The assessment of mood in adults who have severe or profound mental retardation

The 10-year trajectory of aggressive behaviours in autistic individuals

BACKGROUND

Aggressive behaviours are common in people with neurodevelopmental conditions, contributing to poorer quality of life and placement breakdown. However, there is limited empirical research documenting the prevalence and persistence of aggressive behaviours in autism. In this longitudinal study, aggressive behaviours were investigated in a sample of autistic individuals over 10 years.

METHODS

Caregivers of autistic individuals, both with and without intellectual disability, completed questionnaires relating to the presence of aggressive behaviours at T1 [N = 229, mean age in years 11.8, standard deviation (SD) 5.9], T2 (T1 + 3 years, N = 81, mean age in years 15.1, SD 5.9) and T3 (T1 + 10 years, N = 54, mean age in years 24.5, SD 8.1). Analyses examined the presence and persistence of aggressive behaviours and the predictive value of established correlates of aggression.

RESULTS

Aggressive behaviours were common at baseline (61.6%) but only persistent in 30% of the sample over 10 years. Higher composite scores of overactivity and impulsivity at T1 were significantly associated with the persistence of aggressive behaviours at T2 (P = 0.027) and T3 (P = 0.012) with medium effect size.

CONCLUSIONS

Aggressive behaviours are common in autism, but reduce with age. Behavioural correlates of attention deficit hyperactivity disorder (ADHD) predict the presence and persistence of aggressive behaviour and as such may be useful clinical indicators to direct proactive intervention resources to ameliorate aggressive behaviours.

The contribution of physical and social activity participation to social support and happiness among people with physical disabilities

BACKGROUND

Prior studies have suggested that certain leisure activities provide health benefits to people with physical disabilities. Participation in social activities has been identified as a strong predictor of active coping strategies and social support from others. In addition, leisure-time physical activity (LTPA) has been found to be positively associated with health perceptions and quality of life.

OBJECTIVES

The purpose of this study was to investigate the relationships between social activity and LTPA to social support and life satisfaction among people with physical disabilities.

METHODS

Data were collected from Korean Association of Persons with Physical Disabilities. A total of 351 surveys were used.

RESULTS

Results indicated that social activity, emotional and informational support, and tangible and affectionate support were significantly associated with happiness. However, there were no direct effects of LTPA and positive social interaction support on happiness. The study results showed significant direct effects of LTPA on emotional and informational support and positive social interaction.

CONCLUSION

This study shows that it is important for people with physical disabilities not only to participate in LTPA, but also to be provided with opportunities for social activities. In particular, the importance of social activity to Korean people with physical disabilities as a means of receiving social support and increasing happiness was confirmed. The results suggest that practitioners need to create a variety of social activity opportunities, such as online social participation programs, community-based social programs, and social events for health.

Identification of emotions and physiological response in individuals with moderate intellectual disability

According to Ekman's model, the basic emotions are anger, disgust, fear, happiness, sadness, and surprise. These emotions are universal and have an adaptative function. However, studies on these emotions among individuals with moderate intellectual disability (MID) are limited, mainly owing to issues in sample size and sample homogeneity. The present study aimed to explore differences between a MID group (n = 10) and a non-MID control group (n = 10) in 1) the identification of basic emotions; and 2) the physiological response with images related to fear, happiness, sadness, anger, and disgust, as well as images with neutral and sexual content. A total of 29 images from The International Affective Picture System and a biofeedback measurement system were used. The results showed no statistically significant differences in the identification of the basic emotions of fear, sadness, and disgust. However, statistically significant differences were found for happiness (p = .008), anger (p = .02), and neutral images (p = .02), and minor statistically significant differences were found for images with sexual content (p < .01) in MID individuals with respect to the control group. The MID group's physiological response was lower compared with the control group, with statistically significant differences for all emotional visual stimuli. This preliminary study showed important and interesting results for the study of emotions and sexuality in MID. Future studies should consider the sample size, sex and age comparisons, and the different levels of intellectual disability.

Age-related Behavioural Change in Cornelia de Lange and Cri du Chat Syndromes: A Seven Year Follow-up Study

Age-related behavioural change in Cornelia de Lange syndrome is poorly understood. We report a 7 year follow-up study of adaptive behaviour, autism spectrum disorder symptomatology, language skills and behavioural characteristics in 30 individuals with Cornelia de Lange syndrome, compared with 18 individuals with Cri du Chat syndrome. The proportion of individuals with Cornelia de Lange syndrome meeting criteria for autism spectrum disorder on the Autism Diagnostic Observation Schedule increased, although patterns of change were complex. For both syndrome groups, absolute levels of adaptive ability were stable and receptive language improved, suggesting that changes over time do not result from an overall decline in ability. Reliable change index scores indicate heterogeneity within both groups in the occurrence of improvement or decline.

