Reliability of the assessment of dual diagnosis (ADD)

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.

Validation of a Revised Version of the Center for Epidemiologic Depression Scale for Youth with Intellectual Disabilities (CESD-ID-R)

This study proposes a revision (R) of the Center for Epidemiologic Studies Depression Scale for youth with ID (CESD-ID) in English and French. 346 youth (36.02% girls) with mild (51.26%) and moderate (48.78%) ID (11-22 years; M = 15.69), enrolled in secondary schools in Canada (French-speaking; n = 115), and Australia (English-speaking; n = 231), as well as their parents and teachers, participated in this study. Results support the reliability, factor validity, equivalence (sex, ID level, comorbidities, and country), and convergent validity (with youth-, parent-, and teacher-rated measures of depression, anxiety, and loneliness/social isolation) of the CESD-ID-R. The CESD-ID-R allows youth with ID to provide a reliable and valid assessment of their depressive mood and happiness suitable for epidemiological studies.

Assessment of Seizures and Related Symptomatology in Persons with Mental Retardation

Seizures can be debilitating across a number of physical, social, occupational, and personal variables. Given the deficits in all of these areas frequently present in persons with mental retardation, effective assessment and subsequent treatment of seizures is a primary goal for individuals with both mental retardation and epilepsy. To thoroughly address the behavioral domains related to seizures in persons with mental retardation and epilepsy, areas of assessment should include seizure behavior, triggering stimuli, reinforcing consequences, and antiepileptic medication side effects. Assessment of these areas in this population often deviates from methods typically used with persons of normal intelligence. Specifically, direct behavioral observation and third-party report with structured interviews are the most viable and accessible means of assessment, and efforts to establish reliable and valid protocols have been successful in some areas. This article reviews this assessment methodology and discusses the extant issues in establishing and proliferating such approaches.

Assessment of Feeding and Mealtime Behavior Problems in Persons with Mental Retardation

Feeding and mealtime behavior problems are commonly observed among individuals with developmental disabilities. These problems include, but are not limited to, food refusal, food selectivity, mealtime aggression, rumination, pica, and insufficient feeding skills. Difficulties of this type can be associated with life-threatening consequences of other serious health-related problems. Because of the nature of these problems and the lack or accurate client self-reporting, an interdisciplinary assessment in addition to a thorough behavioral assessment is recommended to ensure the best quality of care. This article discusses the role of the various disciplines, and the types of behavioral assessments that are currently being utilized by clinicians and researchers.

Concordance of the mini-Psychiatric Assessment Schedule for Adults who have Developmental Disabilities (PASADD) and the Brief Symptom Inventory

BACKGROUND

When assessing the mental health needs of people who have intellectual disabilities (ID) it is important to use measures that have good validity and reliability to ensure accurate case recognition and reliable and valid outcome data. Measures developed for this purpose tend to be self-report or by informant report. Multi-trait screening tools developed to identify psychological and psychiatric disorders in people who have ID tend to be informant based. Research examining the concordance of different tools has found this to be high but not for specific diagnoses. Multi-trait self-report measures are fewer and have not been compared with informant approaches. This study aims to examine the concordance between two multi-trait measures of mental health used with people who have ID. One administered to informants [the Mini-Psychiatric Assessment Schedule for Adults who have Developmental Disabilities (PASADD)] and one self-report [Brief Symptom Inventory (BSI)]

METHOD

The measures were completed with 109 adults who have ID and with someone who knows them well.

RESULTS

Level of agreement across the four scales in common was good for three. The poorest convergence was for the obsessive compulsive disorder sub-scales. However, a high level of concordance was found between most sub-scales.

CONCLUSION

The BSI and the PASSAD seem to be good indicators of psychiatric problems and psychological distress; however, similar to other multi-trait measures they did not demonstrate appropriate specificity for particular disorders.

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.

Validity and reliability of the Spanish version of the diagnostic assessment for the severely handicapped (DASH-II)

BACKGROUND AND OBJECTIVES

The DASH-II scale is a specific instrument for measuring psychopathological symptoms in people with severe and profound intellectual disability (ID). The aim of the study is the validation of the Spanish version, evaluating its reliability and validity. At the same time we examine the prevalence of mental disorders in our sample.

