Psychometric properties of the psychopathology instrument for mentally retarded adults

Developing and Implementing a Web-Based Branching Logic Survey to Support Psychiatric Crisis Evaluations of Individuals With Developmental Disabilities: Qualitative Study and Evaluation of Validity

BACKGROUND

Individuals with developmental disabilities (DD) experience increased rates of emotional and behavioral crises that necessitate assessment and intervention. Psychiatric disorders can contribute to crises; however, screening measures developed for the general population are inadequate for those with DD. Medical conditions can exacerbate crises and merit evaluation. Screening tools using checklist formats, even when designed for DD, are too limited in depth and scope for crisis assessments. The Sources of Distress survey implements a web-based branching logic format to screen for common psychiatric and medical conditions experienced by individuals with DD by querying caregiver knowledge and observations.

OBJECTIVE

This paper aims to (1) describe the initial survey development, (2) report on focus group and expert review processes and findings, and (3) present results from the survey's clinical implementation and evaluation of validity.

METHODS

Sources of Distress was reviewed by focus groups and clinical experts; this feedback informed survey revisions. The survey was subsequently implemented in clinical settings to augment providers' psychiatric and medical history taking. Informal and formal consults followed the completion of Sources of Distress for a subset of individuals. A records review was performed to identify working diagnoses established during these consults.

RESULTS

Focus group members (n=17) expressed positive feedback overall about the survey's content and provided specific recommendations to add categories and items. The survey was completed for 231 individuals with DD in the clinical setting (n=161, 69.7% men and boys; mean age 17.7, SD 10.3; range 2-65 years). Consults were performed for 149 individuals (n=102, 68.5% men and boys; mean age 18.9, SD 10.9 years), generating working diagnoses to compare survey screening results. Sources of Distress accuracy rates were 91% (95% CI 85%-95%) for posttraumatic stress disorder, 87% (95% CI 81%-92%) for anxiety, 87% (95% CI 81%-92%) for episodic expansive mood and bipolar disorder, 82% (95% CI 75%-87%) for psychotic disorder, 79% (95% CI 71%-85%) for unipolar depression, and 76% (95% CI 69%-82%) for attention-deficit/hyperactivity disorder. While no specific survey items or screening algorithm existed for unspecified mood disorder and disruptive mood dysregulation disorder, these conditions were caregiver-reported and working diagnoses for 11.7% (27/231) and 16.8% (25/149) of individuals, respectively.

CONCLUSIONS

Caregivers described Sources of Distress as an acceptable tool for sharing their knowledge and insights about individuals with DD who present in crisis. As a screening tool, this survey demonstrates good accuracy. However, better differentiation among mood disorders is needed, including the addition of items and screening algorithm for unspecified mood disorder and disruptive mood dysregulation disorder. Additional validation efforts are necessary to include a more geographically diverse population and reevaluate mood disorder differentiation. Future study is merited to investigate the survey's impact on the psychiatric and medical management of distress in individuals with DD.

Psychometric properties of measures designed to assess common mental health problems and wellbeing in adults with intellectual disabilities: a systematic review

BACKGROUND

Multiple measures of mental health problems and mental wellbeing for adults with intellectual disabilities are available, but investigations into their reliability and validity are still in the early stages. The aim of this systematic review was to provide an update to previous evaluations of measures of common mental health problems and wellbeing in adults with mild to moderate intellectual disabilities (ID).

METHODS

A systematic search was performed across three databases (MEDLINE, PsycINFO and SCOPUS). The literature search was limited to the years from 2009 to 2021 and to the original English versions. Ten papers evaluating nine measures were reviewed, and the psychometric properties of these measures were discussed using the Characteristics of Assessment Instructions for Psychiatric Disorders in Persons with Intellectual Developmental Disorders as a framework.

RESULTS

Four measures had at least one rating of 'good' across both dimensions of reliability and at least one dimension of validity and were deemed to have promising psychometric properties: the Clinical Outcomes in Routine Evaluation-Learning Disabilities, Impact of Events Scale-Intellectual Disabilities, Lancaster and Northgate Trauma Scales and Self-Assessment and Intervention (self-report section). Additionally, these measures were developed through consultations with mental health professionals and/or people with IDs and thus were deemed to have good content validity.

CONCLUSIONS

This review informs measurement choice for researchers and clinicians while highlighting a need for continued research efforts into the quality of measures available for people with IDs. The results were limited by incomplete psychometric evaluations of measures available. A paucity of psychometrically robust measures of mental wellbeing was observed.

Effect of Peer Victimization on the Long-Term Mental Health Status among Adults Users of Intellectual Disability Services: A Longitudinal Follow-Up Study

Caregiving for mental health among people with intellectual disabilities (IDs) in the ID services was reported as insufficient. The purposes of this study were to investigate five types of peer victimization (PV) experiences among adults with ID using ID services, and to gain a deeper understanding of the influence of PV experience on adults with ID’s long-term mental health status. A one-year longitudinal follow-up study was conducted from eight long-term care ID services (n = 176). Logistic regression analysis was applied to variables comprising personal characteristics, various types of PV experience and polyvictimization to predict period prevalence of psychiatric symptoms. The data indicated that nearly one-third of individuals with ID experienced at least one psychiatric symptom. The three most common psychiatric symptoms prevalent after one year were adjustment disorder, anxiety disorder, and somatoform disorder. Over the 1-year study period, approximately 40% of adults with ID reported experiencing PV. The most frequently reported types of PV were physical force (26%) and verbal victimization (22%). Polyvictimization was experienced by approximately a quarter of adults with ID. The findings suggest that PV is a common experience among adults in ID services. Thus, for a clearer understanding of mental health risks, caregivers should pay attention to adults with ID who experienced PV.