Prevalence of anxiety and depressive disorders among youth with intellectual disabilities: A systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analytic study was to determine the pooled prevalence estimates of anxiety and depressive disorders among children and adolescents with intellectual disabilities (ID) and to assess the extent to which these pooled prevalence rates differed according to studies' characteristics.

METHOD

A systematic literature search was performed in nine databases and 21 studies, published between 1975 and 2015, met the inclusion criteria.

RESULTS

The resulting pooled prevalence estimates of combined subtypes of anxiety and depressive disorders were respectively (a) 5.4% and 2.8% across samples; (b) 1.2% and 0.03% among children; and (c) 7.9% and 1.4% among adolescents. Pooled prevalence estimates for specific subtypes of anxiety disorders ranged from (a) 0.2% to 11.5% across samples; (b) 0.7% to 17.6% among children; and (c) 0.6% to 19.8% among adolescents. Pooled prevalence estimates of dysthymic disorder and major depressive disorder were respectively (a) 3.4% and 2.5% across samples; (b) 2.1% and 3.2% among children; and (c) 6.9% and 5.7% among adolescents. Finally, subgroup analyses showed significant variations in the pooled prevalence estimates of combined subtypes of anxiety disorders, obsessive-compulsive disorder, and generalized anxiety disorder; and combined subtypes of depressive disorders.

LIMITATIONS

The present findings of this meta-analysis should be interpreted with caution given several limitations related to the characteristics of the populations, diagnostic method and sampling method.

CONCLUSION

Findings provide recommendations for future studies investigating psychological disorders among youth with ID, as well as how clinicians and policy makers can improve diagnostic practices and support for youth with ID.

Identifying perception behaviours in people with profound intellectual and multiple disabilities

BACKGROUND

To support people with profound intellectual and multiple disabilities (PIMD), it is essential to understand how they experience their environment. Insight into perception behaviour may provide an entry point for improved understanding.

MATERIALS AND METHODS

A random sample of a 30-min video registration of five participants with PIMD was used to code behaviours per second based on an ethogram containing 157 different perception behaviours in nine categories.

RESULTS

Eighty-nine different perception behaviours were observed, of which movements with eyes, head and arms were most common. The senses used most were seeing, hearing and touching. Finally, the function of five perception patterns was established in relation to their function:awareness, focusing attention and tension regulation.

CONCLUSIONS

Close observation using an observation ethogram provides insight into how people with PIMD perceive their environment.

A preliminary investigation of the suitability of aquatics for people with severe and profound intellectual disabilities

BACKGROUND

Aquatics is an under-researched but possibly appropriate form of activity for people with severe to profound intellectual disabilities (SPIDs).

AIM

The current pilot study investigates the suitability of an aquatics programme for service users with SPIDs.

METHOD

Four service users with SPID completed an 8-12-session aquatics programme. Front-line staff ( N = 6) were interviewed after the programme to explore its suitability. A thematic analysis of the interviews was utilized.

RESULTS

The thematic analysis unearthed main themes of effects, facilitators, barriers, strengths and needs.

CONCLUSION

Aquatics can be an appropriate and beneficial form of physical activity for people with SPIDs, but there are many barriers to participation. Tailored programmes are required. Further investigation of the experiences of people with SPIDs in relation to physical activity is recommended.

Assessing a Microswitch-Based Stimulation Procedure for Eye-Blinking Responses in a Young Woman with Profound Multiple Disabilities

We applied a new microswitch-based stimulation procedure for eye-blinking responses with a young woman with profound multiple disabilities, and compared effects of this procedure on the eye-blinking responses and smiling with the effects of a caregiver-based stimulation condition. Analysis showed that the microswitch-based stimulation procedure, with stimulation occurring contingent on eye-blinking responses, increased the frequencies of these responses significantly above the levels recorded in baseline and caregiver-based stimulation conditions. No changes in smiling frequencies occurred. Implications of the findings in terms of alertness, learning, and quality of life are discussed.

