Learning disability

Risks Associated With Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review

BACKGROUND

The two most prevalent neurodevelopmental disorders-Attention Deficit Hyperactivity Disorder (ADHD) and Autism (ASD)-(ASD/ADHD) strongly impact individuals' functions. This is worsened when individuals are undiagnosed and risks such as increased imprisonments, depression or drug misuse are often observed. This systematic review synthesizes the risks associated with late/undiagnosed ASD/ADHD.

METHODS

Four databases were searched (Medline, Scopus, PsychInfor, and Embase). Published studies exploring the impact of undiagnosed ASD/ADHD were included. Exclusion criteria included, lack of diagnosis status, studies not solely on ASD or ADHD, gray literature and studies not in English. The findings were summarize through a narrative synthesis.

RESULTS

Seventeen studies were identified, 14 on ADHD and three on ASD. The narrative synthesis identified three main themes: (1) Health, (2) Offending behavior, and (3) Day-to-day impact. The risks highlighted a significant impact on mental wellbeing and social interactions, higher risks of substance abuse, accidents and offending behavior as well as lower levels of income and education.

DISCUSSION

The findings suggest that undiagnosed ASD/ADHD is linked to many risks and negative outcomes affecting individuals, their families, and the wider society. The restricted number of studies on ASD are a limitation to the generalization of these findings Implications for research and practice are discussed, highlighting the importance of screening and acknowledging the possibility of ASD/ADHD in many settings such as psychiatric and forensic.

How paediatricians investigate early developmental impairment in the UK: a qualitative descriptive study

Background

Early developmental impairment (EDI) is common and has many aetiologies and, therefore, potential investigations. There are several published guidelines recommending aetiological investigations, and paediatricians’ views of them varies. Little is known on the thought processes underlying clinical decisions in investigating EDI. This study aimed to describe the thought processes affecting clinical decisions on the investigation of EDI within a nationalised health care system.

Methods

A qualitative descriptive study using semi-structured qualitative interviews performed in person or via video link with paediatricians who see children with EDI in England. As part of the interview, a case study of a fictional disease, Cavorite deficiency, modelled on biotinidase deficiency, was given to participants with the cost of testing, incidence and likelihood it would respond to treatment. This allowed exploration of cost without encumbrance from predisposing views and training on the condition. Thematic analysis was performed by iterative approach. Where participants stated they wanted to redirect money from investigations to treatment, were that even possible, we asked which services they would like to be better funded in their area.

Results

Interviews were conducted with 14 consultant paediatricians: 9 Community / Neurodisability, 2 General paediatricians, and 3 Paediatric Neurologists. Two themes were identified: the value of an aetiological diagnosis to families and managing risk and probability when investigating EDI. The latter contained 4 subthemes: ‘circumspection’ involved blanket investigations chosen irrespective of phenotype and high regard for guidelines; ‘accepting appropriate risk’ involved participants choosing investigations based on clinical phenotype, recognising some aetiologies would be missed; consultants found they ‘transitioned between practices’ during their career; and ‘improved practice’ was thought possible with better evidence on how to stratify investigations based on phenotype. Services that were most frequently reported to need additional funding were therapy services, early community developmental services, management of behaviour, sleep and mental health, and educational support.

Conclusions

There are many factors that influence paediatricians’ choice of aetiological investigation in EDI, but clinical factors are the most important. Paediatricians want better evidence to allow them to select the right investigations for each child without a significant risk of missing an important diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03233-1.

Autism spectrum disorder in older adults with intellectual disability: a scoping review

INTRODUCTION

Ireland has an ageing population of persons with intellectual disability (ID), autism spectrum disorder (ASD) and both (ID/ASD). Despite this, little is known about the prevalence of ASD and its effect on functional outcomes, psychiatric comorbidity or diagnostic issues in an older population with ID. This article reviews the literature on older adults with ID/ASD and identifies opportunities for future research in this population.

METHOD

The authors searched the Medline, Pubmed, Embase, CINAHL and PsychInfo databases using the search terms using key words: (older adults) AND (ID OR mental retardation OR learning disability) AND (autism OR ASD). After excluding articles for relevance, a scoping review was carried out on the results retrieved.

RESULTS

Of the 1227 articles retrieved from the literature on ID and autism/ASD in older adults, 85 articles were relevant to an adult population with ID/ASD. The data were collated and are presented covering domains of diagnosis, prevalence, psychiatric comorbidities and functional outcomes.

CONCLUSIONS

Despite increased prevalence in childhood ASD in the last 20 years, there is a lack of research regarding adults, especially older adults, with ASD, up to half of whom will have some level of ID. The existing literature suggests that older adults with ID/ASD may have reduced functional independence, increased psychiatric comorbidity and psychotropic prescribing and more behavioural presentations than the older population generally or those with ID only. There is a need for longitudinal data to be collected on this ageing population so that care and management needs can be met in the future.

Auditory processing disorder evaluations and cognitive profiles of children with specific learning disorder

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Children with altered auditory processing exhibit a specific cognitive profile.

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Lower verbal and spatial reasoning performance are associated with altered auditory processing.

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Children with specific learning disorder should undergo a complete multimodal examination.

