to participate in work, family, and community life. However, as individuals with I/DD have at least the same prevalence of mental health disorders as the general population and possibly an increased susceptibility to some mental health disorders, their ability to participate in work, housing, and social opportunities is hampered. It is important to improve nursing education about the specific issues of mental health care of individuals with I/DD. An important area for nursing research and education are improved clinical and practice guidelines. Research on medications and other therapies in mental health care of individuals with I/DD is limited and has methodological limitations. Nursing education and training are holistic, and nursing has the potential of positive impact on practice, education, and research that will improve the mental health care of individuals with I/DD.

Challenging behaviour: a challenge to change

People with intellectual disability often exhibit severe behavioural problems. Treatment of these problems is frequently very difficult. In The Netherlands, parents, institutes, schools and others can request the services of an independent advisory team with a pool of professionals who have experience with individuals who exhibit challenging behaviour. In this article the methods of the team will be described using a 24-year-old man as an example. The process took almost 7 years. Finally, this man, who had been living full time in one room in total isolation from the rest of the world, fulfilled his heart's desire--visiting the UK by Hovercraft.

Assessment of anxiety and depression in adolescents with mental retardation

This report examines the concurrent validity of different informant and self-report assessment instruments of psychopathology, both general and specific for anxiety and/or depression, in referred mentally retarded adolescents with a depressive and anxiety disorders, according to DSM IV criteria. A consecutive, unselected sample of 50 mildly and moderate mentally retarded adolescents (29 males and 21 females, aged 11.8 to 18 years, mean age 15.1) were assessed using standardized assessment techniques: Psychopathology Instrument for Mentally Retarded Adults (PIMRA) (informant version) (total score, affective and anxiety subscales), Child Behavior Checklist (CBCL) (informant version) (total score, internalizing and externalizing scores, anxiety-depression scale), Zung Self-Rating Depression Scale and Zung Self-Rating Anxiety Scale. Patterns of correlation among measures were calculated. PIMRA and CBCL total scores were closely intercorrelated. Internalizing and externalizing scores of CBCL were not intercorrelated, but they both correlated with CBCL and PIMRA total scores. Anxiety measures were positively correlated; they correlated with PIMRA and CBCL total scores, as well as with the internalizing score of CBCL. Depression measures were not correlated; their correlation with more general measures of psychopathology was weak. Clinical implications of these findings are discussed.

The psychopathological phenotype of velo-cardio-facial syndrome

Velo-cardio-facial syndrome (VCFS) is mostly associated with deletions of chromosome 22q11, and is thought to be characterized by an increased frequency of major psychiatric disorders. Sixteen patients adults with VCFS and psychiatric symptoms were evaluated using a semi-structured investigation of history, symptoms, signs and behaviour. All available data were used in consensus meetings to obtain a classifiable diagnostic category. In contrast to other reports, no categorical diagnosis could be established. Instead, a quite specific psychological, behavioural and psychopathological constellation emerged that should most adequately be denominated as a VCFS-psychiatric syndrome. It is concluded that VCFS is associated with a specific psychopathological syndrome.

Psychometric properties of the revised Developmental Behaviour Checklist scales in Dutch children with intellectual disability

The present study assessed the reliability and validity of the revised scales of the Developmental Behaviour Checklist (DBC) in a Dutch sample of children with intellectual disability (ID). The psychometric properties of the parent and teacher versions of the DBC were assessed in various subsamples derived from a sample of 1057 Dutch children (age range=6-18 years) with ID or borderline intellectual functioning. Good test-retest reliability was shown both for the parent and teacher versions. Moderate inter-parent agreement and high one-year stability was found for the scale scores. Construct validity was satisfactory, although limited by high informant variance. The DBC scales showed good criterion-related validity, as indicated by significant mean differences between referred and non-referred children, and between children with and without a corresponding DSM-IV diagnosis. The reliability and validity of the revised DBC scales are satisfactory, and the checklist is recommended for clinical and research purposes.

Pharmacotherapy of disorders in mental retardation

This is a review of pharmacotherapy in children and adolescents with mental retardation from the perspective of DSM and ICD disorders. The existing research is reviewed in young people with mental retardation but, when data are lacking, we examined the literature from adults with mental retardation and from typically-developing children. The literature is discussed for each of the following disorders: ADHD, anxiety disorders, bipolar disorder, conduct disorder, depression, enuresis, schizophrenia, self injury, and tics and movement disorders. With the possible exception of ADHD, there is a woeful lack of empirical data on most of these disorders in young people with mental retardation. Clinicians will often be forced to extrapolate from data on adults having mental retardation and from typically-developing children. The best policy is probably to treat such patients cautiously, while gathering data on the effects of such therapy in the hopes of beginning a data base.