MATERIAL AND METHODS

Two reviewers independently passed the Spanish version of the DASH-II (DASH-II-S) to 83 users to establish inter-rater reliability. To assess inter-rater reliability or test-retest reliability, fifty participants were reassessed by the same rater within 7 days.

RESULTS

DASH-II-S showed good internal consistency (Cronbach's α=0.879) and good reliability, both intra and inter-rater reliability. The prevalence of psychopathology in the sample is 94%, and the use of psychotropic drugs is also high, with 61.4% receiving one or more antipsychotics.

CONCLUSIONS

DASH-II-S is a valid and reliable instrument that can be used for the assessment of psychopathology in people with ID. The translated version retains the psychometric properties of the original English version. Moreover, the high prevalence of mental disorders in this population may explain the widespread use of psychotropic drugs, but it forces us to continuous reassessment and justification.

Criterion-related validity of challenging behaviour scales: a review of evidence in the literature

BACKGROUND

Behaviour that challenges has negative impacts on physical and emotional well-being and quality of life. Challenging behaviour scales are used to identify needs and evaluate interventions and must be valid measures. Criterion-related validity is important, and the best quality assessment uses direct measures of behaviour as criteria. Previous reviews of scales affirm their validity but present little supporting evidence. The current review examines the evidence presented in studies of validity.

METHODS

Searches of MEDLINE and PsycINFO to identify scales that focus on challenging behaviour and find publications that assess their criterion-related validity.

RESULTS

Searches identified twelve scales and 21 publications that assess validity. One assessment used direct measures of behaviour, and the remainder used indirect measures that themselves have limited evidence of validity, including membership of diagnostic or service groups and other scales.

CONCLUSIONS

Little firm evidence of validity was found, but what was found is encouraging.

The making of a field: the development of comorbid psychopathology research for persons with intellectual disabilities and autism

Knowledge in the area of developmental disabilities has been expanding rapidly. One area that has received particular attention is the topic of related comorbid conditions. This phenomenon is not exclusive to the field of developmental disabilities. However, research with this population is of recent origin. The purpose of this paper is to review the origins of this field including some of the notable developments and potential future trends.

Translation, adaptation, and preliminary validation of the Brazilian version of the Behavior Problems Inventory (BPI-01)

Introduction: Children with atypical development often present behavior problems that impair their psychosocial adaptation. Objective: To describe the cultural adaptation to Brazilian Portuguese of the Behavior Problems Inventory (BPI-01), as well as preliminary indicators of instrument reliability and validity. Methods: The process involved translation, back-translation, and cultural adaptation of the instrument. Psychometric properties (reliability and validity) were assessed comparing scores obtained with the BPI-01, the Wechsler Intelligence Scales for Children and Adults, the Child Behavior Checklist for Ages 6-18 (CBCL/6-18), and the Autism Screening Questionnaire (ASQ). The sample comprised 60 children (30 typically developing and 30 atypically developing). Results: The cultural adaptation process was considered adequate. Internal consistency of the BPI-01 was satisfactory, with a Cronbach's alpha of 0.65 for the self-injurious behavior scale, 0.82 for stereotyped behaviors, and 0.91 for aggressive/destructive behaviors. Considering a mean frequency of 0.5, the receiver operating characteristic (ROC) curve revealed 80% sensitivity and 3% specificity in the stereotyped behavior scale, 50 and 10% in aggressive/destructive behaviors, and 76 and 6% in self-injurious behaviors, respectively. Low-to-moderate correlations were observed between BPI-01, ASQ, and CBCL/6-18 scores. Conclusion: BPI-01 showed good psychometric properties, with satisfactory preliminary indicators of reliability, convergent validity, and sensitivity for the diagnosis of atypical development.

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.