Prevalence and associated features of depression in women with Rett syndrome

BACKGROUND

Little is known about depression among women with Rett syndrome (RTT) despite recent advances in knowledge about RTT. In this study, we aimed to establish the prevalence of depression among women with RTT as identified by a screening telephone interview and to explore the clinical factors associated with this.

METHODS

The study employed the cross-sectional analysis of data from telephone interviews with carers of 56 women with RTT, using validated questionnaires for assessing mental health problems, challenging behaviour and RTT severity.

RESULTS

Scores on the mental health assessment reached the affective/neurotic threshold in eight cases (14.3%). No significant differences were found between those reaching the threshold and those who did not in terms of severity of RTT phenotype, health problems or social circumstances. There was a significant association between screening identified depression and higher lethargy and social withdrawal.

CONCLUSIONS

Screening identified depression was found among a sizeable minority of women with RTT. Further investigation is needed to establish a clinically validated prevalence of depression among this group and to identify behavioural features that would lead to prompt psychiatric assessment.

The Diagnostic Guideline for Anxiety and Challenging Behaviour for Persons with Intellectual Disabilities: Preliminary Outcomes on Internalizing Problems, Challenging Behaviours, Quality of Life and Clients' Satisfaction

BACKGROUND

People with intellectual disabilities are vulnerable to develop psychopathology (in particular anxiety) and related challenging behaviour. A diagnostic guideline was developed to support professionals to better diagnose and thus treat psychopathology and related CB. This study examined preliminary outcomes from the application of this guideline.

METHOD

A comparative multiple case study with an experimental and a control condition.

RESULTS

The application of the guideline showed a trend of decreases of internalizing problems (P = 0.07) and anxiety/depressed problems (P = 0.09). We found no statistically significant decreases of externalizing problems and no increases in perceived quality of life as compared with care as usual. Clients were not more satisfied with the support they received for coping with their emotional and behaviour problems.

CONCLUSION

The application of the Diagnostic Guideline for Anxiety and Challenging Behaviour did not show statistically significant changes in externalizing problems and Quality of Life. Despite the small sample size of n = 59, we did find a trend in decreasing internalizing problems and anxiety/depressed problems. Further research into either or not confirming these trends is recommended.

Operationalisation of quality of life for adults with severe disabilities

BACKGROUND

The operationalisation of quality of life for people with more severe disabilities has been acknowledged in the published research for more than two decades. This study aims to contribute to our knowledge and understanding of the quality of life of adults with severe disabilities by developing a set of quality of life indicators appropriate to this population using a Delphi method and the eight-domain conceptual model proposed by Schalock & Verdugo (2002).

METHOD

The participating panel in the Delphi method included 12 experts who evaluated each proposed item according to four criteria: suitability, importance, observability and sensitivity. Descriptive analyses were used to select the best items in each of the four rounds of this Delphi study, as well as examining the coefficients of concordance that were calculated for the final pool of items.

RESULTS

The four rounds of the Delphi study resulted in a final pool of 118 items (91 that were considered valid in the first round plus 27 items proposed, reformulated or discussed in the following rounds). Importance and sensitivity were the criteria that received the highest and lowest ratings, respectively, but also the ones that had the highest and lowest mean coefficients of concordance. Experts showed the strongest agreement for items related to material well-being, while the weakest was found for items related to personal development.

CONCLUSIONS

This study further contributes to our understanding of how to operationalise and measure quality of life in adults with severe disabilities. The item pool generated may prove helpful in the development of instruments for the measurement of quality of life-related outcomes in this population.

The purported association between depression, aggression, and self-injury in people with intellectual disability: a critical review of the literature

The prevalence of depression in individuals with an intellectual disability is estimated to lie between 3% and 6%. It has been suggested that symptoms of depression in this population might be atypical and include unusual features such as challenging behavior. However, there is significant disagreement regarding the use of challenging behavior as "depressive equivalent" symptomatology. The aim of this review is to evaluate published research reporting on the association between challenging behavior, specifically aggression and self-injury, and depression in people with an intellectual disability as a first step toward evaluating whether challenging behaviors might be considered as depressive equivalent symptoms. The results of the studies identified indicated that the association between depression and aggression, and depression and self-injury are equivocal and the interpretations of the results limited by threats to validity. Based on this analysis, there is insufficient evidence to support the use of challenging behavior as a depressive equivalent symptom. Further research to examine potentially confounding variables and the association between challenging behaviour and depression using methodologically robust designs and measures is clearly warranted.