Association between epilepsy and psychiatric disorders in adults with intellectual disabilities: systematic review and meta-analysis

BACKGROUND

Psychiatric disorders, such as depression and anxiety, are commonly associated with epilepsy in the general population, but the relationship between psychiatric disorders and epilepsy among adults with intellectual disabilities is unclear.

AIMS

To conduct a systematic review and meta-analysis to assess whether epilepsy is associated with an increased rate of psychiatric disorders in adults with intellectual disabilities.

METHOD

We included literature published between 1985 and 2020 from four databases, and hand-searched six relevant journals. We assessed risk of bias by using SIGN 50 and the Cochrane risk of bias tool. Several meta-analyses were carried out.

RESULTS

We included 29 papers involving data on 9594 adults with intellectual disabilities, 3180 of whom had epilepsy and 6414 did not. Of the 11 controlled studies that compared the overall rate of psychiatric disorders between the epilepsy and non-epilepsy groups, seven did not show any significant inter-group difference. Meta-analysis was possible on pooled data from seven controlled studies, which did not show any significant inter-group difference in the overall rate of psychiatric disorders. The rates of psychotic disorders, depressive disorders and anxiety disorders were significantly higher in the non-epilepsy control groups compared with the epilepsy group, with effect sizes of 0.29, 0.47 and 0.58, respectively. Epilepsy-related factors did not show any definite association with psychiatric disorders.

CONCLUSIONS

It is difficult to pool data from such heterogeneous studies and draw any definitive conclusion because most studies lacked an appropriately matched control group, which will be required for future studies.

A systematic review of the behaviours associated with depression in people with severe-profound intellectual disability

The assessment of depression in people with severe to profound intellectual disability (severe-profound ID) is challenging, primarily due to inability to report internal states such as mood, feelings of worthlessness and suicidal ideation. This group also commonly presents with challenging behaviours (e.g. aggression and self-injury) with debate about whether these behaviours should be considered 'depressive equivalents' or are sensitive for, but not specific to, depression in severe-profound ID. We conducted a systematic review exploring behaviours associated with depression and low mood in individuals with severe-profound ID. The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (2009) guidelines. Three electronic databases were searched (Embase, PsycINFO and Ovid MEDLINE), and 13 studies were included and rated for quality. Few studies were rated as having high methodological quality. Behaviours captured by standard diagnostic schemes for depression (e.g. Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases) showed a relationship with depression in severe-profound ID, including the two core symptoms (depressed affect and anhedonia), as well as irritability, sleep disturbance, psychomotor agitation, reduced appetite and fatigue. Challenging behaviours such as aggression, self-injury, temper tantrums, screaming and disruptive behaviour were associated with depression. Challenging behaviours show a robust relationship with depression. Whilst these behaviours may suggest an underlying depression, study limitations warrant caution in labelling them as 'depressive equivalents'. These limitations include not controlling for potential confounds (autism, other affective disorders and pain) and bias associated with comparing depressed/non-depressed groups on the same behavioural criteria used to initially diagnose and separate these groups. Future studies that use depressive measures designed for ID populations, which control for confounds and which explore low mood irrespective of psychiatric diagnosis, are warranted to better delineate the behaviours associated with depression in this population (PROSPERO 2018: CRD42018103244).

Psychometric properties of the Clinical Outcome Routine Evaluation-Learning Disabilities 30-Item (CORE-LD30)

BACKGROUND

There is paucity in availability of valid and reliable measures of psychopathology that can be routinely applied with an intellectual disability (ID) population in clinical practice. The psychometric properties of the Clinical Outcome Routine Evaluation-Learning Disabilities 30-Item version (CORE-LD30) are examined.

METHOD

The CORE-LD30 was administered to 271 sequential referrals to three National Health Service (NHS) ID services providing psychological support. A principal components analysis with oblique rotation was conducted with examination of convergent validity for extracted domains.

RESULTS

Three rotated factors were extracted with good levels of internal consistency reported for the overall measure (α = 0.92) and each of the domains, conceptually labelled Problems/Symptoms (α = 0.90), Risk to Self (α = 0.76) and Risk to Others (α = 0.71). Convergent validity is reported for two domains [Problems/Symptoms with the Glasgow Depression Scale for people with a learning disability (LD) and Risk to Others with the Health of the Nation Outcome Scale-LD], and support for the CORE-LD30 as a 'core' measure indicated.

CONCLUSIONS

The CORE-LD30 is recommended as a useful broad ranging measure of psychopathology for use with an ID population. Domains may prove to be useful for research and clinical purposes. Further research is recommended to examine the ability to monitor clinical change associated with specific levels of presentation and different clinical presentations/cohorts.

Antipsychotic medication in learning disability Impact of audit and evidence-based medicine on quality of prescribing in a community assessment treatment unit

Aims and method

Antipsychotic medication, an effective treatment modality in the management of psychiatric/behaviour disorders in people with learning disability, is often criticised because of poor clinical practice. Rational and judicious use, subject to evidence-based guidelines and systematic monitoring, is mandatory. A five-year clinical audit programme on the quality of prescribing for this clientele was undertaken.

Results

Significant quality improvement with minimal resource consumption was demonstrated.

Clinical implications

Clinical audit facilitates high-quality prescribing: pragmatic and economic, it can easily be integrated into routine clinical practice.

Epidemiology of mental health problems in adults with learning disability: an update

Epidemiological studies measuring prevalence rates and factors associated with mental health problems in adults with learning disability have produced very different and sometimes contradictory results, mainly because of methodological problems. Consequently, much of the epidemiology of mental health problems in this population is still unknown, although improved methodology and additional information are emerging. This article describes the methodological difficulties of studies, the reported prevalence rates in the context of these difficulties and what is currently known about the factors associated with mental health problems in this population.