Objective

This study investigated the auditory sensory-perceptual level of specific learning disorder (SLD) and explored relationships among neuropsychological assessments for SLD, auditory processing, and short and long latencies of auditory event-related potentials (ERPs).

Methods

Fifteen children (7–14 years old) comprised the control group; 34 children comprised the SLD group. Audiologic assessments included tone audiometry, acoustic immittance measurements, acoustic reflex, central auditory processing, brainstem evoked response audiometry, and long latency potentials (P3 and N2). Children’s intelligence levels were assessed with 2 intelligence batteries, 1 verbal and 1 non-verbal, as well as with visuomotor skills.

Results

Multiple regression showed a significant interaction effect of APE tests and P3/N2 over Wechsler Scale performance in freedom of distractibility indexes and multiple subtests. Errors in the Bender Visual Motor Gestalt Test were predicted by lower parental education, lower performance in APE tests: dichotic digits and pediatric/synthetic sentence identification-ipsilateral, and longer P3/N2 latencies, particularly regarding integration and rotation distortions.

Conclusions

Children with altered auditory processing exhibit a specific cognitive profile, including lower verbal and spatial reasoning performance, that is sensitive to parental education level.

Significance

Children with SLD should undergo a complete multimodal examination to identify their specific difficulties and needs.

Coping strategies of families of persons with learning disability in Imo state of Nigeria

BACKGROUND

Coping with a relative with a learning disability could be a stressful experience for family members. The present study is aimed at exploring the coping strategies adopted by families in trying to make meaning of their situation.

METHOD

A qualitative study design using focus group discussions (FGDs) was adopted. Ten FGD sessions were held with family members of persons with a learning disability.

RESULTS

Findings revealed patterns of family coping to include problem-focused, emotion-focused, and spiritual/religious-focused. Also, coping responses to a learning disability varied based on the level of information available to families about the condition of their relative. In some cases, interspousal relationship was strained due to stress.

CONCLUSION

It was recommended that families of persons with a learning disability need social support and professional help from social workers to facilitate the adoption of more positive-oriented coping strategies by family members.

High prevalence of diabetes mellitus, hypertension and obesity among persons with a recorded diagnosis of intellectual disability or autism spectrum disorder

BACKGROUND

Obesity and lack of physical activity are frequently reported in persons with intellectual disability (ID) or autism spectrum disorder (ASD). We hypothesised a higher prevalence of diabetes and hypertension in this population.

METHOD

We used administrative data for all primary and specialist outpatient and inpatient healthcare consultations for people with at least one recorded diagnosis of diabetes mellitus, hypertension or obesity from 1998 to 2015. Data were drawn from the central administrative database for Stockholm County, Sweden. It was not possible to separate data for type 1 and type 2 diabetes. We stratified 26 988 individuals with IDs or ASD into three groups, with Down syndrome treated separately, and compared these groups with 1 996 140 people from the general population.

RESULTS

Compared with the general population, men and women with ID/ASD had 1.6-3.4-fold higher age-adjusted odds of having a registered diagnosis of obesity or diabetes mellitus, with the exception of diabetes among men with Down syndrome. A registered diagnosis of hypertension was only more common among men with ID/ASD than in the general population.

CONCLUSIONS

Diabetes and blood pressure health screening, along with efforts to prevent development of obesity already in childhood, are necessary for individuals with IDs and ASD. We believe that there is a need for adapted community-based health promotion programmes to ensure more equitable health for these populations.

Mortality patterns and risk among older men and women with intellectual disability: a Swedish national retrospective cohort study

Background

Sweden has closed all institutions and imposed legislation to ensure service and support for individuals with intellectual disability (ID). Understanding mortality among older individuals with ID is essential to inform development of health promotion and disease control strategies. We investigated patterns and risk of mortality among older adults with ID in Sweden.

Methods

This retrospective cohort study compared older adults aged 55 years and older with ID with a control population. Participants were followed during 2002–2015 or death, and censored if they moved out of Sweden. Individuals with ID were identified from two national registers: one covering all specialist health-care visits (out-patient visits and hospitalisation) and the other covering people accessing social/support services. Individuals with ID (n = 15,289) were matched with a control population by sex, birth year, and year of first hospitalisation/out-patient visit/access to LSS services. Cause-of-death data were recorded using International Classification of Diseases, Tenth Revision. Cox proportional hazards regression were conducted to assess if overall and cause-specific mortality rate among individuals with ID was higher than in the Swedish population.

Results

The overall mortality rate among individuals with ID was 2483 per 100,000 people compared with 810 in the control population. Among those who died, more individuals with ID were younger than 75 years and unmarried. Leading causes of death among individuals with ID were circulatory diseases (34%), respiratory diseases (17%) and neoplasms (15%). Leading causes of death in a sub-sample with Down syndrome (DS) were respiratory diseases (37%), circulatory diseases (26%) and mental/behavioural disorders (11%). Epilepsy and pneumonitis were more common among individuals with ID than controls. Alzheimer’s disease was common in the control population and individuals with DS, but not among those with ID when DS was excluded. Individuals with ID had a higher overall mortality risk (hazard ratio [HR] 4.1, 95% confidence interval [CI] 4.0–4.3) and respiratory disease death risk (HR 12.5, 95% CI 10.9–14.2) than controls.