Behaviour profile of Hungarian adolescent outpatients with a dual diagnosis

The behaviour dimensions of 244 Hungarian adolescent psychiatric outpatients with a dual diagnosis (intellectual disability and psychiatric diagnosis) were examined by means of the adapted version of the Behaviour Problem Inventory (BPI, Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). Four IQ subgroups were created: borderline, mild, moderate and profound ID subsamples. Significantly higher means were found in the self-injury/stereotyped behaviour/summarized scale categories both in the frequency and severity of symptoms in the more disabled groups against the samples having milder IQ impairment. Adolescents with a dual diagnosis showed much higher BPI scale means than an adult residential ID sample. ADHD and emotional disorders were the most frequent psychiatric diagnostic comorbidities of ID (20.67% and 11.73%). Academic achievement disorder, depression and psychosis had low occurrences (3.35, 2.23 and 1.17%, respectively) but showed convergency with other authors' data. The comorbid emotional disorders may create challenges for the care of the mildly intellectually disabled group.

Suicide risk in youth with intellectual disabilities: the challenges of screening

Children and adolescents with intellectual disabilities (IDs), often diagnosed with comorbid psychiatric disorders, are a vulnerable population who may be at risk for developing suicidal thoughts and behaviors. Previous research has demonstrated that direct suicide screening can rapidly and effectively detect suicide risk and facilitate further clinical evaluation and management. Currently, there are no measures that screen for suicide risk designed specifically for individuals with ID. A review of the literature was conducted to (1) estimate the prevalence of suicidal thoughts, behaviors, and deaths by suicide in children and adolescents with ID; (2) describe associations between youth with ID and suicide risk; and (3) identify the limitations of commonly used suicide screening measures developed for non-ID youth. The literature review confirms that suicide risk exists in this population; youth with ID think about, attempt, and die by suicide. Standardized suicide risk screening is challenged by the lack of measures developed for this population. A summary of the findings is followed by a discussion of the practical clinical considerations surrounding the assessment of suicide risk in youth 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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of gender and age on repetitive and/or restricted behaviors and interests in adults with autism spectrum disorders and intellectual disability

Frequency of repetitive and/or restricted behaviors and interests (RRBIs) was assessed in 140 adults with autism spectrum disorders (ASDs) and severe or profound intellectual disability (ID). The associations of gender and age range were analyzed with RRBI frequency which was obtained using the Stereotypies subscale of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). A significant main effect of gender was found. Male participants had higher frequency of RRBIs than females regardless of age range. There was not a significant main effect of age range or a significant interaction between gender and age range. Results and implications are discussed.

Psychometric properties of the Aberrant Behavior Checklist, the Anxiety, Depression and Mood Scale, the Assessment of Dual Diagnosis and the Social Performance Survey Schedule in adults with intellectual disabilities

Progress in clinical research and in empirically supported interventions in the area of psychopathology in intellectual disabilities (ID) depends on high-quality assessment instruments. To this end, psychometric properties of four instruments were examined: the Aberrant Behavior Checklist (ABC), the Assessment of Dual Diagnosis (ADD), the Anxiety, Depression and Mood Scale (ADAMS), and the Social Performance Survey Schedule (SPSS). Data were collected in two community-based groups of adults with mild to profound ID (n = 263). Subscale reliability (internal consistency) ranged from fair to excellent for the ABC, the ADAMS, and the SPSS (mean coefficient α across ABC subscales was .87 (ranging from fair to excellent), the ADAMS subscales .83 (ranging from fair to good), and the SPSS subscales .91 (range from good to excellent). The ADD subscales had generally lower reliability scores with a mean of .59 (ranging from unacceptable to good). Convergent and discriminant validity was determined by bivariate Spearman ρ correlations between subscales of one instrument and the subscales of the other three instruments. For the most part, all four instruments showed solid convergent and discriminant validity. To examine the factorial validity, Confirmatory Factor Analyses (CFA) were attempted with the inter-item covariance matrix of each instrument. Generally, the data did not show good fits with the measurement models for the SPSS, ABC, or the ADAMS (CFA analyses with the ADD would not converge). However, most of the items on these three instruments had significant loadings on their respective factors.

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.