Anxiety disorders in people with learning disabilities

People with learning disabilities are much more vulnerable to psychiatric illnesses, and will increasingly be accessing generic services. Treatment and management of psychiatric disorders is problematic, primarily because of difficulties in diagnosis, since classificatory systems are standardised on people with average intellectual functioning. This article provides an overview of the clinical implications of anxiety disorders within the context of learning disability.

Phenotypic characterization of an older adult male with late-onset epilepsy and a novel mutation in ASXL3 shows overlap with the associated Bainbridge-Ropers syndrome

The additional sex combs like 3 gene is considered to be causative for the rare Bainbridge-Ropers syndrome (BRPS), which is characterized by severe intellectual disability, neonatal hypotonia, nearly absent development of speech and language as well as several facial dysmorphisms. Apart from disruptive autistiform behaviors, sleep disturbances and epileptic phenomena may be present. Here, a 47-year-old severely intellectually disabled male is described in whom exome sequencing disclosed a novel heterozygous frameshift mutation in the ASXL3 gene leading to a premature stopcodon in the last part of the last exon. Mutations in this very end 3' of the gene have not been reported before in BRPS. The phenotypical presentation of the patient including partially therapy-resistant epilepsy starting in later adulthood shows overlap with BRPS, and it was therefore concluded that the phenotype is likely explained by the identified mutation in ASXL3.

Framework for assessing individuals with rare genetic disorders associated with profound intellectual and multiple disabilities (PIMD): the example of Phelan McDermid Syndrome

BACKGROUND

Specialized strategies are needed to understand the complex neuropsychological impairments reported in individuals with profound intellectual and multiple disabilities (PIMD) associated with rare genetic disorders.

METHODS

This narrative review focuses on assessment of individuals with Phelan-McDermid Syndrome (PMS) as a condition commonly associated with PIMD. Published case series and prospective studies were reviewed to evaluate approaches to cognitive, language, motor/sensory, and behavioral domains. This review is framed using general principles for neuropsychological evaluation in PIMD.

RESULTS

Neuropsychological assessment domains and tools varied across published reports. Adaptive behavior measures, out-of-range developmental assessments, and social-communication measures were commonly used. Available findings were used to shape a recommended framework with potential to improve measurement of clinical outcomes and advance scientific discovery.

CONCLUSIONS

The recommended framework outlines an inter-disciplinary and multimodal neuropsychological assessment process relying on modified standardized assessments, functional assessments, and caregiver/informant reports when evaluating individuals with PIMD. Arrested development and skill variability/regression are also discussed as additional, important considerations in neuropsychological evaluation of individuals with PIMD and rare genetic disorders.

Development and psychometric properties of the Psychological Therapies Outcome Scale - Intellectual Disabilities (PTOS-ID)

BACKGROUND

There are few valid and reliable psychological therapy outcome measures available for use with people with intellectual disabilities (ID). The current study involved the development of a new scale; the Psychological Therapies Outcome Scale - Intellectual Disabilities (PTOS-ID), and the examination of its validity and internal consistency.

METHOD

The PTOS-ID was administered to 175 people who have ID accessing specialist ID services. The construct validity of the scale was investigated through exploratory factor analysis, concurrent validity through comparison with the Brief Symptom Inventory and internal reliability through internal consistency analysis.

RESULTS

Three factors emerged from the principal components analysis with high levels of internal consistency: (1) anger and mood (α = 0.82); (2) positive well-being (α = 0.81); and (3) anxiety (α = 0.76). Factors (1) and (2) were combined to measure psychological distress (α = 0.85), which correlated strongly with the Global Severity Index of the Brief Symptom Inventory (r = 0.85).

CONCLUSIONS

This preliminary study suggests that the PTOS-ID is a psychometrically robust measure of psychological distress and psychological well-being that can be used with people with ID. Further research is required to assess its reliability and ability to detect change.

Non-verbal Communication Method Based on a Biochemical Marker for People with Severe Motor and Intellectual Disabilities

This study evaluated a novel non-verbal communication method for people with severe motor and intellectual disabilities (SMID) based on a biochemical marker, salivary amylase. The physical and psychological status of 10 people with SMID was quantitatively evaluated using a hand-held salivary amylase activity monitor. Each patient needed daily gastric and/or bronchial tube exchanges and these medical procedures were thought to cause severe distress and pain. Salivary amylase activity and heart rate were simultaneously measured during 32 medical procedures. The medical procedures resulted in a significant mean increase for individuals of 70% in salivary amylase activity. The increase in salivary amylase activity was more than four-fold that observed for heart rate. The structural equation modelling analysis also demonstrated a significant correlation between pain and salivary amylase activity. Our data indicate that salivary amylase activity might be used as a non-verbal method of assessing pain in people with SMID.

Statistical modelling studies examining the dimensional structure of psychopathology experienced by adults with intellectual disabilities: Systematic review

Diagnosing mental ill-health using categorical classification systems has limited validity for clinical practice and research. Dimensions of psychopathology have greater validity than categorical diagnoses in the general population, but dimensional models have not had a significant impact on our understanding of mental ill-health and problem behaviours experienced by adults with intellectual disabilities. This paper systematically reviews the methods and findings from intellectual disabilities studies that use statistical methods to identify dimensions of psychopathology from data collected using structured assessments of psychopathology. The PRISMA framework for systematic review was used to identify studies for inclusion. Study methods were compared to best-practice guidelines on the use of exploratory factor analysis. Data from the 20 studies included suggest that it is possible to use statistical methods to model dimensions of psychopathology experienced by adults with intellectual disabilities. However, none of the studies used methods recommended for the analysis of non-continuous psychopathology data and all 20 studies used statistical methods that produce unstable results that lack reliability. Statistical modelling is a promising methodology to improve our understanding of mental ill-health experienced by adults with intellectual disabilities but future studies should use robust statistical methods to build on the existing evidence base.

