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

Review of cases, case series and prevalence studies of zoophilia in the general population

BACKGROUND

Information about the frequency of zoophilic behaviour in the general population is scarce.

OBJECTIVE

To review cases, case series and prevalence studies of zoophilia in adults in the general population.

METHODS

A review of publications was carried out in MEDLINE via PubMed, Scopus and the Biblioteca Virtual en Salud [Virtual Health Library] ranging from January 2000 to December 2017.

RESULTS

Thirteen papers were reviewed (ten case reports, two case series and one cross-sectional study). Twelve patients were described, the case series totalled 1,556 people and the cross-sectional study included 1,015 participants and reported a prevalence of zoophilic behaviour of 2%.

CONCLUSIONS

Information on the prevalence of zoophilic behaviour in the general population is limited. The Internet will probably be a valuable tool for further investigating these behaviours in coming years.

Overdiagnosis of mental disorders in children and adolescents (in developed countries)

During the past 50 years, health insurance providers and national registers of mental health regularly report significant increases in the number of mental disorder diagnoses in children and adolescents. However, epidemiological studies show mixed effects of time trends of prevalence of mental disorders. Overdiagnosis in clinical practice rather than an actual increase is assumed to be the cause for this situation. We conducted a systematic literature search on the topic of overdiagnosis of mental disorders in children and adolescents. Most reviewed studies suggest that misdiagnosis does occur; however, only one study was able to examine overdiagnosis in child and adolescent mental disorders from a methodological point-of-view. This study found significant evidence of overdiagnosis of attention-deficit/hyperactivity disorder. In the second part of this paper, we summarize findings concerning diagnostician, informant and child/adolescent characteristics, as well as factors concerning diagnostic criteria and the health care system that can lead to mistakes in the routine diagnostic process resulting in misdiagnoses. These include the use of heuristics instead of data-based decisions by diagnosticians, misleading information by caregivers, ambiguity in symptom description relating to classification systems, as well as constraints in most health systems to assign a diagnosis in order to approve and reimburse treatment. To avoid misdiagnosis, standardized procedures as well as continued education of diagnosticians working with children and adolescents suffering from a mental disorder are needed.

Understanding relationships between autism, intelligence, and epilepsy: a cross-disorder approach

AIM

As relationships between autistic traits, epilepsy, and cognitive functioning remain poorly understood, these associations were explored in the biologically related disorders tuberous sclerosis complex (TSC), neurofibromatosis type 1 (NF1), and epilepsy.

METHOD

The Social Responsiveness Scale (SRS), a quantitative measure of autistic traits, was distributed to caregivers or companions of patients with TSC, NF1, and childhood-onset epilepsy of unknown cause (EUC), and these results were compared with SRS data from individuals with idiopathic autism spectrum disorders (ASDs) and their unaffected siblings. Scores and trait profiles of autistic features were compared with cognitive outcomes, epilepsy variables, and genotype.

RESULTS

A total of 180 SRS questionnaires were completed in the TSC, NF1, and EUC outpatient clinics at the Massachusetts General Hospital (90 females, 90 males; mean age 21 y, range 4-63 y), and SRS data from 210 patients with ASD recruited from an autism research collaboration (167 males, 43 females; mean age 9 y, range 4-22 y) and 130 unaffected siblings were available. Regression models showed a significant association between SRS scores and intelligence outcomes (p<0.001) and various seizure variables (p<0.02), but not with a specific underlying disorder or genotype. The level of autistic features was strongly associated with intelligence outcomes in patients with TSC and epilepsy (p<0.01); in patients with NF1 these relationships were weaker (p=0.25). For all study groups, autistic trait subdomains covaried with neurocognitive comorbidity, with endophenotypes similar to that of idiopathic autism.

INTERPRETATION

Our data show that in TSC and childhood-onset epilepsy, the severity and phenotype of autistic features are inextricably linked with intelligence and epilepsy outcomes. Such relationships were weaker for individuals with NF1. Findings suggest that ASDs are not specific in these conditions.

Improved access to mental health evaluation for patients with developmental disabilities using telepsychiatry

The Cedars-Sinai Telepsychiatry Clinic uses a collaborative-care model to treat patients with developmental disabilities. We examined its practice in four areas: patient characteristics, clinical care, symptom severity and diagnostic outcomes to describe the care provided and the population seen in the telepsychiatry clinic. In a chart review, 45 out of 126 cases were selected and evaluated at three times: initial evaluation, year one and year three. Most of the patients (84%) had an intellectual disability, 55% had a pervasive developmental disorder and 71% spoke approximately 50 words or less. Prior to the initial assessment, none of the patients were diagnosed with anxiety or mood disorders, while almost one-third of patients received one of these diagnoses in the telepsychiatry clinic. Patients were seen six times on average in the first year and three times in the second and third years. The telepsychiatrist recommended a change in the patient's medication for 82% of patients at initial assessment, 41% at year one and 46% at year three. The review suggests that telepsychiatry evaluations can be valuable for patients with developmental disabilities, providing diagnostic clarity and specific recommendations that can be implemented by the primary care physician.