Conclusion

Older adults with ID in Sweden carry a higher mortality risk compared with the general population, mainly attributable to respiratory, nervous and circulatory diseases. Care for this group, particularly during the terminal stage of illness, needs to be tailored based on understanding of their main health problem.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0665-3) contains supplementary material, which is available to authorized users.

Neurodevelopmental disorders in young violent offenders: Overlap and background characteristics

Neurodevelopmental disorders (Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), tic disorder, intellectual disability (ID)), in prison populations have received increased attention but the focus has generally been on one single condition leaving out the global picture. This study assessed the prevalence and overlap of neurodevelopmental disorders (NDD) in a consecutive cohort (n=270) of young adult male offenders (age 18-25 years), sentenced for "hands-on" violent offences and serving prison time in Swedish prisons. Seventy-one percent of all who met inclusion criteria participated. Comprehensive clinical assessments were carried out including history of early antisocial behavior and maladjustment, self-report questionnaires and an intelligence test. Sixty-three percent of the study group met DSM-IV criteria for childhood ADHD, 43% for ADHD in adulthood, 10% met criteria for an ASD, 6% for Tourette syndrome, and 1% for ID. Twenty-two percent had borderline intellectual functioning. A substantial rate of overlap between the NDDs was found. The combined NDD group had an earlier onset of antisocial behavior, had more aggressive behavior and lower school achievements than the non-NDD group. The results highlight the need for prison and probation services to be attentive of and screen for neurodevelopmental disorders in young violent offenders.

Physical activity during school and after school among youth with and without intellectual disability

BACKGROUND

Little is known about physical activity (PA) among children with intellectual disability (ID) or their reasons to take part in PA and sport.

AIMS

To investigate PA and PA patterns during school and after school among Icelandic children with mild-to-severe ID.

METHODS AND PROCEDURES

Ninety-one children with ID and a matched group of 93 typically developed individuals (TDI) took part. PA was assessed with accelerometers and a questionnaire was used to collect data on PA behavior.

RESULTS AND OUTCOMES

TDI children were more active and less sedentary than children with ID (p<0.001). Both sexes with ID were more active and less sedentary during school than after school (p<0.003) but no difference was found among TDI children. Children with ID (60%) were more likely to name weight loss as a reason to participate in PA than TDI children (34%, p=0.002) but a higher proportion (96%) of TDI children than children with ID (50%) participated in PA to improve skills (p<0.001).

CONCLUSION AND IMPLICATIONS

Children with ID depend more on schools to accumulate their PA and their reasons for PA participation differ from TDI children. This needs to be considered when designing and implementing PA promotion campaigns for children with ID.

Infant Motor Delay and Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations in Japan

BACKGROUND

Abnormalities of early motor development have been reported in autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual developmental disorder, developmental coordination disorder, and other Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE). However, few studies have been conducted with a view to following up a clinically representative cohort of children coming for assessment of motor delay before age two years. We performed a prospective clinical cohort study to examine whether or not early motor delay is often an indication of ESSENCE.

METHODS

The sample comprised a one-year cohort of all children who came to a Japanese neurodevelopmental center before their second birthday because of delayed or abnormal gross motor development. The children were followed up from the ESSENCE viewpoint.

RESULTS

Of the 30 children, 28 (18 boys and 10 girls) (93%) were given diagnoses subsumed under the ESSENCE umbrella. Of the 15 children with an identified or strongly suspected etiology, 13 (8 boys and 5 girls) (87%) had ESSENCE disorders or symptoms. Of the 15 children without a known etiology, all had ESSENCE disorders or symptoms.

CONCLUSION

This study indicated that the vast majority of children with motor delay or abnormality in the first two years of life meet criteria for a disorder within the group of ESSENCE at follow-up; this means that young children, presenting with motor problems always need a broad clinical assessment, not just related to motor function, and systematic follow-up.

Diabetes in people with intellectual disabilities: A systematic review of the literature

OBJECTIVE

To present an analysis of the evidence related to the prevalence of diabetes in people with intellectual disabilities (ID), their experiences of their condition and treatment and those of their carers.

MATERIALS AND METHODS

A systematic literature review was conducted. A total of 22 studies exploring diabetes prevalence and 5 exploring views and experiences of diabetes in people with ID were identified and included. A narrative synthesis approach was utilised to amalgamate data extracted from the included studies regarding some 49,046 participants with ID and diabetes and 31 care professionals and family members across Europe, North America, New Zealand, Australia, China and Hong Kong.

RESULTS

Prevalence rates of diabetes in people with ID were highly varied, ranging from 0.4% to 25%. 7 studies reported significantly higher rates of diabetes in people with ID than the general population. People with ID reported a basic understanding of diabetes and wanted to know more. Carers reported that they lack diabetes knowledge and do not routinely encourage diabetes self-management skills. Several studies neglected to report vital demographic information such as participants' level of ID (13 studies) and diabetes type (16 studies) and the quality of included prevalence studies was variable.