Neuropsychological phenotype and psychopathology in seven adult patients with Phelan-McDermid syndrome: implications for treatment strategy

Phelan-McDermid syndrome (PMS) or 22q13.3 deletion syndrome is characterized by a variable degree of intellectual disability, impaired speech and language as well as social communicative skills and mild dysmorphic features. The SHANK3 gene is thought to be a major contributor to the phenotype. Apart from the syndrome-associated autistic features, symptoms from the bipolar spectrum can be discerned, in particular behavior instability and fluctuating mood culminating in a (hypo)manic state. In case of coincident major somatic events, a deteriorating course may occur. This study comprises seven adult patients (four females and three males; aged 21-44 years) with genetically proven PMS. Data from medical records were collected and extensive assessment of neuropsychological variables was performed to identify cognitive characteristics and their relation with psychopathology and treatment. All patients showed profound communication deficits and their developmental functioning ranged from 1.0 to 6.3 years. In addition, they had slow speed of information processing, impairment of attentional and executive functions and cognitive alexithymia. As to psychopathology, features from the affective and anxiety domains were prominent findings in these seven patients suggesting the presence of a bipolar spectrum disorder that could be effectively moderated with mood-stabilizing agents. Results are discussed in terms of the putative involvement of structural brain abnormalities, in particular cerebellar vermis hypoplasia and corpus callosum thinning and their cognitive and emotional sequelae. It is concluded that the treatment of 22q13.3-associated psychopathology should include prescription of mood-stabilizing agents in combination with individually tailored contextual neuropsychological measures.

Absence epilepsy and the CHD2 gene: an adolescent male with moderate intellectual disability, short-lasting psychoses, and an interstitial deletion in 15q26.1-q26.2

Deletions of the 15q26 region encompassing the chromodomain helicase DNA binding domain 2 (CHD2) gene have been associated with intellectual disability, behavioral problems, and several types of epilepsy. Including the cases mentioned in ECARUCA (European cytogeneticists association register of unbalanced chromosome aberrations) and DECIPHER (database of genomic variation and phenotype in humans using ensembl resources), so far, a total of 13 intellectually disabled patients with a genetically proven deletion of the CHD2 gene are described, of whom eleven had a history of severe forms of epilepsy starting from a young age. In this article, a moderately intellectually disabled 15-year-old male with a 15q26.1-q26.2 interstitial deletion is reported, who was referred for analysis of two recent short-lasting psychotic episodes that were nonresponsive to antipsychotic treatment and recurrent disinhibited behaviors since early infancy. Careful interdisciplinary assessment revealed that the psychotic phenomena originated from a previously unrecognized absence epilepsy. Treatment with valproic acid was started which resulted in full remission of psychotic symptoms, and consequently, substantial improvement of behavior. It was concluded that in case of (rare) developmental disorders with genetically proven etiology, a detailed inventory of anamnestic data and description of symptomatology over time may elucidate epilepsy-related psychopathology for which a specific treatment regimen is needed.

Examining the psychometrics of the Psychopathology Inventory for Mentally Retarded Adults-II for individuals with mild and moderate intellectual disabilities

With growing recognition of the occurrence of psychological disorders in individuals with intellectual disability (ID), researchers and clinicians alike have placed emphasis on developing measures to assess for psychopathologies in this population. Despite an increased interest in the topic, there is still a dearth of psychometrically robust measures available to assess for psychopathology in adults with mild and moderate ID. The purpose of this study was to examine the psychometric properties of a revised measure for psychopathology in individuals with mild and moderate ID, the Psychopathology Inventory for Mentally Retarded Adults - second edition (PIMRA-II). Internal consistency, inter-rater reliability, and test-retest reliability were investigated. Validity was studied via convergent validity by comparing the PIMRA-II to the Assessment of Dual Diagnosis (ADD) and via discriminate validity by comparing the PIMRA-II to the Social Performance Survey Schedule (SPSS) prosocial scores. Lastly, an exploratory factor analysis was conducted to determine the factor structure of the scale.

Anxiety disorders in children and adolescents with intellectual disability: Prevalence and assessment

Children and adolescents with intellectual disability are known to experience mental health disorders, but anxiety disorders in this population have received relatively little attention. Firstly, this paper provides a review of published studies reporting prevalence rates of anxiety disorders in children and adolescents with intellectual disability. Secondly, the paper reviews measures of anxiety that have been evaluated in children/adolescents with intellectual disability, and details the associated psychometric properties. Seven studies reporting prevalence rates of anxiety disorders in this population were identified, with reported rates varying from 3% to 22%. Two-one studies evaluating a measure of anxiety in a sample of children/adolescents with intellectual disability were identified. While these studies indicate that several measures show promise, further evaluation studies are needed; particularly those that evaluate the capacity of measures to screen for anxiety disorders, not only measure symptoms.

The assessment of the quality of life of adults with intellectual disability: the use of self-report and report of others assessment strategies

Assessment strategies that reliably and validly assess the indicators of quality of life (QOL) of individuals with intellectual disability (ID) are necessary for planning interventions and evaluating outcomes. In the present study, inter-rater reliability and concordance of the two assessment strategies report of others and self-report were evaluated in a group of 176 Italian adults with ID using the Personal Outcomes Scale, which employs the same QOL indicators in the self-report and report of others versions. Report of others resulted a reliable assessment strategy. Clients' point of view was compared with both the estimation of their point of view and third-party-point-of-view obtained by two independent caregivers for each client. Results indicated that both self-report and report of others assessment strategies are necessary and that estimation of the client's point of view may be a valid and reliable substitute of self-report when clients are not able to answer.