Seizure disorders in people with intellectual disability: an analysis of differences in social functioning, adaptive functioning and maladaptive behaviours

The present study is an investigation into the effects of seizure disorders/epilepsy on psychopathology, social functioning, adaptive functioning and maladaptive behaviours using a sample of 353 people diagnosed with a seizure disorder, and either severe or profound intellectual disability. People with a diagnosis of seizure disorder were found to have significantly less social and adaptive skills when compared to developmentally disabled controls with no seizure disorder diagnosis. Additionally, patterns of maladaptive behaviours were identified for individuals with seizure disorders and found to be similar to those found in people without seizure activity. The implications of the present findings are discussed.

Observations on the use of the ICD-10 guide for mental retardation

In acknowledgement of the challenges posed by the diagnosis of mental disorders in people with intellectual disability (ID), the World Health Organization (WHO) has recently published a multi-axial guide to assist clinicians in applying the ICD-10 to this group of people. The WHO has invited users to review of the ICD-10 Guide for Mental Retardation. In order to review its usefulness in clinical practice, the present authors used the Guide together with the ICD-10 in the psychiatric assessment of 106 young people with ID, and emotional and behavioural problems of varying severity. Strengths and weaknesses in the utility of the Guide were noted. As a result of the clinical audit process, the present authors identified a number of inconsistencies, significant gaps and assertions unsupported by the available literature in the Guide. They also noted aspects of the ICD-10 itself which are problematic when applied to people with ID. Despite these limitations, the Guide is a valuable first attempt to establish a standardized structure for multi-axial diagnosis in this population. A number of suggestions for major changes and refinements to future editions are made, and a strategy for development of research to establish validity and reliability is proposed.

Utility of modified DCR-10 criteria in the diagnosis of depression associated with intellectual disability

A retrospective study of 11 inpatients with intellectual disability who received antidepressant treatment over a 12-month period indicated the utility of minor modifications to DCR-10 criteria in the diagnosis of depressive illness. The modifications were made by adding items found in previous research to be behavioural equivalents of depression in people with severe intellectual disability to DCR-10 criteria. The time course of symptom response to antidepressant treatment was documented. All 11 patients had a remission of depressive symptoms, as described by the modified criteria, within 5 weeks of starting antidepressant treatment

Dysthymic disorder in adolescents with intellectual disability

The present report examines the clinical features of dysthymic disorder in a sample of adolescents with mild intellectual disability (ID). Frequency of symptoms, comorbidity, agreement between reports of subjects and parents, comparison between the frequency of depressive symptoms in subjects with ID and in two different groups of normal IQ dysthymic subjects (aged 7-11, 11 and 12-18 years) are described. The sample consisted of 12 subjects (age range = 12-25.6 years; mean age = 16.3 years) screened from unselected consecutively referred patients with mild ID. All the subjects were comprehensively diagnosed with a structured diagnostic interview, the Kiddie-Schedule for Affective Disorder and Schizophrenia (K-SADS), according to DSM-IV criteria. A symptomatic profile in the group with ID showed that intrapsychic and cognitive symptoms, such as depressed mood, irritability, pathological guilt and low self-image, were frequently reported in people with ID. Parents were less aware of depressed mood, but they reported high rates of low self-esteem; the agreement between the depressive reports of ID subjects and their parents was higher than in previous findings in normal IQ children. The symptomatic profile of subjects with ID was more comparable to that of prepubertal dysthymic children than that of dysthymic adolescents, but more significant are the analogies between dysthymic disorder in ID and normal IQ subjects. High rates of comorbidity with generalized anxiety disorder were evident in the group with ID. According to the present data, dysthymic disorder can be diagnosed in adolescents with mild ID. The K-SADS clinical interview seems to be a reliable instrument for the diagnosis and clinical definition of depressive symptomatology in this special population.

Diagnosis and dimensional pharmacotherapy of challenging behaviour in mental retardation

Classical psychiatric taxonomy appears to be increasingly inadequate in the diagnostic process of mentally retarded subjects. The reasons for this are the atypical presentation of classical psychiatric disorders, special diagnostic entities like cycloid psychosis and unstable mood disorder and the existence of so-called behavioural phenotypes related to syndromes with a known genetic etiology. In addition, disturbed behaviour may be the result of somatic or neurologic comorbidity and induced to adverse drug events.

Reliability of the assessment of dual diagnosis (ADD)

Emotional and behavioral problems are a major source of additional handicap for children, adolescents, and adults with mental retardation. To address these problems, clinicians need psychometrically sound instruments for assessing psychopathology in individuals with mental retardation. The initial psychometric properties of the Assessment for Dual Diagnosis (ADD), a new scale designed to screen for psychopathology in individuals with mild and moderate mental retardation, was examined. The authors conducted a preliminary evaluation of the interrater and test-retest reliability of the ADD. It was determined that the ADD had high stability across raters and high stability over time. In addition, good internal consistency was established with coefficient alpha. Potential uses for the scale and directions for future research are discussed.