An Examination of Psychotropic Medication Side Effects: does taking a greater number of psychotropic medications from different classes affect presentation of side effects in adults with ID?

This study examined whether the number of psychotropic medications an individual is taking across classes influences side effects among adults with Intellectual Disability (ID). Participants were 80 adults diagnosed with ID. Dependent variables were the composite score and domain scores of the Matson Evaluation of Drug Side-effects (MEDS), which is an instrument used to assess side effects. There were three levels of the independent variable: Group 1--those taking zero psychotropic medications, Group 2--those taking one psychotropic medication, and Group 3--those taking two psychotropic medications across different medication classes. There was a significant main effect regarding number of psychotropic medication classes prescribed. Further analysis revealed that four of the nine MEDS domains had significantly different mean scores for number of psychotropic medication classes. For the majority of MEDS domains, such as Central Nervous System-General, Parkinsonism/Dyskinesia, and Behavioral/Akathesia domains, participants in the no psychotropic medication group had significantly lower mean scores than those in the one and two psychotropic medication groups. Only two MEDS domains, Cardiovascular and Hematologic Effects as well as Skin, Allergies, and Temperature, were significantly different between participants taking one psychotropic medication as compared with two psychotropic medications from different classes. Implications of these findings and recommendations for future research are discussed.

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.

Cut-offs, norms and patterns of problem behaviours in children with developmental disabilities on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 3)

PURPOSE

Challenging behaviours present major impediments to a young child's life. Being able to properly assess these behaviours can lead to early intervention and remediation.

METHOD

In the present study, the problem behaviours of 644 children 17-37 months of age who were at risk for developmental disabilities were studied using the BISCUIT-Part 3. In study one, norms and cut-off scores were established for this new scale using this sample. In study 2, the frequency and patterns of various challenging behaviours were evaluated.

RESULTS

The majority of developmentally delayed children who had severe challenging behaviours engaged in aggressive/destructive acts. However, severe problem behaviours were in the minority of occurrence.

CONCLUSIONS

Outcomes suggest that these behaviours can be identified at an early age using a validated instrument tool. Implications are that pinpointing emerging problematic behaviours allows for a more accurate assessment of the delayed child's overall functioning. Being able to pinpoint behaviour problems allows for earlier and more effective treatment.

Utility of reiss screen in identifying psychiatric problems in persons with mental retardation

BACKGROUND

Almost all psychiatric disorders found in general population can also be found in mental retardation (MR). Identification of the psychiatric problems in MR is a difficult process, primarily due to inherent communication and cognitive deficits wherein comes the role of psychological scales. There are few scales of which Reiss screen for maladaptive behaviors (RSMB) is popularly used in the West. Nevertheless, the utility of RSMB is less known in India.

AIM

In this context, the present study was designed to study the diagnostic utility of RSM.

MATERIALS AND METHODS

Fifty six persons with ICD-10 diagnosis of MR and psychiatric diagnoses or behavioral disorders were selected through purposive sampling. RSMB was used to screen psychiatric problems and the findings were contrasted with that of the ICD-10 diagnoses.

RESULTS AND CONCLUSION

RSMB could differentiate well between those with and without psychiatric diagnoses. The diagnostic efficiency statistics were found to be satisfactory. Therefore, RSMB can be used in Indian settings without any cultural limitations.

Examination of adaptive behavior differences in adults with autism spectrum disorders and intellectual disability

Autism spectrum disorders (ASD) and intellectual disabilities (ID) are high prevalence developmental disabilities that co-occur at high rates. Furthermore, Axis I psychopathology is known to occur more frequently in individuals with ID than the general population. The problems are lifelong and can be major impediments to independent living. Despite this, little research with adults is available to determine the effects of these disabilities on specific adaptive skills. In this study, 337 adults were evaluated using the Vineland Adaptive Behavior Scale to assess the effects of these disabilities on looking at an ID, ID plus ASD, and ID and ASD plus Axis I psychopathology group. Adaptive skills were greatest for the ID group followed by the ID plus ASD, and ID and ASD plus psychopathology. Thus, the more handicapping conditions, the greater the skills deficits observed, particularly where psychopathology was concerned. As such, accurately identifying the causes of adaptive skill deficits will likely result in more precise and effective treatment.