Reliability and validity of the SPAID-G checklist for detecting psychiatric disorders in adults with intellectual disability

SPAID (Psychiatric Instrument for the Intellectually Disabled Adult) is the first Italian tool-package for carrying out psychiatric diagnosis in adults with Intellectual Disabilities (ID). It includes the "G" form, for general diagnostic orientation, and specific checklists for all groups of syndromes stated by the available classification systems. SPAID was established to provide an easy and quick tool for daily practice of the personnel working with ID. The present study was aimed at evaluating psychometric and psychodiagnostic characteristics of the SPAID-G and at supplying new data on the prevalence rate of psychiatric disorders in a multicentric Italian sample of people with ID living in different settings. The SPAID-G was randomly applied to 304 participants with ID attending residential facilities or assessment services across Italy. A part of the sample was also consecutively assessed through the use of DASH, PDD-MRS and by the clinical application of the DSM-IV TR criteria. The correlation between SPAID-G scores and those provided by other evaluation tools was over 60%. Additionally, the internal consistency and inter-rater reliability resulted to be good. Psychopathological symptoms were detected in approximately 40% of the sample. Respectively, autistic spectrum disorders, impulse control disorders, mood disorders, and dramatic personality disorders were the diagnostic orientations providing the most prevalent over-threshold scores. SPAID-G seems to be a valid diagnostic tool, quick and easy to use in psychiatric disorders assessment within the Italian population with ID.

Scaling methods to measure psychopathology in persons with intellectual disabilities

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

Phelan-McDermid syndrome in two adult brothers: atypical bipolar disorder as its psychopathological phenotype?

The 22q13.3 deletion, or Phelan-McDermid syndrome, is characterized by global intellectual disability, generalized hypotonia, severely delayed or absent speech associated with features of autism spectrum disorder, and minor dysmorphisms. Its behavioral phenotype comprises sleep disturbances, communication deficits, and motor perseverations. Data on psychological dysfunctions are so far not available. Previous studies have suggested that the loss of one copy of the gene SH3 and multiple ankyrin repeat domains 3 (SHANK3) is related to the neurobehavioral phenotype. Additional genes proximal to SHANK3 are also likely to play a role in the phenotype of patients with larger deletions. The present paper describes two adult brothers with an identical 2.15 Mb 22qter (22q13.32q13.33) deletion, of whom the youngest was referred for evaluation of recurrent mood changes. In both patients, magnetic resonance imaging of the brain showed hypoplasia of the vermis cerebelli. Extensive clinical examinations led to a final diagnosis of atypical bipolar disorder, of which symptoms fully remitted during treatment with a mood stabilizer. In the older brother, a similar psychopathological picture appeared to be present, although less severe and with a later onset. It is concluded that the behavioral phenotype of the 22q13.3 deletion syndrome comprises absent or delayed speech and perseverations with associated autistic-like features, whereas its psychopathological phenotype comprises an atypical bipolar disorder. The latter may have implications for the treatment regime of the syndrome-related behavioral disturbances.

Examining reports of mental health in adults with Williams syndrome

Prior research suggests that individuals with Williams syndrome (WS) have a disposition towards anxiety. Information regarding this is typically derived from parents and carers. The perspectives of the individuals with WS are rarely included in research of this nature. We examined the mental health of 19 adults with WS using explicit (psychiatric interview) and implicit (modified Stroop task) measures and compared informant (parents/carers) and respondent (adults with WS) reports of psychiatric symptoms. Informants and respondents both reported more symptoms of anxiety (n=7-9) than depression (n=2). Strong positive correlations were found between informant and respondent reports of symptoms of mental health problems. Compared to informants, respondents reported significantly more symptoms overall and somewhat more symptoms of anxiety. Results from the Stroop task indicated that the adults with WS were more vigilant to anxiety-related words than to depression-related words. The adults with WS provided reliable information regarding their mental health, thus providing further evidence that anxiety is part of the behavioural phenotype of the syndrome.

Kleefstra syndrome in three adult patients: further delineation of the behavioral and neurological phenotype shows aspects of a neurodegenerative course

Kleefstra syndrome (KS), previously known as the 9q subtelomeric deletion syndrome (9qSTDS) is caused by haploinsufficiency of the EHMT1 gene. Both a single mutation and 9q34 microdeletions encompassing the entire gene can be responsible for this syndrome which is characterized by intellectual disability, hypotonia, and typical dysmorphisms, and may be associated with congenital heart and/or renal defects and epilepsy. Its behavioral phenotype has recently been described and comprises particular sleep disturbances and apathy. In this report, the evolution of the behavioral profile of KS is outlined by the description of three female patients aged 19, 33, and 43 years, respectively. In two patients, the syndrome was caused by an intragenic mutation and in the third by a 9q34 microdeletion encompassing the EHMT1 gene. MRI scanning of the brain in the two eldest patients demonstrated multifocal subcortical signal abnormalities. In general, the severity of the behavioral and motor deficiencies increased over time and became apparent after adolescence. It is concluded that the "regressive" phenotype of KS seems to be associated with the EHMT1 gene in particular. In addition, the utility of uncritical use of a classificatory diagnostic approach is discussed in the context of the motor and motivational disturbances that are prominent in this syndrome.