The emotional experience of people with intellectual disability: an analysis using the international affective pictures system

The present study provides information on the emotional experience of people with intellectual disability. To evaluate this emotional experience, we have used the International Affective Pictures System (IAPS). The most important result from this study is that the emotional reaction of people with intellectual disability to affective stimuli is very similar to that of the control groups. The way in which people with intellectual disability express basic affect to emotional stimuli in terms of happy-sad and calm-nervous is very similar to that of the general population. However, there are also some differences in how basic affect is expressed in the affective dimensions that might be relevant to our understanding of the emotional life of people with intellectual disability.

Treatments for the challenging behaviours of adults with intellectual disabilities

OBJECTIVE

To provide an overview and critical assessment of common problems and best evidence practice in treatments for the challenging behaviours (CBs) of adults with intellectual disabilities (IDs).

METHOD

Commonly observed problems that present obstacles to successful treatment plans are discussed, followed by an analysis of available research on the efficacy of behavioural and pharmacological therapies.

RESULTS

Behavioural and pharmacological interventions are most commonly used when addressing CBs in people with IDs. However, within each of these techniques, there are methods that have support in the literature for efficacy and those that do not. As clinicians, it is important to follow research so that we are engaging in best practices when developing treatment plans for CBs.

CONCLUSIONS

One of the most consuming issues for psychiatrists and other mental health professionals who work with people who evince developmental disabilities, such as IDs, are CBs. These problems are very dangerous and are a major impediment to independent, less restrictive living. However, there is a major gap between what researchers show is effective and much of what occurs in real-world settings.

The tell-tale: what do heart rate; skin temperature and skin conductance reveal about emotions of people with severe and profound intellectual disabilities?

Identifying emotions in people with severe and profound intellectual disabilities is a difficult challenge. Since self-reports are not available, behaviour is the most used source of information. Given the limitations and caveats associated with using behaviour as the sole source of information about their emotions, it is important to supplement behavioural information with information from another source. As it is accepted that emotions consist of language, behaviour and physiology, in this article we investigated if physiology could give information about the emotions of people with severe and profound intellectual disabilities. To this aim we tested hypotheses derived from the motivational model of Bradley, Codispoti, Cuthbert, and Lang (2001) about the relation between heart rate and the valence of emotions and between heart rate, skin conductance and skin temperature and behavioural expressions of emotions of people with severe and profound intellectual disability. We presented 27 participants with 4 staff-selected negative and 4 staff-selected positive stimuli. The situations were videotaped and their heart rate, skin conductance and skin temperature was measured. Each behaviour of the participant was coded using the observational method developed by Petry and Maes (2006). As hypothesized, we found a lower heart rate when participants were presented with negative stimuli than when they were presented with positive stimuli in the first 6s of stimuli presentation. Their skin temperature was higher for the expression of low intensity negative emotions compared to the expression of low intensity positive emotions. The results suggest that, as with people without disability, heart rate and skin temperature can give information about the emotions of persons with severe and profound ID.

Review: a systematic review of quality of life measures for people with intellectual disabilities and challenging behaviours

BACKGROUND

The quality of life (QOL) construct is proposed as a method to assess service outcomes for people utilising disability services. With this in mind, the aim of this study was to conduct a systematic review of available QOL measures for people with intellectual disability (ID) to pinpoint psychometrically sound measures that can be routinely used for service evaluation.

METHOD

A systematic search of the disability literature published between 1980 and 2008 was conducted in order to identify appropriate QOL tools for use within an Australian context. Twenty-four QOL instruments were identified and each instrument was then evaluated against a set of psychometric and measurement criteria.

RESULTS

Six of the instruments examined were deemed to be psychometrically sound on the available information. No instruments were found that specifically assess QOL for people with ID who exhibit challenging behaviour. Most of the instruments assess QOL from a subjective perspective, use a questionnaire format and measure only some (not all) of the eight theoretically accepted domains of QOL.

CONCLUSIONS

More instruments that measure QOL need to be developed and rigorously validated. This is especially the case for high-needs disability populations like those individuals that exhibit challenging behaviour or have severe to profound ID, as it is questionable whether existing measures can be used with these populations.

