Observations on the use of the ICD-10 guide for mental retardation

Systematic management approach to pharmacotherapy for people with learning disabilities

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

ICD-10 and alternative diagnostic criteria for childhood autism among children with intellectual disability

OBJECTIVES

The diagnosis of Childhood Autism (CA) among children with Intellectual Disability (ID) based on clinical criteria validated for populations with average intelligence compromises it's diagnostic accuracy in this special population. This study documents the diagnostic accuracy of ICD-10 and alternative criteria for CA in ID population.

METHODS

Consensus clinical diagnosis of autism made by a multi-disciplinary team as the reference data were extracted from the case notes and psychological tests details by two trainee psychologists, and ICD-10 based clinical diagnosis, demographics, ID, CA related data documented independently of the psychiatrist. The appropriate statistical analyses were completed.

RESULTS

Repetitive behaviors formed the most common symptom cluster. The high internal consistency (κ = 0.75) among the three groups of ICD-10 symptoms indicate their usefulness in the diagnosis of CA among children with ID, but significantly more children with ID failed to meet the ICD-10 criteria for CA. The fourth alternative criteria had the highest concordance with the reference standard (100%) and the first alternative criteria had the highest agreement with the reference standard (κ = 0.88) in identifying CA among ID. The diagnostic accuracy of all the alternative criteria was significantly better than that of ICD-10 with the first alternative criteria having the best diagnostic accuracy (Sn = 98%; Sp = 100%; PPV = 1; NPV =0.83) closest to the reference standard.

CONCLUSIONS

The symptom clusters in ICD-10 for CA should be retained, however reorganising the diagnostic criteria is required for diagnosing CA accurately among children with ID. The first alternative criteria can significantly improve the case identifying ability and diagnostic accuracy altering there by the epidemiological data on Childhood Autism among children with Intellectual Disability.

A general practice-based study of the relationship between indicators of mental illness and challenging behaviour among adults with intellectual disabilities

BACKGROUND

Existing studies tend to show a positive association between mental illness and challenging behaviour among adults with intellectual disabilities (ID). However, whether the association is direct or artefactual is less clear. The purpose was to explore the association between psychiatric status and level of challenging behaviour, while controlling for adaptive behaviour and occurrence of autistic spectrum disorders.

METHODS

Data were collected on the age, gender, adaptive and challenging behaviour, social impairment and psychiatric status of 312 adults with ID. Participants were divided according to psychiatric status, group equivalence in adaptive behaviour and the presence of autistic spectrum disorders achieved, and differences in challenging behaviour explored. In addition, multiple regression was used to examine the association between psychiatric status and challenging behaviour after controlling for other participant characteristics and to test whether the interaction between psychiatric status and adaptive behaviour added significantly to explanation.

RESULTS

Challenging behaviour was higher among participants meeting threshold levels on the psychiatric screen. The regression analysis confirmed the association and demonstrated an interaction between total score on the psychiatric screen and level of adaptive behaviour. This moderated effect showed the relationship between psychiatric status and challenging behaviour to be stronger at lower adaptive behaviour.

CONCLUSIONS

This study reinforces previous findings that psychiatric morbidity among people with ID is associated with higher levels of challenging behaviour and supports predictions that this association is more pronounced for people with severe ID. The precise nature and causal direction of the association requires further clarification. However, the understanding of how psychiatric problems might contribute to challenging behaviour needs to be part of the clinical appreciation of such behaviour.

Diagnosis and treatment of aggression in individuals with developmental disabilities

Aggressive behavior is a common referral problem for individuals with developmental disabilities (DD), placing them at risk for institutionalization, social isolation, physical restraint, over-use of medication to treat behavior problems, exclusion from services, and becoming a victim of abuse. Aggression strains relationships between individuals being supported and their caregivers, whether professionals or family members. The treatment of aggression is persons with DD, with or without comorbid mental illness, remains a controversial area and changes in practice have been slow to come. The evidence related to pharmacotherapy and psychological treatment is, in general, either lacking or poor. This does not suggest that these treatments are necessarily ineffective but that there is not enough good quality evidence to support their usefulness. This review considers the prevalence and correlates of aggression, as well as possible causative factors. The relationship between mental illness, intellectual disability and aggression is explored. The psychopharmacological and psychological treatment literature is reviewed with implications for clinical care and future research.