The effect of stereotypies on adaptive skills as assessed with the DASH-II and Vineland Adaptive Behavior Scales

The relationship of the Stereotypy subscale of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II) to adaptive functioning was investigated. Differences in adaptive skills measured with the Vineland Adaptive Behavior Scales (VABS) for individuals scoring at or above the cutoff of the Stereotypy scale and below the cutoff of the scale were analyzed. Individuals with high stereotypy scores had significantly lower VABS scores. Implications of these findings for assessment and treatment are discussed.

The psychiatric care of people with intellectual disabilities: the perceptions of consultant psychiatrists in Victoria

OBJECTIVE

This study was undertaken to establish the perceptions of psychiatrists regarding the care of people of intellectual disabilities.

METHOD

A 28-item self-administered questionnaire was developed, piloted and sent on two occasions to 467 psychiatrists who receive the newsletter of the Victorian branch of the Royal Australian and New Zealand College of Psychiatrists. The questionnaire incorporated a Likert scale to document the opinions of the respondents.

RESULTS

A response rate of 51.1% was achieved. The respondents indicated that, in their opinion, people with intellectual disabilities receive a poor standard of care in the inpatient and community setting. To improve this situation, the following strategies were recommended: the development of improved liaison between services; improved training for all personnel who provide services to people with intellectual disabilities; the development of greater resources; and support for professionals working in the area. The study also indicates that there is a core group of very interested psychiatrists who are currently practising and that people with intellectual disabilities are accessing private psychiatric services. In addition, the results suggest that diagnostic overshadowing is not a major barrier to psychiatric assessment, and that disorders which were presumed to be commonly overlooked by doctors (such as depression) are in fact frequently being diagnosed.

CONCLUSIONS

Despite some positive findings, the majority of psychiatrists who responded held major concerns about the situation of people with intellectual disabilities. To improve the care provided to these people, it is recommended that these concerns are addressed by the psychiatric profession and responsible government departments in conjunction with university departments of psychiatry.

Case study: risperidone treatment of children and adolescents with developmental disorders

In a clinical trial, 20 children and adolescents with developmental disorders (age range 8 through 17 years) refractory to previous psychotropic treatments were administered the atypical neuroleptic risperidone (dose range 1.5 to 10 mg/day). In a follow-up period ranging from 8 to 15 months, risperidone demonstrated clinical efficacy in 13 children. Twelve patients were free of side effects and two had minor ones. Three patients had marked weight increase, and galactorrhea developed in two adolescent girls. In this open study, risperidone was associated with clinical improvement. However, controlled studies are needed to determine its relative efficacy and safety in this special population.

Population prevalence of psychopathology in children and adolescents with intellectual disability: II. Epidemiological findings

This paper reports findings from an epidemiologically derived population in a multicentre study in NSW, Australia. The design of this study is described in the accompanying paper. Those with mild intellectual disability (ID) were likely to have been underascertained, but identification and participation rates for those with more severe ID were high. The study found that in the regions surveyed 40.7% of those with ID and aged between 4 and 18 could be classified as having severe emotional and behaviour disorder or as being psychiatrically disordered. The profoundly intellectually handicapped had lower levels of disturbance overall compared with those with mild, moderate and severe ID. The level of ID affected scores on a number of behavioural dimensions, with disruptive and antisocial behaviours more prominent in the mild ID group, and 'self-absorbed' and 'autistic' behaviours more prominent in those with severe ID. Age and sex did not affect prevalence, a finding that is in contrast to that found in general child psychopathology. The study found that fewer than 10% of children with intellectual disability and major psychiatric disorder had received specialist assistance.

The Developmental Behavior Checklist: the development and validation of an instrument to assess behavioral and emotional disturbance in children and adolescents with mental retardation

Describes the development and validation of the Developmental Behavior Checklist (DBC), a standardized instrument completed by lay informants to assess behavioral and emotional disturbance in children and adolescents with mental retardation (MR). Items describing common behavioral and emotional problems in this population were generated by extracting descriptions from 664 case files of children and adolescents with behavior disorders seen at a specialist developmental assessment service over 12 years. These items were reduced to a set of 96 items administered to a sample of 1,093 children and adolescents with mental retardation and then submitted to a principal components analysis. Six interpretable and partly validated subscales were obtained which explained 36% of the total variance and had satisfactory internal consistency. Interrater and test-retest agreement were satisfactory for both total scale score and for scores on each of the subscales. Good evidence of concurrent validity was provided by substantial positive correlations between total scores on the DBC completed by lay informants and the ratings of experienced psychiatrists based upon interviews and scores on two standardized instruments that must be completed by health professionals. The discriminative validity of the total score as assessed by area under the ROC curve was excellent (92%). Standardized norms for the DBC are derived from an epidemiological study of behavior problems in children and adolescents with mental retardation undertaken in two Australian States. Norms are available for the mild, moderate, severe, and profound MR groups and for the MR population as a whole.