The Center for Epidemiologic Studies Depression Scale: factor validity and reliability in a French sample of adolescents with Intellectual Disability

The purpose of this study was to test the factor validity and reliability of the Center for Epidemiologic Studies Depression Scale (CES-D) within a sample of adolescents with mild to moderate Intellectual Disability (ID). A total sample of 189 adolescents (121 boys and 68 girls), aged between 12 and 18 years old, with mild to moderate ID were involved in two studies. In study 1, the content, phrasing and answering format of the CES-D were adapted for adolescents with ID. This instrument was renamed CES-D for ID (CES-D-ID) and two different versions based on two alternative answer scales (Likert and Likert-graphical) were developed and their psychometric properties were verified in study 2. The results provided support for the factor validity, reliability and invariance across gender and age of a 14-item version of the CES-D-ID based on a Likert-graphical answer scale.

The relationship between psychopathology symptom clusters and the presence of comorbid psychopathology in individuals with severe to profound intellectual disability

In the typically developing population, comorbid psychopathology refers to the co-occurrence of two different psychopathologies other than cognitive impairments. With respect to individuals with intellectual disability, comorbidity is often described as cognitive deficits and one additional psychopathology manifesting together. However, just as within the typically developing population, individuals with intellectual disability may also present with symptoms of two or more additional disorders. The presentation of these symptom clusters may similarly correlate. Therefore, the current study used the Diagnostic Assessment for the Severely Handicapped-II in order to examine relationships between psychopathological symptom clusters in adults with severe to profound intellectual disability. Additionally, we assessed comorbid presentation of disorders other than cognitive impairments in these same adults. Several symptom clusters were identified as being related with moderate to strong positive correlations. Furthermore, elevations on the Impulse subscale were noted to be the most prevalent in the current sample, with comorbid elevations most commonly occurring along the Mood, Mania, and Anxiety subscales. The significance of these findings is discussed.

Instruments assessing anxiety in adults with intellectual disabilities: a systematic review

BACKGROUND

In the last decades several instruments measuring anxiety in adults with intellectual disabilities have been developed.

AIM

To give an overview of the characteristics and psychometric properties of self-report and informant-report instruments measuring anxiety in this group.

METHOD

Systematic review of the literature.

RESULTS

Seventeen studies studying 14 different instruments were found. Methodological quality as measured with the Quality Assessment of Diagnostic Accuracy Studies checklist was insufficient for four studies, sufficient for seven, and good for six. For self-report, the Glasgow Anxiety Scale for people with a learning disability appears most promising, with good internal consistency (a = 0.96), high test-retest reliability (r = 0.95), sensitivity (100%) and specificity (100%). For informant-report, the general anxiety subscale of the Anxiety, Depression and Mood Scale may be promising, with good internal consistency (a = 0.83 and a = 0.84) and excellent test-retest reliability (ICC = 0.78 and ICC = 0.92), but poor interrater reliability (ICC = 0.39).

CONCLUSIONS

Two instruments appear promising. However, these instruments have only been studied once or twice, whereas the methodological quality of these studies was varying.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The expression and assessment of emotions and internal states in individuals with severe or profound intellectual disabilities

The expression of emotions and internal states by individuals with severe or profound intellectual disabilities is a comparatively under-researched area. Comprehensive or standardized methods of assessing or understanding the emotions and internal states within this population, whose ability to communicate is significantly compromised, do not exist. The literature base will be discussed and compared to that applicable to the general population. Methods of assessing broader internal states, notably depression, anxiety, and pain within severe or profound intellectual disabilities are also addressed. Finally, this review will examine methods of assessing internal states within genetic syndromes, including hunger, social anxiety, and happiness within Prader-Willi, Fragile-X and Angelman syndrome. This will allow for identification of robust methodologies used in assessing the expression of these internal states, some of which may be useful when considering how to assess emotions within individuals with intellectual disabilities.

The association between repetitive behaviours, impulsivity and hyperactivity in people with intellectual disability

BACKGROUND

There is a need for assessments of psychological difference and disorder in people who have more severe intellectual disability (ID). Hyperactivity and impulsivity are two behavioural domains of importance as they are correlated with self-injury and aggression and this alludes to a shared cognitive correlate of compromised behavioural inhibition. Additionally, compromised behavioural inhibition is demonstrably related to repetitive behaviour and the latter might be expected to be associated with impulsivity and hyperactivity.

METHODS

The Activity Questionnaire (TAQ) was developed for this study. Three sub-scales with high levels of face validity were supported by factor analysis of the scoring of 755 intellectually disabled participants on the TAQ items. These sub-scales mapped onto the constructs of Overactivity, Impulsivity and Impulsive Speech. Test-retest, inter-rater reliability and internal consistency were robust. TAQ scores and scores on the Repetitive Behaviour Questionnaire (RBQ) were collected for a sample of 136 participants with varying degrees of ID.