Intellectual disability and its relationship to autism spectrum disorders

Intellectual disability (ID) and autism spectrum disorders (ASDs) covary at very high rates. Similarly, greater severity of one of these two disorders appears to have effects on the other disorder on a host of factors. A good deal of research has appeared on the topic with respect to nosology, prevalence, adaptive functioning, challenging behaviors, and comorbid psychopathology. The purpose of this paper was to provide a critical review and status report on the research published on these topics. Current status and future directions for better understanding these two covarying disorders was reviewed along with a discussion of relevant strengths and weaknesses of the current body of research.

Parent training: a review of methods for children with developmental disabilities

Great strides have been made in the development of skills and procedures to aid children with developmental disabilities to establish maximum independence and quality of life. Paramount among the treatment methods that have empirical support are treatments based on applied behavior analysis. These methods are often very labor intensive. Thus, parent involvement in treatment implementation is advisable. A substantial literature on parent training for children has therefore emerged. This article reviews recent advances and current trends with respect to this topic.

A critical item analysis of the QABF: development of a short form assessment instrument

Due to the relative inability of individuals with intellectual disabilities (ID) to provide an accurate and reliable self-report, assessment in this population is more difficult than with individuals in the general population. As a result, assessment procedures must be adjusted to compensate for the relative lack of information that the individual may be able to provide and rely more on the behavioral expression of communication. One method commonly used is the indirect functional assessment that utilizes behavior rating scales developed to gather behavioral data in a short time. One of the few empirically derived and psychometrically sound scales is the Questions About Behavioral Function (QABF), a 25-item questionnaire designed to rate specific behavioral functions and maintaining variables. The purpose of this study was to use both exploratory and confirmatory factor analytic procedures to examine the psychometric properties of the QABF, conduct an item analysis, and determine if a short form version could be developed that is both psychometrically valid and reliable, and clinically useful. Results of the item selection procedure indicated that the original 25 items could be reduced to 15. Evaluation of the 15-item short form showed that the QABF-SF maintained the original five-factor structure of the original form, while maintaining an equivalent degree of reliability and validity. The QABF-SF appears to be a useful tool to aid clinicians in the brief functional assessment of behavior in individuals with ID.

Instruments for the detection of depressive symptoms in people with intellectual disabilities: a systematic review

Affective disorders, particularly depression, are common in adults with intellectual disabilities. However the detection of these disorders is hindered by the varied presentation of depressive symptoms across the range of intellectual disability. We undertook a systematic review of the available English-language diagnostic instruments for depressive disorders for adults with all levels of intellectual disability. We appraised the studies based on the instruments' psychometric properties, sensitivity and specificity. We included 21 of 28 identified studies which contained original data on validity and reliability; the ;gold standard' ranged from clinical opinion to other established instruments, some of which had limited validation in people with intellectual disability. In view of the benefits of psychological treatments for common mental disorders, it is important to develop instruments to be used in monitoring cognitive as well as behavioural outcomes for people with intellectual disability and depressive disorders.

Comorbidity of Asperger's syndrome and Bipolar disorder

Background and objective

Asperger's Syndrome (AS) is a pervasive developmental disorder that is sometimes unrecognized, especially in the adult psychiatric setting. On the other hand, in patients with an AS diagnosis, comorbid psychiatric disorders may be unrecognized in the juvenile setting. The aim of the paper is to show and discuss some troublesome and complex problems of the management of patients with AS and comorbid Bipolar Disorder (BD).

Methods

The paper describes three patients affected by AS and bipolar spectrum disorders.

Results and conclusion

Mood stabilizers and 2^nd generation antipsychotics were effective in the treatment of these AS patients with comorbid BD, while the use of antidepressants was associated with worsening of the mood disorder.

It is of importance to recognize both the psychiatric diagnoses in order to arrange an exhaustive therapeutic program and to define specific and realistic goals of treatment.