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.

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.

Mental ill-health in adults with intellectual disabilities: prevalence and associated factors

BACKGROUND

Reported prevalence of mental ill-health among adults with intellectual disabilities ranges from 7 to 97%, owing to methodological limitations. Little is known about associations.

AIMS

To determine the prevalence of mental ill-health in adults with intellectual disabilities and to investigate factors independently associated with it.

METHOD

Population-based study (n=1023) with comprehensive individual assessments modelled using regression analyses.

RESULTS

Point prevalence of mental ill-health was 40.9% (clinical diagnoses), 35.2% (DC-LD), 16.6% (ICD-10-DCR) and 15.7% (DSM-IV-TR). The most prevalent type was problem behaviours. Mental ill-health was associated with more life events, female gender, type of support, lower ability, more consultations, smoking, incontinence, not having severe physical disabilities and not having immobility; it was not associated with deprived areas, no occupation, communication impairment, epilepsy, hearing impairment or previous institutional residence.

CONCLUSIONS

This investigation informs further longitudinal study, and development of appropriate interventions, public health strategy and policy. ICD-10-DCR and DSM-IV-TR undercount mental ill-health in this population compared with DC-LD.

Comorbid Psychiatric Disorders in Children with Autism: Interview Development and Rates of Disorders

The Kiddie Schedule for Affective Disorders and Schizophrenia was modified for use in children and adolescents with autism by developing additional screening questions and coding options that reflect the presentation of psychiatric disorders in autism spectrum disorders. The modified instrument, the Autism Comorbidity Interview-Present and Lifetime Version (ACI-PL), was piloted and frequently diagnosed disorders, depression, ADHD, and OCD, were tested for reliability and validity. The ACI-PL provides reliable DSM diagnoses that are valid based on clinical psychiatric diagnosis and treatment history. The sample demonstrated a high prevalence of specific phobia, obsessive compulsive disorder, and ADHD. The rates of psychiatric disorder in autism are high and are associated with functional impairment.

Assessment of patients with intellectual disability using the International Classification of Functioning, Disability and Health to evaluate dental treatment tolerability

BACKGROUND

Patients with serious intellectual disability (ID) are occasionally unable to tolerate dental treatment when intravenous sedation or general anaesthesia (IVS/GA) is involved. In order to make a decision regarding the application of IVS/GA, the International Classification of Functioning, Disability and Health (ICF) is useful. Therefore, in this study, a set of codes involved in dental problems were chosen from the ICF, and patients with ID who could tolerate dental treatments were compared with those who could not.

METHODS

From preliminary interviews of six patients with ID, 16 codes were chosen, and an objective five-rank scale was then constructed for use with all chosen codes. Forty-nine ID patients who visited the Okayama University Hospital for dental treatment between January and April 2003 were evaluated. Facility workers were interviewed according to the code set chosen. The participants were then divided into two subgroups depending on their tolerability of dental treatment. The results of these groups for all 16 codes were then compared.

RESULTS

Of the 49 patients interviewed, 23 were able to tolerate the dental treatment. In the 'Activities & Participation' section of the ICF, the tolerable group showed lower disability levels with regard to d110 Watching, d540 Dressing and d550 Eating. In other sections, there were no significant differences between the groups. The code set chosen in this study and the five-rank scales in each code were useful as they enabled easy interviewing.

CONCLUSIONS

The ICF was raised as a possibility for considering the application of IVS/GA for dental treatment on patients with ID. For clinical use of the ICF, it is recommended that significant codes should be selected and that the five-rank scale is used so that more objective results are obtained from interviews.

Psychiatric diagnosis, intellectual disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD)

BACKGROUND

Classification of psychopathology using operationalized diagnostic criteria is one component of psychiatric assessment. Previous literature has demonstrated that there are limitations in the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual-IV (DSM-IV) when used with adults with intellectual disabilities.