RESULTS

Scores on the TAQ at sub-scale and full-scale level were not related to level of adaptive functioning. There were significant positive associations between overactivity (TAQ) and stereotyped behaviour (RBQ), impulsivity (TAQ) and restricted preferences (RBQ), and impulsive speech (TAQ) and repetitive speech (RBQ).

CONCLUSIONS

The TAQ is a reliable assessment of hyperactivity and impulsivity for people with ID with robust factor structure. Validity requires evaluation. The relationship between impulsivity and restricted preferences may result from a common cognitive impairment in inhibition, which may underpin these two classes of behaviour.

Psychometric evaluation of a questionnaire to measure the quality of life of people with profound multiple disabilities (QOL-PMD)

Because of a shortage of valid instruments to measure the QOL of people with profound multiple disabilities (PMD), the QOL-PMD was developed. In the present study, possibilities for item reduction as well as the psychometric properties of the questionnaire were examined. One hundred and forty-seven informants of people with PMD participated in the study. Fifty items were removed from the questionnaire on the basis of preset criteria. Internal consistency was good for the total questionnaire as well as for the subscales. Evidence of the construct validity of the questionnaire was found. Correspondence between the groups of informants was moderate. The results of this preliminary analysis of the psychometric properties of the QOL-PMD are encouraging, but further validation of the measure is warranted.

An overview of research on increasing indices of happiness of people with severe/profound intellectual and multiple disabilities

PURPOSE

This paper was to provide an overview of research studies aimed at increasing indices of happiness of persons with severe/profound intellectual and multiple disabilities.

METHODS

Computerized and manual searches were carried out to identify the studies published from 1990 to 2004 (i.e., the period during which the issues of quality fo life and happiness in people with disabilities have become more prominent). Twenty-four research studies were identified. They involved the use of six different procedures, that is, structured stimulation sessions, microswitch-based simulation sessions, leisure activities and favourite work tasks or conditions, positive environment or positive behaviour support programmes and mindful caregiving, favourite stimulation automatically delivered on exercise engagement, and snoezelen.

RESULTS AND CONCLUSION

Data tended to be positive with increases in the participants' indices of happiness, but some failures also occurred. The outcomes were discussed in relation to (a) methodological issues, such as designs of the studies, length of the intervention, and number of participants, and (b) personal and practical implications of the procedures. Some suggestions for future research (particularly focused on extending evidence and overcoming present methodological weakness) were also examined.

Depression in adults with intellectual disability: symptoms and challenging behaviour

BACKGROUND

Psychiatric evaluation of adults with intellectual disability (ID) remains complex because of limitations in verbal abilities, atypical clinical presentation and challenging behaviour. This study examines the clinical presentation of adults with depression compared with bipolar disorder, anxiety disorders and non-psychiatric control patients.

METHOD

This study is a retrospective record review of the initial psychiatric diagnostic evaluation for 300 adult patients with ID drawn from a clinic population. Patients with major depression (n = 85) were compared with those with bipolar disorder (n = 70), anxiety disorders (n = 30) and control patients without psychiatric disorder (n = 27). Key symptoms of depression assessed during the interview were examined as well as challenging behaviour.

RESULTS

Three symptoms were useful in differentiating depressed patients from all other groups: sad mood, crying, and anhedonia. Withdrawal, suicidality, and awakening during the night were significant compared with anxiety patients and controls; however, few patients reported suicidality. Bipolar patients were significantly different from depressed patients for elevated mood, acute anger episodes, increase in verbalization, pressure of speech, talk of sexual themes, increase in appetite and poor concentration. Anxiety patients had more fearfulness without withdrawal, sad mood, crying, anhedonia and suicidality. Challenging behaviour was most pronounced in bipolar patients; for depressed patients, aggression and impulsivity were significant compared with anxiety patients and controls. Overall, the control patients presented with few symptoms in any category.

CONCLUSIONS

Sad mood, crying and anhedonia are key significant features of depression. Most patients with ID cannot meet the required number of DSM criteria or suggested DM-ID adapted criteria for major depression. Many depressive symptoms were reported in modest numbers and this was probably related to deficiencies in self-report or observational skills of caregivers. Challenging behaviour is not diagnostically specific. It is, however, a key atypical feature of depression.