Investigating the relationship between challenging behavior, co-morbid psychopathology and social skills in adults with moderate to severe intellectual disabilities in Ireland

Researchers suggest that social skill deficits and psychiatric issues may be affected by the presence of maladaptive behaviors in people with intellectual disabilities. A sample of 39 participants with intellectual disability was surveyed for the presence of psychiatric symptoms and social skills deficits. Outcomes indicated that individuals with severe challenging behaviors scored significantly higher than those without problem behaviors in terms of presence of psychiatric symptoms in ten of the thirteen subscales of the DASH-II. Results also showed that individuals with severe problem behaviors scored significantly lower on social skills measures, using the MESSIER, than those without. A significant difference was observed between participants presenting with psychiatric symptoms and those who did not in terms of social skills, with the former scoring significantly lower than the latter. Results of the study provide weight to current research supporting the relationships between problem behaviors, co-morbid psychopathology and social skill deficits. This information could be used to further develop positive supports for adults with intellectual disability and challenging behaviors in order to improve their quality of life, community inclusion and social networks.

Characteristics of instruments screening for depression in adults with intellectual disabilities: systematic review

The aim of this study was to obtain information on feasibility, reliability and validity of available instruments screening for depression applied in people with intellectual disabilities (ID). Therefore, literature was systematically reviewed. For self-report, the Glasgow Depression scale for people with a Learning Disability appears most promising (internal consistency α=0.90, test-retest reliability r=0.97, sensitivity 96% and specificity 90%). For informant-report three instruments seem promising: the Assessment of Dual Diagnosis (internal consistency α=0.77 and α=0.91, test-retest reliability r=0.94, interrater reliability r=0.98), the Reiss Screen for Maladaptive Behaviour (internal consistency α=0.58-0.83, interrater reliability r=0.61-0.84, sensitivity 80%, specificity 83%), and the Children's Depression Inventory (internal consistency α=0.86, sensitivity 83%, specificity 93%). None of these three instruments have been studied satisfactorily in this group, yet. More research on psychometric properties, especially sensitivity and specificity in the ID population, is needed.

Behavioral phenotype in the 9q subtelomeric deletion syndrome: a report about two adult patients

The 9q Subtelomeric Deletion Syndrome (9qSTDS) is clinically characterized by mental retardation, childhood hypotonia, and facial dysmorphisms. Haploinsufficiency of the EHMT1 gene has been demonstrated to be responsible for its core phenotype. In a significant number of patients behavioral abnormalities like aggression, impulsivity, and chaotic behaviors are present as well as epileptic phenomena. Reports about the developmental, behavioral, and neuropsychiatric aspects of 9qSTDS are scarce and mostly limited to young patients only. In this report, the behavioral and neuropsychiatric characteristics of one male and one female middle-aged patient are described in whom the genetic diagnosis, interstitial and telomeric 9q deletion, respectively, was established recently. In both patients a remarkable sleep disturbance, characterized by frequent awakenings and daytime sleepiness, was present as well as a prominent apathy syndrome. The observed motor signs such as rigid flexure of the arms and finger stereotypies persisted over a period of many years and could therefore not be viewed as symptoms of catatonia. It is concluded that the proposed behavioral phenotype of 9qSTDS comprises at least an erratic sleep pattern and an enduring severe apathy.

Pharmacotherapy for aggressive behaviours in persons with intellectual disabilities: treatment or mistreatment?

BACKGROUND

Antipsychotic medications have been used extensively to treat aggressive behaviours in persons with intellectual disabilities (ID) when the main psychiatric diagnoses given to them in the past were schizophrenia, childhood psychoses and ID with behaviour problems. Today, antipsychotics are still estimated to comprise 30-50% of all the psychotropics prescribed for persons with ID, although the prevalence of psychotic disorders is only 3% in this population. The overuse of antipsychotics in persons with ID could be justified if their aggressive behaviours were associated with mostly psychotic disorders and not other psychiatric disorders or factors and if the anti-aggressive properties of the antipsychotics have been supported by basic research or reviews of clinical studies. Is that so? This article explores these questions.

METHODS

The literature on aggressive behaviours, their associations with psychiatric disorders and other contributing factors and the past and current treatment options for aggressive behaviours in persons with and without ID was reviewed. Also, the literature on basic research regarding the brain receptors implicated in aggressive behaviours and the basic research and clinical studies on the anti-aggressive properties of antipsychotics was reviewed.

RESULTS

Aggressive behaviours in persons with ID serve different functions and many factors contribute to their initiation, maintenance and exacerbations or attenuation including most of the psychiatric and personality disorders. Genetic disorders, early victimisation, non-enriched and restrictive environments during childhood or later on and traumatic brain injury, which are common in persons with ID, have been associated with aggressive behaviours and with mostly non-psychotic disorders in persons with and without ID. If the factors above and the knowledge derived from studies of domestic violence and premeditated aggression in persons without ID are considered and applied during the evaluation of the most severe aggressive behaviours in persons with ID, more appropriate and effective treatment than antipsychotics can be implemented. Basic research implicates mostly the GABA and the serotonin pre-post synaptic brain receptors influence the initiation, modulation or inhibition of aggression in animals. The anti-aggressive properties of the antipsychotics have not been supported by reviews of clinical studies and basic research is absent. Antipsychotics are the indicated treatment only for psychiatric disorders and for aggressive behaviours associated with psychotic disorders and psychotic features as activation of dopamine receptor leads to defensive aggression.

CONCLUSIONS

Most of the persons with ID and aggressive behaviours do not have a diagnosis of psychotic disorder and there is lack of strong evidence supporting the anti-aggressive properties of the antipsychotics. The overuse of antipsychotics in this population may be explained by the old, faulty notion that aggressive behaviour in persons with ID is mostly associated with psychotic disorders. Given the discrediting of this notion, the use of antipsychotics in persons with ID may, in some cases, be considered mistreatment rather than proper treatment. In order to reverse the practice of over-prescribing antipsychotics for aggressive behaviours in persons with ID, basic research information on aggression must be disseminated, the search for the 'quick fix' must be abandoned and the promotion of antipsychotics as anti-aggressive drugs must be discouraged. Matching the treatment with the variables contributing to the aggressive behaviours, seeking a long-term rather than a short-term solution and avoiding the promotion of only one type of treatment for all types of aggression might change the current practice and improve the quality of life for many persons with ID.