Life events as a risk factor for psychological problems in individuals with intellectual disabilities: a critical review

BACKGROUND

Stressful life events such as bereavement, moving house and changing jobs have repeatedly been implicated as risk factors for mental and physical ill health. Since the 1940s, researchers have demonstrated the negative effects of stressful life events, refined methods of recording such events and investigated the relative impact of different types of event. These investigations have generally not extended to include people with intellectual disabilities.

METHODS

We conducted a narrative review of research on life events as they occur to people with intellectual disabilities and critically assessed the evidence that life events function as a risk factor for psychological problems. Evidence was reviewed for an association between life events and a range of outcome variables, including affective disorders, challenging behaviour, psychosis and psychological problems more generally. We also critiqued the methodology behind the current evidence base and discussed a number of methodological advances that would help to strengthen it.

CONCLUSIONS

There is reasonable evidence that life events are associated with psychological problems, and that there is some tentative evidence that life events play a causal role, although to date, no relationship with psychosis in people with intellectual disabilities has been demonstrated. Life events are likely to be pertinent in clinical work with people with intellectual disabilities.

Psychiatric disorders and behavior problems in people with intellectual disability

The relationship between behavior problems and psychiatric disorders in individuals with intellectual disability is still unresolved. The present study compares the prevalence and pattern of psychiatric disorders in individuals with intellectual disability who were assessed on the ABC to have moderate and severe behavior problems and a matched group of individuals without such problems. Both groups were living in community settings and had their intellectual disability varied from mild to profound degrees. The participants were screened for psychiatric disorders using four different instruments; the Reiss Screen, the Mini PAS-ADD, the DASH-II and the ADD. The group with moderate and severe behavior problems showed significantly more symptoms of psychiatric disorders than the group without such problems when items related to behavior disorders were omitted, and the majority of the participants with behavior problems had symptoms of the main psychiatric disorders. The participants with mild and moderate intellectual disability showed more symptoms of psychosis and depression than the participants with severe and profound intellectual disability. There were no direct associations between individual behavior problems and psychiatric disorders, but the group with mild/moderate intellectual disability showed a somewhat different pattern of associations than the group with severe/profound intellectual disability. Depression was associated with screaming and aggression in the participants with severe and profound intellectual disability, and with self-injury in the participants with mild and moderate intellectual disability. The finding that the majority of the participants with behavior problems showed symptoms of psychiatric disorders suggests that many behavior problems may be (unconventional) symptoms of psychiatric disorders or reflect a difficult life situation caused by a psychiatric disorders, or that a difficult life situation may contribute to both psychiatric disorders and behavior problems in individuals with intellectual disability.

A prospective analysis of life events, problem behaviours and depression in adults with intellectual disability

BACKGROUND

Life events have consistently been found to be associated with behaviour problems and depression among individuals with intellectual disability (ID). However, prior findings have typically been based on correlational or retrospective analyses of case files. The current study attempted to replicate prior findings from life events with concurrent data and extend them to the prospective prediction of behaviour problems and depression. The influence of impact ratings of life events was also explored.

METHODS

Seventy-four informants rated 104 adults with ID on measures of life events, behaviour problems and depressive symptoms. Life events were rated as having either a positive, negative or no impact on the life of the individual with ID. Measures were completed twice, at a 4-month interval.

RESULTS

Behaviour problems were both correlated with and predicted by frequency counts of life events and life events perceived as negative. However, the predictive ability depended on which measure of problem behaviour was selected. Positive life events were not associated with concurrent behaviour problems. Depressive symptoms were correlated with all life changes, but only predicted by frequency counts of life events and life events perceived as negative. Again, the predictive ability depended on which measure of depression was selected. Findings were corroborated with a group of individuals with clinical diagnoses of major depression.

CONCLUSIONS

Frequency counts of all life events and life events perceived as negative play a role in the development of behaviour problems and depressive symptoms among adults with ID. The results have implications for interventions for behaviour problems following a life event, and for reducing depressive symptoms for adults with mild ID.

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.