Diagnosis and treatment of mood disorders in adults with developmental disabilities

While the idea that individuals with developmental disabilities (DD) can suffer from mental illness has been largely accepted since the late 1980's, this is still an underserved and poorly studied population. In particular, mood disorders have traditionally been misdiagnosed, under-recognized and poorly treated. Through the years, reported rates of mood disorders in adults with DD have varied widely. Recent epidemiological studies have focused on community samples and find rates of mood disorders from 3 to 8.1%. Mood disorders are found to be more prevalent than psychotic disorders or anxiety disorders. The empirical literature on assessment of mood symptoms in adults with DD is limited, particularly in individuals with severe and profound DD. Several tools have been developed to assist in identification and diagnosis. However, the work on their psychometric properties and validity studies is still quite limited. The treatment literature is sparse and focused primarily on pharmacotherapy. This review considers the epidemiology and diagnosis of mood disorders in individuals with DD. Recent developments in assessment are reviewed. The literature regarding pharmacological treatment with antidepressants, mood stabilizers, electroconvulsive therapy and antipsychotics is summarized and the current state of psychological treatments for mood disorders in persons with DD is presented. Implications for clinical care and future research are considered.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Screening tests for adults with intellectual disabilities

Adults with intellectual disabilities need thoughtful, well-coordinated primary care from family physicians. However, evidence-based screening recommendations are lacking. We examined screening recommendations for common preventable conditions using the US Preventative Service Task Force guidelines. We also reviewed the literature about the prevalence of these conditions in adults with intellectual disabilities. Obesity, osteoporosis, and smoking are more prevalent in adults with intellectual disabilities, and enhanced screening for these conditions is recommended. Abnormal Papanicolaou smears and cervical cancer are less common in adults with intellectual disabilities and screening recommendations should be individualized. We also discussed strategies to make screening procedures less stressful for these patients.

Assessing the effects of stimulation versus microswitch-based programmes on indices of happiness of students with multiple disabilities

BACKGROUND

Stimulation and microswitch-based programmes are considered main strategies to promote indices of happiness in students with multiple disabilities. However, only limited attempts have been made to assess the relative effects of the two programmes. This study conducted such an assessment with seven students with multiple disabilities.

METHODS

The first four phases of the study served to: (1) provide the students with a systematic exposure to each of the programmes; and (2) measure the programmes' effects on indices of happiness by comparing them with baseline levels. The fifth phase served to compare the programmes with each other.

RESULTS

The first four phases of the study showed that the microswitch-based programme produced a significant increase in indices of happiness for all seven students, and the stimulation programme produced a significant increase for six students. During the fifth phase of the study (i.e. when the two programmes were alternated), the microswitch-based programme promoted significantly higher indices of happiness than the stimulation programme for four of the seven students.

CONCLUSIONS

Microswitch-based programmes might be deemed preferable to stimulation programmes because they can promote higher or comparable indices of happiness while promoting the acquisition of adaptive responses and self-determination.

Functional behavioural assessment in people with intellectual disabilities

PURPOSE OF REVIEW

The presence of problem behaviours often impede an individual's quality of life and ability to be fully included in the environments of his or her choice. Functional behavioural assessment has been gaining widespread use in all settings in which people with intellectual disabilities might present problem behaviours. Understanding the function of these problem behaviours is a critical component to developing an effective intervention plan. This paper presents a review of the current knowledge and findings regarding functional behavioural assessments.

RECENT FINDINGS

The recent studies on functional behavioural assessment have supported the well established fact that success in reducing behaviour problems is closely linked to understanding the function of the problem behaviour. Implementing functional behavioural assessment in school settings has been met with some challenges. Although a complex process, recent research has shown promise in training nonprofessionals in learning to carry out a functional behavioural assessment and implementing the information gained from the functional behavioural assessment into an effective behavioural intervention.

SUMMARY

The necessity of conducting a functional behavioural assessment is uncontested. Developing a behavioural intervention on the information obtained from a thorough functional behavioural assessment is part of best practice in the field of intellectual disabilities. We have the tools to conduct, and train others to conduct, a comprehensive functional behavioural assessment.