Comorbid psychopathology in adults with Autism Spectrum Disorders and intellectual disabilities

There is an abundance of research investigating Autism Spectrum Disorders (ASD) in children; however, little emphasis has been placed on ASD in adults, especially in regards to comorbid psychopathology. Although scales are available that measure comorbidity in adults with ID, what is needed are scales that measure comorbidity in adults with ID and ASD. One such scale is the newly developed Autism Spectrum Disorders-Comorbidity for Adults (ASD-CA). There are two purposes of this study. The first is to further develop the ASD-CA by calculating cutoff scores for its subscales. The second is to compare the frequency of symptom endorsements on the ASD-CA among three groups: individuals with ID; individuals with ID and ASD; and individuals with ID, ASD, and additional psychopathology.

The psychosocial impact of epilepsy in adults with an intellectual disability

Epilepsy has a pervasive impact on the quality of life, and thus the psychosocial well-being, of adults with an intellectual disability. Social and economical well-being appears to be affected by an increase in restrictions on activities and thus social contact. The population has very high rates of challenging behaviors and of mental illness. It is likely that these have a significant impact on epilepsy management. When populations with and without epilepsy are controlled for level of ability, no difference in prevalence of behavior or mental illness is seen between the populations. Current knowledge is limited on crucial issues such as the long-term effect of seizure disorder on mental health, quality of life, and cognition.

The overlap between psychiatric symptoms and challenging behaviour: a preliminary study

Increasingly, challenging behaviour is explained by way of psychiatric symptomatology. This poses possible pitfalls. First, the possibility exists that both psychiatric symptoms and challenging behaviour are concurrent expressions of common underlying factors. Second, psychiatric symptoms may be rated as present on the basis of challenging behaviour, which may render it more difficult to explain the latter by way of the former. The present study was conducted in order to investigate possible overlaps between psychiatric symptoms and challenging behaviour, when symptoms are rated by caregivers. The results indicate considerable overlaps. Implications for explaining challenging behaviour are discussed, as well as limitations of the study, first and foremost the use of untrained assessors and small sample size.

Amfetamine for attention deficit hyperactivity disorder in people with intellectual disabilities

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is increasingly recognised as occurring in people with intellectual disability (ID), although treatment of ADHD in this population has not been tested widely. Amfetamine has been used to treat ADHD in people with and without ID, although the evidence for its efficacy in people with ID is unclear.

OBJECTIVES

To examine the effectiveness of amfetamine for the treatment of attention deficit hyperactivity disorder in people with intellectual disabilities.

SEARCH STRATEGY

MEDLINE, PsycINFO, EMBASE, AMED, ISI Web of Science and WorldCat Dissertations were searched using an extensive list of synonyms for ADHD and ID. CENTRAL, Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register, clinicaltrials.gov were searched in August 2007. Pharmaceutical companies and experts in the field were contacted. Reference lists of review articles were examined and citation searches were performed in ISI Web of Knowledge.

SELECTION CRITERIA

All randomised controlled studies, both published and unpublished, in any language, in which children or adults with ADHD and ID were treated with amfetamine.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers using a standardised extraction sheet. Risk of bias was assessed by two authors using a standardised framework. Meta-analyses were planned but were not performed due to a lack of suitable studies.

MAIN RESULTS

Only one study was suitable for inclusion. This was a cross-over study in 15 children with ADHD, ID and Fragile X syndrome. Duration of treatment was only one week. No significant difference was reported between amfetamine and placebo for any of the ADHD measures, but significantly more side effects were reported while taking amfetamine, mainly mood lability and irritability.

AUTHORS' CONCLUSIONS

There is very little evidence for the effectiveness of amfetamine for ADHD in people with ID . Prescribing in this population is based on extrapolation of research in people without ID. More research into effectiveness and tolerability is urgently needed.

Checklists for general practitioner diagnosis of depression in adults with intellectual disability

BACKGROUND

In Australia, diagnosis and management of depression in adults with intellectual disability (ID) often occurs within the primary care setting. Few tools are available to assist general practitioners (GPs) in the diagnostic process. The study aim was to assess properties of carer and GP checklists developed to address this problem.

METHOD

Participants were 49 adults with ID and their paid carers (support workers), and GPs for 27 adults. Data from carer and GP checklists were gathered, in addition to carer completed Developmental Behaviour Checklist-Adults (DBC-A). Adults with ID also received a comprehensive psychiatric assessment.

RESULTS

Both checklists demonstrated good internal consistency (KRS-20 = 0.90). A factor analysis of the carer checklist indicated a single factor on which three section totals had loadings of greater than 0.722 (depressed mood, loss of interest, and social interaction and communication). This factor was interpreted to be depression. The GP checklist data were insufficient for factor analysis, but section totals were moderately correlated with most corresponding carer checklist section totals. Carer section totals related to depression also correlated highly with the DBC-A Depression sub-scale, demonstrating good concurrent validity. Contrasting results were obtained for the GP checklist. Most (n = 42) of the participants were diagnosed with a psychiatric disorder, precluding the testing of checklist specificity and sensitivity.

CONCLUSION

The carer checklist shows promise as a means of gathering information needed by a GP in the diagnosis of depression in adults with ID. Further research into its underlying properties and clinical uses of a combined depression checklist is warranted.