CONCLUSIONS

Further research in this field is required, notably prevalence studies which control for participant demographics and personal situations to obtain more accurate diabetes prevalence rates in this population group. People with ID and diabetes should be encouraged to participate in future research and we recommend exploring the feasibility of adapting current mainstream diabetes management programmes for these individuals.

Sociocultural Factors Associated With Abuse of Mentally Impaired Persons in Imo State, Nigeria

This study examined sociocultural factors associated with abuse of mentally impaired persons (MIP) in Imo state, Nigeria. A cross-sectional survey of 1,147 persons aged 10 years and above who had at least one MIP in their household was conducted. Six in-depth interviews and 21 focus group discussion (FGD) sessions with 160 study participants comprising adult male and female members of the communities, respectively, were conducted. The study established that a multitude of cultural and social factors shape the attitude of individuals toward mental impairment and MIPs. It was found that cultural perceptions of the cause of mental impairment as supernatural and evil forces were widespread within the study communities. Among those surveyed, 74.6% were aware that MIPs are victims of abuse. Perpetrators identified were mostly relatives and persons close to MIPs. The findings provide useful insights into gaps in conventional understanding of mental impairment and abuse of MIPs in Imo State.

Childhood Symptoms of ADHD Overrule Comorbidity in Relation to Psychosocial Outcome at Age 15: A Longitudinal Study

Objective

Neurodevelopmental problems (NDPs) may influence the transition from childhood to adolescence. Our aim was to study long-term psychosocial outcomes of NDPs, focusing on ADHD.

Method

Data was collected through a telephone interview with parents of twins at ages 9 or 12 years. NDP screen-positive children were clinically assessed at age 15; N = 450. Psychosocial outcome concerning peers, school, internalizing problems, antisocial behavior, alcohol misuse, drug misuse, and impaired daily functioning was examined.

Results

Even after controlling for other NDP comorbidity, screen-positivity for ADHD doubled or tripled the odds of later psychosocial problems. When controlling for parental education level, the significant effect of ADHD remained only for antisocial behavior and impaired daily functioning.

Conclusions

Signs of NDPs as well as other psychiatric diagnoses at ages 9 or 12 years are associated with a more problematic adolescence. However, despite the presence of comorbidity, early ADHD symptoms stand out as the most important risk factor for later antisocial development and impaired daily functioning.

The study of psychiatric disease genes and drugs in zebrafish

Mutations associated with psychiatric disease are being identified, but it remains unclear how the affected genes contribute to disease. Zebrafish is an emerging model to study psychiatric disease genes with a rich repertoire of phenotyping tools. Recent zebrafish research has uncovered potential developmental phenotypes for genes associated with psychiatric disorders, while drug screens have behaviorally characterized small molecules and identified new classes of drugs. Behavioral studies have led to promising models for endophenotypes of psychiatric diseases. While further research is needed to firmly link these models to psychiatric disorders, they are valuable tools for phenotyping genetic mutations and drugs. Recently developed tools in genome editing and in vivo imaging promise additional insights into the processes disrupted by mutations in psychiatric disease genes.

Education, cognition, health knowledge, and health behavior

Using data from NLSY97, we analyze the impact of education on health behavior. Controlling for health knowledge does not influence the impact of education on health behavior, supporting the productive efficiency hypothesis. Accounting for cognitive ability does not significantly alter the relationship between education and health behavior. Similarly, the impact of education on health behavior is the same between those with and without a learning disability, suggesting that cognition is not likely to be a significant factor in explaining the impact of education on health behavior.

Trends in the use of psychotropic drugs in people with intellectual disability in Taiwan: a nationwide outpatient service study, 1997-2007

This study aims to examine trends in outpatient psychotropic drug use among people with intellectual disabilities in Taiwan. The NHI outpatient medication records between January 1, 1997 and December 31, 2007 for people with intellectual disabilities were analyzed to observe the percent change, prevalence and prescription trends in psychotropic drugs. The overall prevalence of psychotropic medication increased from 17.82% to 23.22% during the study period. Results from stepwise logistic analysis demonstrated that females, the elderly, and individuals suffering from catastrophic disease were more prone to receive psychotropic drugs and that those with mild intellectual disability were less likely to receive psychotropic drugs. The percentage change in prescription rates of antipsychotics, hypnotics/sedatives, and antidepressants were 85.30%, 127.25%, and 167.50%, respectively, and the trends were statistically significant (p<0.05). Taiwan's NHI program and off-label use of psychotropic drugs might have attributed to this trend.

The ESSENCE in child psychiatry: Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations

Co-existence of disorders--including attention-deficit/hyperactivity disorder, oppositional defiant disorder, tic disorder, developmental coordination disorder, and autism spectrum disorder--and sharing of symptoms across disorders (sometimes referred to as comorbidity) is the rule rather than the exception in child psychiatry and developmental medicine. The acronym ESSENCE refers to Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations. It is a term I have coined to refer to the reality of children (and their parents) presenting in clinical settings with impairing child symptoms before age 3 (-5) years in the fields of (a) general development, (b) communication and language, (c) social inter-relatedness, (d) motor coordination, (e) attention, (f) activity, (g) behaviour, (h) mood, and/or (i) sleep. Children with major difficulties in one or more (usually several) of these fields, will be referred to and seen by health visitors, nurses, social workers, education specialists, pediatricians, GPs, speech and language therapists, child neurologists, child psychiatrists, psychologists, neurophysiologists, dentists, clinical geneticists, occupational therapists and physiotherapists, but, usually they will be seen only by one of these specialists, when they would have needed the input of two or more of the experts referred to. Major problems in at least one ESSENCE domain before age 5 years often signals major problems in the same or overlapping domains years later. There is no time to wait; something needs to be done, and that something is unlikely to be just in the area of speech and language, just in the area of autism or just in special education.

Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications

Conforming to a medical disease model rooted in phenomenology and natural science, psychiatry classifies mental disorders according to signs and symptoms considered to be stable and homogeneous across individuals. Scientific studies addressing the validity of this classification are scarce. Following a seminal paper by Robins and Guze in 1970, validity of categories has been sought in specific criteria referring to symptoms and prognosis, aggregation in families, and "markers", preferentially laboratory tests. There is, however, a growing misfit between the model and empirical findings from studies putting it to the test. Diagnostic categories have not been shown to represent natural groups delineated from the normal variation or from each other. Aetiological factors (genetic and/or environmental), laboratory aberrations, and treatment effects do not respect categorical boundaries. A more adequate description of mental problems may be achieved by: 1) a clear definition of the epistemological frame in which psychiatry operates, 2) a basic rating of the severity of intra- and interpersonal dysfunctions, and 3) empirical comparisons to complementary rather than exclusive dimensions of inter-individual differences in context-specific mental functions, treatment effects, and laboratory findings. Such a pluralistic understanding of mental health problems would fit empirical models in the neurosciences and postmodern notions of subjectivity alike. It would also clarify the assessment of dysfunction and background factors in relation to the requisites for penal law exemptions or insurance policies and make them empirically testable rather than dependent on expert opinion on issues such as whether a specific dysfunction is "psychiatric", "medical", or ascribable to "personality".

Is there a protective effect of normal to high intellectual function on mental health in children with chronic illness?

BACKGROUND

High intellectual function is considered as a protective factor for children's mental health. Few studies have investigated the effect of intellectual function on mental health in children with chronic illness (CI). The aim of the present study was twofold: First, we asked if normal to high intellectual function (IQ) has a protective effect on mental health in children with CI, and secondly, if this effect is more substantial than in their peers (NCI).

METHODS

The participants were selected among children who participated in the Bergen Child Study (BCS): 96 children with CI (the CI-group) and 96 children without CI (the NCI-group). The groups were matched on intellectual function as measured by the WISC-III by selecting the same number of children from three levels of the Full Scale IQ Score (FSIQ): "very low" (<70),"low" (70 to 84), or "normal to high" (>84). CI was reported by parents as part of a diagnostic interview (Kiddie-SADS-PL) that also generated the mental health measures used in the present study: the presence of a DSM-IV psychiatric diagnosis and the score on the Children's Global Assessment Scale.

RESULTS

The risk of a psychiatric diagnosis was significantly lower for children with a normal to high FSIQ-level than for children with a very low and low FSIQ-level in the CI-group as well as in the NCI-group. The group differences were statistically non-significant for all three FSIQ-levels, and the effect of the interaction between the group-variable (CI/NCI) and the FSIQ-level was non-significant on both measures of mental health.

CONCLUSION

The present study showed a protective effect of normal to high intellectual function on children's mental health. This protective effect was not more substantial in children with CI than in children without CI.

High prevalence of cardio-metabolic risk factors among adolescents with intellectual disability

Adults with intellectual disabilities (IDs) have poor lifestyle-related health compared with the general population. Our aim was to study whether such differences are present already in adolescents.

AIM

To compare the prevalence and severity of cardio-metabolic risk factors and cardio-vascular fitness in adolescents with and without IDs.

METHODS

Intellectual disability (ID) students (n = 66) and non-intellectual disability (non-ID) students from practical (non-ID-p) (n = 34) and theoretical (non-ID-t) (n = 56) programmes were recruited from three upper secondary schools. Anthropometric data, blood pressure, body composition, fasting-insulin, fasting-glucose, fasting-lipids and cardio-vascular fitness were measured.

RESULTS

Participants with and without ID differed significantly in the prevalence of cardio-metabolic risk factors with participants with ID having a higher percentage of total fat mass, wider waist circumferences (WCs), lower levels of fat-free mass (FFM), lower bone mineral density (BMD) and higher insulin and homeostasis model assessment of insulin resistance (HOMA) levels and poorer cardio-vascular fitness. The healthiest levels were found in the non-ID-t group compared to the group with ID and the group with non-ID-p in between.

CONCLUSION

The prevalence of cardio-metabolic risk factors and poor cardio-vascular fitness was found to be high in this young population with intellectual disabilities. Measures should be taken to improve the health messages directed towards children and adolescents with intellectual disabilities.

Psychiatric service use and psychiatric disorders in adults with intellectual disability

BACKGROUND

UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population.

METHODS

A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated.

RESULTS

Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID.

CONCLUSIONS

Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.