Diagnosis and treatment of depression in patients with mental retardation

Depression in mentally retarded individuals is not uncommon and usually is treatable. However, studies of the diagnosis and treatment of psychiatric illnesses in general and depression specifically in this population are relatively rare. Although Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria can be applied to mildly and moderately retarded individuals, the diagnosis of depression in those with intelligence quotients below 35 is challenging. However, the diagnosis of depression in the latter group is possible using modified criteria emphasizing observational data. Criteria include symptoms such as sadness, irritability, decreased social interaction, regression of skills, sleep disturbances, diurnal variation, and aggression. Furthermore, there is a growing body of evidence that antidepressant treatments, especially administration of selective serotonin reuptake inhibitors, are effective in treating depression in mentally retarded patients. This article reviews numerous studies elaborating on the diagnosis, phenomenology, and treatment of depression in mentally retarded individuals.

Microswitch programs for persons with multiple disabilities: an overview of the responses adopted for microswitch activation

BACKGROUND

To introduce a person with multiple disabilities to a microswitch-aided program, one has to select a plausible response(s), that is, a response(s) that can be performed reliably and without excessive effort by the person and can successfully activate the microswitch(es) available (producing preferred stimuli). This paper provides an overview of the responses adopted for microswitch activation in research studies during the last 20 years.

METHOD

Computerized and manual searches were carried out to identify the studies published between 1986 and 2005. Forty-eight research studies were identified. They concerned the use of (1) a single (typical) response, (2) a single (non-typical) response, (3) multiple (typical and non-typical) responses, and (4) multiple (vocal) responses.

RESULTS AND DISCUSSION

The results showed that 151 of the 190 participants involved in the studies had a positive outcome (i.e., clear increases in their responding, which suggested that they had learned the association between responding and consequent preferred stimuli). Failures were largely concentrated in the first group of studies. The discussion focused on (a) the importance of selecting plausible responses for increasing the chances of success, (b) the need of non-typical responses for persons with minimal motor behavior, (c) implications of programs with multiple responses on engagement and choice, and (d) relevance of using vocal utterances. Some suggestions for future research concerning these points were also examined.

The development of a new measure for the assessment of psychopathology in adults with intellectual disability

BACKGROUND

People with intellectual disability (ID) and untreated psychiatric disorder lead unnecessarily difficult and unhappy lives. The prevalence of mental illness in children and adults with ID is greater than that found in the general population. A carer-completed checklist of psychopathology that could be used with both children and adults would help identify those individuals with ID most likely to have a mental health problem, help ensure that they receive the limited services that are usually available and also assist the process of clinical assessment, diagnosis and management.

METHOD

This research aimed to develop a reliable and valid carer-completed checklist of psychopathology for adults with ID by redeveloping an existing measure for children with ID, the Developmental Behaviour Checklist (DBC-P). The new checklist, The Developmental Behaviour Checklist for Adults (DBC-A) was devised by changing, deleting and adding to DBC-P items. Reliability studies were conducted with paid and family carers, and DBC-A scores were compared with the results from two other measures of psychopathology.

RESULTS

One DBC-P item was deleted, seven items changed and 12 items added. The psychometric properties of this new checklist, the DBC for Adults with ID (DBC-A), were investigated and found to be satisfactory. Intraclass correlations for test-retest and inter-rater reliability ranged from 0.72 to 0.85, and concurrent validity with two measures of emotional and behavioural disturbance was satisfactory.

CONCLUSIONS

The carer-completed DBC-A provides a broad and comprehensive survey of the emotional and behavioural problems of adults with ID. It has satisfactory psychometric properties and therefore can be used with confidence in clinical, research and service settings, and its development allows continuous assessment of psychopathology across the lifespan for all people with ID.

Mindful caregiving increases happiness among individuals with profound multiple disabilities

Happiness is a critical indicator of quality of life in humans. A few studies have measured levels of happiness displayed under different conditions by individuals with profound multiple disabilities. We were interested in determining whether increasing the mindfulness of caregivers would result in increased levels of happiness in adults with these conditions. Using alternating treatments embedded within a multiple baseline across caregivers design, we measured baseline levels of happiness displayed by three adults with profound multiple disabilities when they engaged in leisure activities, each by a different pair of caregivers. Then, we taught mindfulness methods to one of each pair and measured the levels of happiness displayed by the individuals during the 8-weeks training for the caregivers. Finally, we measured the levels of happiness displayed by the three individuals for 16 weeks following the termination of mindfulness training. We found that, regardless of whether the level of happiness was initially observed to be high or low in the presence of a caregiver, it increased markedly when an individual interacted with a caregiver who received training in mindfulness when compared to the control caregiver, who did not receive such training. Our study provides evidence that increasing the mindfulness of a caregiver can produce a substantial increase in the levels of happiness displayed by individuals with profound multiple disabilities.