Assessing challenging behaviors in children with autism spectrum disorders: a review

A common covarying group of behaviors with ASD are self-injury, aggression, noncompliance, and stereotypies. These problems and related challenging behaviors are problematic in that they are physically dangerous and can impede learning and access to normal activities. Additionally, they require a considerable amount of resources, and compound the difficulty in treating core ASD symptoms. Despite the high profile challenging behaviors present in this population, there has not been a great deal of research regarding assessment, identification, and monitoring of such difficulties. This review covers available empirical based methods for assessing these behaviors. A discussion is provided of potential avenues for future research and clinical practice which is urgently needed for ASD children at this time.

Comorbid psychopathology with autism spectrum disorder in children: an overview

Comorbidity, the co-occurrence of two or more disorders in the same person, has been a topic receiving considerable attention in the child psychopathology literature overall. Despite many publications in the ADHD, depression and other child literatures, autism spectrum disorder has not received such scrutiny. The purpose of this review will be to discuss the available evidence. We address specific variables in diagnosis and classification of comorbid symptoms, and propose potential avenues for research and practice with respect to differential diagnosis. A brief discussion of the implications for treatment is also provided.

The impact of child symptom severity on depressed mood among parents of children with ASD: the mediating role of stress proliferation

Stress proliferation (the tendency of stressors to engender additional stressors in other life domains) is explored in a sample of 68 parents of children identified with ASD. Regression analyses showed that parent depression was predicted by both child symptom severity and by stress proliferation and that stress proliferation partially mediated the effect of child symptom severity on parent depression. In addition, informal social support was found to reduce levels of parent stress proliferation and parent depression; however, contrary to the stress buffering hypothesis, the ameliorative effect of support on stress proliferation was shown to be greatest when reported child symptomatology was less (rather than more) severe. Study implications for future research and practice are discussed.

A psychometric evaluation of a Swedish version of the psychopathology inventory for mentally retarded adults (PIMRA)

Given the difficulties with symptom identification and the assessment of mental health problems in persons with intellectual disabilities (ID) there has been a focus on the development of relevant assessment schedules for persons with ID. A Swedish version of the psychopathology inventory for mentally retarded adults (PIMRA, informant version), an instrument designed for identification of specific mental health problems in persons with ID, was evaluated in terms of inter-rater reliability, internal consistency, item grouping, criterion and concurrent validity based on a sample of 101 adults with different levels of ID. The Swedish version of the PIMRA had low inter-rater agreement on specific items but good agreement on low or high total score. In order to investigate internal validity, principal component analyses (PCA) were conducted in steps. Consequently, the majority of the 26 items, which remained after three PCA analyses, were grouped in a pattern approximating five of the original PIMRA subscales. The present analysis identified no item grouping matching the original Affective disorder subscale. Based on these results a revised Swedish version was developed. The concurrent validity analysis yielded a strong association between the total scores of the PIMRA and Reiss Screen for Maladaptive Behaviour (RSMB), between subscales on both instruments describing psychotic symptoms and between the RSMB subscale Aggressive behaviour and the PIMRA subscale Adjustment problems. The outcome of the criterion validity analysis indicated that individuals with a clinical diagnosis obtained higher total PIMRA scores than individuals without a clinical diagnosis and a comparison between the PIMRA subscale Psychosis and the clinical diagnosis indicating psychoses according to DSM-III-R or DSM-IV yielded a higher specificity than sensitivity measure. The results indicate that the PIMRA had a potential to identify individuals with mental health problems in persons with different levels (mild, moderate and severe) of ID and identify individuals with a specific mental disorder. Thus, professionals might use the PIMRA as a complement in the diagnostic process.

Assessing psychopathology in individuals with developmental disabilities

Individuals with developmental disabilities are at high risk for developing mental health problems. The prevalence of psychopathology is approximately 4 times higher than that found in the general population. Yet there is a tendency to underdiagnose psychiatric disorders in the developmentally delayed population because of diagnostic overshadowing, the lack of appropriate diagnostic criteria, and the paucity of appropriate assessment measures. Over the past decade, there has been an emergence of scales developed specifically to screen for psychopathology in individuals with developmental disabilities. In addition, advancements have been made in observation techniques, thus facilitating the ability to objectively observe behaviors often described as internal events. A description of a multimethod approach to assessing psychopathology in individuals with developmental disabilities is provided incorporating the recent advancements in the field, as well as suggestions for future research.

Life events as correlates of problem behavior and mental health in a residential population of adults with developmental disabilities

Very few existing empirical studies have explored the putative association between exposure to negative life events and psychological well-being in adults with developmental disabilities. In the present study, data on exposure to life events in the previous 12 months, adaptive behavior, problem behavior, and psychiatric problems were provided by care staff for 93 adults with developmental disabilities living in a residential hospital setting. Residents had typically been exposed to between three and four negative life events mainly relating to staffing and residence changes, conflict, family bereavements and relationships, and illness or injury. Those exposed to more recent life events were also rated as displaying more frequent aggressive/destructive behavior, and were at increased risk for affective/neurotic disorder. The need for replication of these data, especially using designs allowing causality to be inferred, is emphasized.

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.

Depression, anxiety, and relevant cognitions in persons with mental retardation

We assessed depression, anxiety, and relevant cognitions in persons with mental retardation by administering modified versions of the Reynolds Child Depression Scale, the Beck Anxiety Inventory, the Automatic Thoughts Questionnaire, and the Cognitions Checklist to 46 persons with borderline to moderate mental retardation. Consistent with research with other groups, self-reports of depression and anxiety were highly correlated (r = .74) in these individuals, and cognitions were strong predictors of negative affect. Subscales measuring cognitions related to depression and anxiety were also highly related, limiting the "cognitive-specificity" hypothesis. Hierarchical multiple regression analyses offered mixed support for cognitive-specificity. We discuss the implications of these findings for the cognitive and affective assessment of persons with intellectual limitations.