Children with learning disabilities

Children with learning disabilities can present numerous challenges in the acute hospital setting. This review article examines the causes and presentations of learning disability, and considers some of the management strategies employed when these children present for surgery.

Management of a first seizure. Special problems: adults and elderly

A first seizure out of a clear blue sky can be a major life-changing event. Careful history-taking and appropriate investigation together with a clear explanation provided to patient and family are an essential requirement. Although for most patients, pharmacotherapy can be withheld and events awaited, there are circumstances where introduction of antiepileptic drug (AED) therapy should be considered. Medical causes of seizures should also be sought and treated. In addition, a first seizure in HIV-positive patients and in those with underlying neurocysticercosis should usually provoke the introduction of AED therapy. Particular problems can occur in patients with a single episode of provoked status epilepticus, a first tonic-clonic seizure during pregnancy and, particularly, an unprovoked event in older and learning disabled people. Treatment following a first seizure should balance risk factors for recurrence with the informed opinion of the patients and their family.

Subtypes of learning disabilities: neuropsychological and behavioural functioning of 495 children referred for multidisciplinary assessment

Aim of the present study was two fold: (1) to evaluate the course of referring and diagnosing Learning Disabilities (LD) and the contribution of multidisciplinary assessment and (2) to describe characteristics of three LD subtypes: Attention with or without Motor function Disabilities (AMD), Verbal Learning Disabilities (VLD) and Non-Verbal Learning Disabilities (NVLD). Diagnostics, behavioural and neuropsychological data from 495 children aged 6-17 years were described. First, AMD and VLD was the most frequent LD. Multidisciplinary assessment could contribute to the diagnostic process of LD, especially in diagnosing uncommon LD and comorbidities. Secondly, behavioural ratings, information processing, attention regularity and visual-motor integration proved to be most sensitive in discriminating between the three LD subtypes. However, diagnosing NVLD requires additional developmental information. Multiple discriminant function analysis correctly classified 61.7% of a selection of the present sample into LD subtypes as diagnosed by the multidisciplinary team. It is believed that the three subtypes are clinically relevant and suggestions are made to test the present classification functions in an independent sample, preferably diagnosed using a structured diagnostic interview.

Association of Trp53 polymorphic variants at codon 72 with nonsyndromic mental retardation

Mental retardation is the most common developmental disability affecting 2-3% of the population, a consequence of a wide range of genetic or nongenetic etiologic factors. The cause of mental retardation remains unknown in about 50% of cases. Trp53 (transformation related protein 53, also known as p53) is a tumor suppressor gene that activates the expression of genes involved in inducing growth arrest of cells in response to multiple forms of cellular stress and it plays a significant role in apoptotic cell death during the early development of the nervous system. In this study, we examined 246 children with nonsyndromic mental retardation from three Italian populations and 213 healthy children from the same populations. We observed that the Pro72/Pro72 genotype of p53 is much less represented in children with nonsyndromic mental retardation than in controls (6.5% versus 14.08%) (OR=0.42; 95% CI 0.21-0.83). These data suggest that subjects carrying the Pro allele are protected from this disease.

Prevalence of violence and its relation to caregivers' demographics and emotional reactions: an explorative study of caregivers working in group homes for persons with learning disabilities

The aim of the study was to investigate the prevalence of violence directed towards caregivers working in group homes for persons with learning disabilities, and to examine the relation between violent incidents and caregivers' demographics such as gender, age, years in service, years at the present workplace and education, as well as emotional reactions to violence expressed by the caregivers. A questionnaire was distributed to all caregivers, i.e. Registered Nurses, assistant nurses and nurse's aides, working in group homes for persons with learning disabilities. The results showed that 31% of the caregivers (n = 120) had been exposed to violence during the preceding year with physical violence being the most common type of violence. All categories of caregivers were exposed to violence and emotional reactions were common. Weak relations were found between reported exposure to violence and various demographics among caregivers, such as age and education. Daytime work was the only independent factor in a regression model predicting violence towards the caregivers. Feelings of powerlessness, insufficiency and anger were the most frequently reported emotional reactions elicited by violent situations.

Cognitive strengths and deficits in schoolchildren with ADHD

BACKGROUND

Few studies provide detailed analyses of the various aspects of the entire cognitive profile of children with ADHD.

MATERIAL AND METHODS

Cognitive test data were analysed for 10- to 11-year-old children with (1) ADHD, (2) subthreshold ADHD and (3) milder attention and/or learning problems, and compared with normative data.

RESULTS

Thirty-two had ADHD and 10 met the criteria for subthreshold ADHD, prevalence rates of 5.4% and 1.6%, respectively. On a group level, children with ADHD/subthreshold ADHD, and those with milder attention and/or learning problems had almost identical cognitive profiles for the 13 subtests comprising the WISC III, with particularly low results on the arithmetic, coding, information and digit span subtests (ACID profile). When analyzed individually, a complete or incomplete ACID profile (three of four subtests) was equally common in children with ADHD/subthreshold ADHD and in children with milder problems, found in about 1/5. The relative strengths of both groups were in areas demanding logical thinking, reasoning and common sense.