Are caregivers' reports of motivation valid? Reliability and validity of the Reiss Profile MR/DD

BACKGROUND

Sensitivity theory proposes that there are wide individual differences in what motivates people with intellectual disability. The Reiss Profile MR/DD is a rating scale that measures 15 fundamental motives. This study examined the internal consistency and interrater reliability of the 15 subscales as well as the validity of motivational profiles.

METHOD

The study consisted of two distinct but related steps. First, the interrater reliability of the rating scale was established by having pairs of raters evaluate 48 individuals. Second, raters were presented with three different motivational profiles and asked to identify which one corresponded to the individual they had rated 4 weeks earlier.

RESULTS

Results indicated good internal consistency (average alpha=0.84), significant variability in the interrater reliability (average intraclass correlation coefficient=0.52), and excellent validity (95% of the correct profiles were chosen). Average discrepancies between pairs of raters are presented.

CONCLUSIONS

Interrater reliability is an important topic for professionals working in the field of intellectual disability and results are discussed in terms of the factors that affect it. This is the first published study to report on the interrater reliability of the Reiss Profile MR/DD.

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.

A system of assessment for adaptive behavior, social skills, behavioral function, medication side-effects, and psychiatric disorders

A reliable and valid assessment is necessary for the effective delivery of services to those with mental retardation (MR). With constraints placed on financial and human resources, assessment must be comprehensive, yet cost-effective. We describe a method of assessment that operates within these constraints using informant-based measures that assess adaptive and maladaptive behavior, psychiatric disorders, behavior function, and medication side-effects.

The MMPI-168(L) and ADD in assessing psychopathology in individuals with mental retardation: between and within instrument associations

An abbreviated version of the Minnesota Multiphasic Personality Inventory, the MMPI-168(L), modified for use with clients who have moderate or mild mental retardation, was administered to 58 clients, most of whom had co-existing dual psychiatric diagnoses. Another recently developed instrument, the Assessment of Dual Diagnosis (ADD), was administered by interviewing a knowledgeable care giver. Correlations were examined among the raw scores on the 13 ADD scales and T scores of the 13 MMPI-168(L) scales. Contrary to expectations few correlations were found between the scales of the two instruments including scales purported to assess similar psychological constructs. The major exception was the Mania scale of the MMPI-168(L), which correlated moderately well with the Schizophrenia and Dementia scales of the ADD. Client age correlated strongly and negatively with scores on the Conduct Disorder and Sexual Disorder scales of the ADD. Finally, intra-instrument scale correlations were surprisingly large and, from a clinical and diagnostic perspective, meaningful. However, the large number of intra-instrument correlations showed that the scales of both instruments possess considerable overlap, which could make differential diagnosis problematic. It is suggested that it might be necessary to administer both instruments, and carefully consider behavioral history, to accurately diagnose psychiatric disturbances or personality characteristics of individuals with mental retardation.

Behaviour/mental health problems in young adults with intellectual disability: the impact on families

BACKGROUND

The present authors studied the impact of dual diagnosis [i.e. intellectual disability (ID) and mental disorder] in young adults on their mothers' perceived levels of stress and decisions about placement.

METHODS

The mothers of 103 young adults with severe ID were interviewed using a 2-3-h in-depth protocol of measures designed to assess their child's adaptive functioning, maladaptive behaviour, mental health problems and negative impact on the family, as well as their own thoughts on out-of-home placement. The Scales of Independent Behavior--Revised Problem Behavior Scale assessed problem behaviours and the Reiss Screen assessed mental disorder.

RESULTS

These measures were highly correlated (r = 0.64), but tapped some different domains of maladaptive behaviour and proved to be most predictive when employed together. Behaviour and/or mental health (B/MH) problems significantly predicted the mothers' perceived negative impact of the young adult on the family, even after controlling for other young adult characteristics. These problems also predicted the family's steps toward seeking out-of-home placement, as did better young adult health and the mother's higher educational attainment; stress did not predict additional variance in placement once these variables were accounted for.

CONCLUSIONS

The discussion focuses on the implications for service provision to families of young adults with B/MH problems.