Epilepsy and autism: is there a special relationship?

Increasingly, there has been an interest in the association between epilepsy and autism. The high frequency of autism in some of the early-onset developmental encephalopathic epilepsies is frequently cited as evidence of the relationship between autism and epilepsy. While these specific forms of epilepsy carry a higher-than-expected risk of autism, most, if not all, of the association may be due to intellectual disability (ID). The high prevalence of interictal EEG discharges in children with autism is also cited as further evidence although errors in the diagnosis of epilepsy seem to account for at least part of those findings. The prevalence of ID is substantially elevated in children with either epilepsy or autism. In the absence of ID, there is little evidence of a substantial, if any, increased risk of autism in children with epilepsy. Further, although the reported prevalence of autism has increased over the last several years, much of this increase may be attributable to changes in diagnostic practices, conceptualization of autism in the presence of ID, and laws requiring provision of services for children with autism. In the context of these temporal trends, any further efforts to tease apart the relationships between epilepsy, ID, and autism will have to address head-on the accuracy of diagnosis of all three conditions before we can determine whether there is, indeed, a special relationship between autism and epilepsy.

A case report for diagnosing anxiety in people with intellectual disability: the role of nurses in the application of a multidimensional diagnostic guideline

PURPOSE

The purpose of this article is the presentation of a multidimensional guideline for the diagnosis of anxiety and anxiety-related behavior problems in people with intellectual disability (ID), with a substantial role for the nurse in this diagnostic process.

DESIGN AND METHODS

The guideline is illustrated by a case report of a woman with ID with severe problems.

FINDINGS

It appears that a multidimensional diagnostic approach involving multidisciplinary team efforts can result in a more accurate diagnosis and improved subsequent treatment.

PRACTICE IMPLICATIONS

Nurses should be engaged in the diagnostic process because of their ability to make direct observations and to actively participate in carrying out all parts of the guideline.

ADHD symptom presentation and trajectory in adults with borderline and mild intellectual disability

BACKGROUND

This study examined symptoms and lifetime course of Attention Deficit Hyperactivity Disorder (ADHD) in adults with borderline and mild Intellectual Disability (ID).

METHOD

A total of 48 adults with ID and ADHD were compared with 221 adults with ADHD without ID using the informant Barkley scale for childhood and adulthood symptoms.

RESULTS

The ADHD/ID group presented with greater severity of (adult and childhood) symptoms compared with the non-ID group. For the ADHD/non-ID group, most symptoms improved significantly from childhood to adulthood, whereas only two symptoms changed significantly for the ID group. Principal component analysis revealed scattered loading of different items into five components for the ADHD/ID group that were not consistent with the classic clusters of inattentive, hyperactive and impulsive symptoms. A negative correlation was found between severity of symptoms and IQ.

CONCLUSIONS

ADHD in adults with ID may have a more severe presentation and an uneven and less favourable pattern of improvement across the lifespan in comparison with adults without ID.

Inter-Rater Reliability of the Diagnoses of Psychosis and Depression in Individuals with Intellectual Disabilities

BACKGROUND: There is a history of over-prescription of antipsychotics to individuals with intellectual disability (ID), while antidepressants may be under-prescribed. However, appropriate treatment is best supported when the diagnosis of psychosis or depression is valid and carries good predictive validity. The present authors report a study examining one aspect of validity, namely whether skilled clinicians can agree on whether an individual with an ID is psychotic or depressed. MATERIALS AND METHODS: Pairs of clinicians assessed 52 individuals. Agreement was assessed using Cohen's kappa statistic and agreement proportion. RESULTS: Overall agreement was high for both psychosis and depression. Whether the individual had mild ID or moderate/severe ID did not have a significant impact on agreement. CONCLUSIONS: Experienced clinicians achieved a high level of agreement as to whether a person with ID was psychotic or depressed similar to that found for those without ID. The findings provide some support for treatment interventions based on diagnosis.

Pervasive developmental disorder, behavior problems, and psychotropic drug use in children and adolescents with mental retardation

OBJECTIVE

This study investigated the interrelationship between psychopharmacotherapy in general and the use of specific psychotropic drugs and pervasive developmental disorder and other behavior problems in children and adolescents with mental retardation.