CONCLUSION

The specific ACID profile is as common in children with ADHD as in those with minor attention and/or learning problems. The cognitive weaknesses reflected in the ACID profile might play a role as an underlying factor in various developmental disorders.

Prevalences and configurations of mental disorders among institutionalized adolescents

OBJECTIVE

To assess prevalence figures for psychiatric disorders among institutionalized adolescents due to behavioural problems and/or delinquency.

METHOD

Participants were recruited from consecutive referrals to/or treated at two Swedish adolescent units, SIS1 (n = 60) and SIS2 (n = 70) with ranging age of 12-20.3 years (mean age = 16.2; SD = 1.8) during 1 year. Clinical and diagnostic information was used to generate DSM-IV diagnoses.

RESULTS

One or several neuropsychiatric disorders were diagnosed in 53% of all subjects: 39% met DSM-IV diagnostic criteria for attention deficit/hyperactivity disorder (AD/HD), 15% for a pervasive developmental disorder (referred to as autism spectrum disorders, ASDs) and 8% had a mental retardation (referred to as a learning disability, LD). The collapsed prevalence for psychiatric disorders requiring specialist attention was 66%, counting severe depression and psychotic disorders but not substance use. About one in three of all adolescents in the study were given psychopharmacological treatment.

CONCLUSION

Published studies and this clinical survey clearly indicate that systematic studies of mental health needs among institutionalized adolescents are warranted to form the basis of adequate treatment and support measures.

Association of adenosine deaminase polymorphism with mild mental retardation

The etiology of mild mental retardation remains undefined in about 60% of cases. Even though the causes of mild mental retardation are likely to be heterogeneous, the evidence for genetic involvement is increasing, along with the development of specific diagnostic techniques. To improve our understanding of the genetic basis of mild mental retardation, we explored the role of polymorphisms of adenosine deaminase, an enzyme that is supposed to act as a neuroregulatory protein. To this end, we conducted an association study comparing children with mild mental retardation of unknown origin with two groups of controls: (1) apparently healthy children and (2) children with moderate or severe mental retardation of known etiology. Overall, 338 participants were enrolled in the study. Cases (ie, 80 children) were more likely than controls (ie, 153 healthy children and 105 children with moderate or severe mental retardation) to have the low-activity ADA-Asn 8 (ADA(1) *2) polymorphism (P < .05) and to present the ADA(1) *2/ ADA(2) *1 haplotype. No significant differences were found with respect to adenosine deaminase polymorphisms when comparing the group with moderate or severe mental retardation of known causes and healthy controls. In conclusion, our findings suggest a possible role for a low-activity genotype (ADA-8Asn) (ADA(1) *2) of adenosine deaminase in the pathogenesis of mild mental retardation.

Trends in childhood disease

Child mortality has declined remarkably during the last decades. While neonatal disorders, diarrhoea, pneumonia, and malaria as well as being underweight account for most of the child deaths worldwide, children's health discussions in Europe and the USA focus on other issues such as asthma, neurodevelopmental disorders, male genital malformations, and childhood cancer. There is clear evidence of increasing rates of asthma in various countries during the last decades, although rates in some countries may now have stabilised or even decline as recent UK data indicate. Although an increase in the frequency of neurodevelopmental disorders such as autism and attention deficit disorder has frequently been discussed, the limited data in this field does not justify such a conclusion. While geographic heterogeneity regarding reproductive outcomes is apparent, global trends have not been identified. Interpretation of the available information on asthma, neurodevelopmental disorders and reproductive outcomes is hampered by inconstant diagnostic criteria over place and time and the lack of good and comprehensive population-based surveillance data, which makes it impossible to ascertain trends in actual disease frequency. Data indicate that developed countries have a gradually increasing incidence in leukaemia with a corresponding drop in the incidence of lymphoma. Increases in brain tumour frequency may be related to the development and wide application of new diagnostic capabilities, rather than a true change in the incidence of malignant disease. With a better prognosis for childhood cancer survival, secondary cancers following chemotherapy appear to be increasing. A wide range of environmental factors is thought to have an impact on children's health. These factors include nutrition (protein, vitamins, antioxidants), lifestyle and behaviour choices such as tobacco and alcohol use, parental health, socio-economic status, choice of living environment (urban versus rural, etc.), and parent-sibling behaviour. From the available data, no general conclusions on the contribution of specific chemicals can be drawn.

Refining diagnoses: applying the DC-LD to an Irish population with intellectual disability

BACKGROUND

The diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation (DC-LD) is a diagnostic tool developed in 2001 to improve upon existing classification systems for adults with learning disability. The aim of this study was to apply the classification system described by the DC-LD to a residential intellectual disability (ID) population to examine whether it improved our diagnostic understanding of residents.

METHODS

Chart reviews of 113 of 178 people in a residential ID service were conducted. For each resident, information was recorded according to the DC-LD multi-axial system. Each resident's case was then discussed with a member of nursing staff familiar with the resident. If diagnosis was unclear, the case was discussed with a senior clinical psychiatrist.

RESULTS

The percentage of residents with a moderate to profound ID was 87.6%. In total, 94 diagnoses of psychiatric illness (Axis III, Level B, DC-LD) were made. Of those 94 diagnoses, seven new diagnoses were found because of DC-LD criteria. Of the total number of psychiatric diagnoses made, 72.3% were non-specific, residual category diagnoses. A total of 79 residents (69.9%) had at least one behaviour problem diagnosed on Axis III, Level D, Problem behaviours. Fifty-six (49.6%) of residents in this sample had co-morbid epilepsy.

CONCLUSIONS

In people with moderate to profound learning disabilities, diagnosis continues to be challenging. The DC-LD is a useful tool in helping to clarify diagnoses in this population by providing revised criteria and a system to classify problem behaviours. The DC-LD would be more helpful if specific axes were included to document medical and psychosocial problems independently from other diagnoses. Further research is warranted to determine whether the DC-LD hierarchical approach to diagnosis improves diagnostic validity.

SNPs, microarrays and pooled DNA: identification of four loci associated with mild mental impairment in a sample of 6000 children

Mild mental impairment (MMI) represents the low extreme of the quantitative trait of general intelligence and is highly heritable. Quantitative trait loci (QTLs) conferring susceptibility to MMI, as for most complex traits, are likely to be of small effect size. Using a novel approach we call SNP-MaP (SNP Microarrays and Pooling), we have identified four loci associated with MMI. These four loci have been replicated in two SNP-MaP studies and verified by individual genotyping. The two SNP-MaP studies conducted were a case versus control comparison (n = 515 and n = 1028, respectively) and a low versus high general intelligence extremes group comparison (n = 503 and n = 505, respectively). Each of the four groups consisted of five independent 'subpools', with each subpool assayed on a separate microarray. Twelve loci showing the largest significant differences in both SNP-MaP studies were individually genotyped on 6154 children. Of the four loci positively associated with MMI, the minor allele of each conferred the greater risk for MMI. Two of the loci are close to known genes and may be in linkage disequilibrium with them. One of the loci is between the candidate genes KLF7 and CREB1, but given possible long-range effects on expression and the unknown importance of untranslated elements such as micro-RNAs, all four loci deserve attention as candidates. Although each SNP accounts for a small amount of variance, their effects are additive and they can be combined in a 'SNP set' that can be used as a genetic risk index for MMI in behavioral genomic analyses.

Clinical neuropsychiatric symptoms in perpetrators of severe crimes against persons

The objective of the study was to explore the possibility of common signs and symptoms of childhood-onset neuropsychiatric disorders and personality disorders, especially psychopathy, in a cohort of violent offenders. A structured neuropsychiatric status comprising features recorded in childhood-onset neuropsychiatric disorders and adult personality disorders was assessed in 89 perpetrators of severe crimes against other persons, analysed for factor structure, and compared to clinical diagnostics of neuropsychiatric disorders and independent assessments of psychopathy rated by the Psychopathy Checklist Revised (PCL-R). One or several childhood-onset neuropsychiatric disorders [autism, attention-deficit/hyperactivity disorder (AD/HD), tics and learning disability] affected the majority of adult offenders. A factor analysis yielded four higher-order problem constellations: Executive Dysfunction, Compulsivity, Social Interaction Problems and Superficiality. All four constellations were positively correlated with life histories of aggression, stressing the clinical importance of these problems in adult forensic psychiatry. Compulsivity and Social Interaction Problems were associated with autistic traits and tics, Executive Dysfunction with AD/HD, conduct disorder and psychopathic as well as autistic traits. Superficiality was a distinct aspect of AD/HD and psychopathic traits, especially the PCL-R factor reflecting interpersonal callousness. Neuropsychiatric disorders and personality disorders such as psychopathy share common symptoms. The various facets of psychopathy are associated with executive dysfunction and empathy deficits with superficial understanding of self, others and the rules of communication.

Levetiracetam for people with mental retardation and refractory epilepsy

Levetiracetam (LEV) is a novel antiepileptic drug (AED) with efficacy against a wide range of seizures types. The aim of this observational study was to assess its effectiveness in patients with mental retardation and refractory epilepsy. Sixty-four patients were started on adjunctive LEV after a 3-month baseline. LEV was initially dosed at 250 mg daily and increased by 250 mg every 2 weeks thereafter according to clinical response. Caregivers rated the patient's sleep, appetite, alertness, and behavior as poor (1), reasonable (2), or good (3) at each clinic visit. Patients were reviewed until one of four endpoints was reached: seizure freedom for at least 6 months, > or = 50% reduction in seizure frequency (responder) over a 6-month period, <50% reduction in seizure frequency (marginal effect) over a 6-month period, or LEV withdrawal due to lack of efficacy, adverse effects, or both. Twenty-four (38%) patients became seizure-free, 10 of whom were controlled on LEV 250 mg twice daily. An additional 18 (28%) patients were classified as responders, and 8 (12%) reported only marginal benefit from adjunctive LEV. Fourteen (22%) patients discontinued LEV (6 worsening seizures, 1 lack of efficacy, 7 adverse effects). Caregivers rated combined sleep, appetite, alertness, and behavior scores as "improved" at the end of follow-up (P<0.001). LEV improved seizure control in the majority of patients with mental retardation and may also have enhanced their quality of life.