METHODS

A total of 862 participants 4 to 18 years of age, including all levels of mental retardation, were recruited through facilities for children with mental retardation in Friesland, The Netherlands. Information on medication was collected through parent interviews. Behavior problems were investigated with a standardized parent questionnaire (Developmental Behavior Checklist). A pervasive developmental disorder classification was based on the Pervasive Developmental Disorder in Mental Retardation Scale, completed by psychologists or teachers. Logistic regression analysis was used to investigate the relationship between the use of psychotropic drugs and pervasive developmental disorder and other behavioral problems, in the presence of possible confounders.

RESULTS

One of 10 participants used psychotropic medication. The main factors associated with psychotropic drug use were pervasive developmental disorder and disruptive behavior. The level of functioning was also associated. Self-absorbed behavior was statistically significantly associated with clonidine use and disruptive behavior with stimulant use. Pervasive developmental disorder and communication problems were the main factors associated with the use of antipsychotic drugs. Age also played a role, whereas gender, living situation, and level of mental retardation did not.

CONCLUSIONS

Antipsychotic drugs were associated with pervasive developmental disorder, whereas clonidine and stimulants were associated with self-absorbed and disruptive behavior, respectively. Although clonidine and risperidone are not registered for the problems reported and the other nonstimulants were only sometimes used on-label, their use was associated with specific psychiatric or behavioral problems.

Target-symptom psychopharmacology: between the forest and the trees

Psychopharmacology practice seeks to fit specific treatments to specific disease processes. Although categorical diagnoses have improved focus on observable symptom constellations, these approximately 300 categories have limited benefits for illuminating underlying disease pathophysiology. Existing medications do not couple well to the symptom constellations of given disorders. Rather, current medications ameliorate symptoms overlapping among various disorders. Harnessing technology to identify a patient's wider symptom constellation, prioritizing and targeting symptoms across disorders, considering symptoms more dimensionally instead of "present or not," and eliciting factors necessary to improve adherence may allow medication selections to be tailored better to individual patients.

Drug utilisation by children and adolescents with mental retardation: a population study

OBJECTIVE

Little is known about the utilisation of drugs by mentally retarded children; population studies are even more sparse. In this study the chronic drug utilisation in children aged 4-18 years with mental retardation in a large population in the Netherlands was investigated.

METHODS

Throughout all special schools and (day) care facilities for children with mental retardation in Friesland, parents/representatives were approached requesting participation of their children. Participants were interviewed about a number of aspects including medication use. For 921 of the 1,057 participants, information was available on medication use for those physical and psychiatric illnesses that bothered them or was expected to bother them for at least 3 months per year; 912 of the participants were within the age category under study: 4-18 years.

RESULTS

About 22% of the 912 participants used chronic medication, 47% of whom used two or more drugs. The prevalence of drug use increased with severity of mental retardation from about 17% to 49%. The exception was the 6% of children with borderline intellectual functioning: their medication prevalence was 27%. Overall, 17% of the study population used a nervous system drug, 4% used a respiratory system drug and 3% used an alimentary tract drug. Of the drugs for the nervous system, alimentary tract and respiratory tract, 32% was prescribed off-label. For 3%, we were unable to establish on/off-label use.

CONCLUSIONS

Chronic drug utilisation patterns in children and adolescents with mental retardation are different from those in the general paediatric population. These different patterns suggest the need for additional research.

Psychotropic medication use among Kansas Medicaid youths with disabilities

Knowledge of current patterns of psychotropic medication use by disabled youths is an important starting point for targeting future efforts to improve prescribing practices. This study provides a retrospective, descriptive analysis of the prevalence and patterns of psychotropic medication among 1022 Kansas Medicaid youths in 2001 who were enrolled with either Supplemental Security Income (SSI) or Medically Needy benefits and who were having clearly defined mental and neurological disabilities. Rates of psychotropic medication use were generally higher for the Medically Needy than for the SSI youths: Central nervous system (CNS) stimulants (24.6% versus 20.0%), antidepressants (30.9% versus 13.7%), anticonvulsants (22.0% versus 13.9%), and antipsychotics (23.3% versus 11.5%). Use of the four major drug classes varied among children with attention-deficit/hyperactivity disorder (ADHD) and disruptive disorders, pervasive developmental disabilities, mental retardation (MR) and learning disabilities, mood and anxiety disorders, and adjustment disorders. Future work should explore the appropriateness and effectiveness of these medications within specifically targeted subgroups.