METHODS

A literature search using Medline, PsychLIT and hand searching of key journals identified the existing literature, which was reviewed by the Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD) Development Working Group. Key findings are integrated into this paper. This, together with expert consensus led to the development of DC-LD, a new psychiatric classificatory system devised specifically for use with adults with intellectual disabilities. The new diagnostic criteria and classification within DC-LD were piloted with 52 field investigators drawing on 709 clinical cases. Validity of DC-LD classification was measured by comparison between the criteria providing DC-LD diagnosis and the gold standard of learning disabilities psychiatric assessment.

RESULTS

In 96.3% of cases, the DC-LD diagnosis was fully concordant with that of clinical opinion. The few discrepancies related to level of detail.

CONCLUSION

DC-LD accommodates the pathoplastic effect of intellectual disabilities on psychopathology. Its use will hopefully improve clinical practice and facilitate research, but further work to determine its usefulness and limitations is required.

Intellectual disabilities, depressive episode, diagnostic criteria and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD)

BACKGROUND

Depressive episode is one of the most common types of psychiatric illness that occurs in adults with intellectual disabilities.

METHODS

A comprehensive literature search was undertaken using Medline, PsychLIT and hand-searching of key journals. This paper reviews the evidence and integrates findings, to report how evidence relates to the development of the new Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation[DC-LD] depressive episode criteria.

RESULTS

This area is better researched than many others, providing evidence on clinical symptomatology and presentation. In view of the lack of utility of standard diagnostic criteria developed for use with the general population, and set within the historical context, there are clearly identified reasons for the introduction of DC-LD. The depressive episode category has been informed by the evidence, and field trials showed excellent validity compared with the gold standard of learning disabilities psychiatric assessment.

CONCLUSIONS

The DC-LD depressive episode category may improve clinical diagnosis and facilitate research. Its usefulness and limitations are yet to be determined in detail.

DSM-IV disorders in children with borderline to moderate intellectual disability. I: prevalence and impact

OBJECTIVE

To assess the prevalence, comorbidity, and impact of DSM-IV disorders in 7- to 20-year-olds with intellectual disability.

METHOD

A total of 474 children (response 86.8%) were randomly selected from a sample of students from Dutch schools for the intellectually disabled. Parents completed the anxiety, mood, and disruptive disorder modules of the Diagnostic Interview Schedule for Children.

RESULTS

A total of 21.9% of the children met the DSM-IV symptom criteria for anxiety disorder, 4.4% for mood disorder, and 25.1% for disruptive disorder. Similar prevalence rates were found for children who screened positive or negative for pervasive developmental disorder. More than half of the children meeting the criteria for a DSM-IV disorder were severely impaired in everyday functioning, and about 37% had a comorbid disorder. Children with multiple disorders were more likely to be impaired across various areas of everyday functioning. Almost 27% of the diagnosed children received mental health care in the last year. Comorbidity and impairment in everyday functioning increased the likelihood of referral.

CONCLUSIONS

Most disorders can be observed in intellectually disabled children. Impairment and comorbidity are high. The finding that less than one third of the children with a psychiatric disorder receive mental health care deserves attention.

Patients with and without intellectual disability seeking outpatient psychiatric services: diagnoses and prescribing pattern

BACKGROUND

The present study examined the presenting problem of psychiatric outpatients, and resulting diagnostic and prescribing patterns, comparing patients with intellectual disability (ID) with non-ID (N-ID) patients seen in the same clinic.

METHODS

This study was a retrospective medical chart review of information in the first psychiatric diagnostic evaluation for the most recent 100 adult patients with mild ID, 100 patients with moderate, severe or profound ID, and 100 matching N-ID patients.

RESULTS

There were significant differences in rates of medical illness, disabilities, history of marriage, children, independent living, and family history of psychiatric and neurological disorders. Individuals with ID were more likely to present with aggression, self-injurious behaviour or physical complaints, whereas N-ID subjects presented more frequently with depression and anxiety complaints. For all groups, depressive disorders were the most frequent class of diagnoses. For those with ID, antipsychotics were used in 32% of subjects, with mood stabilizers in 28% and antidepressants in 27%. The N-ID subjects were most frequently prescribed antidepressants (40%) and anxiolytics (22%). Polypharmacy did not differ significantly among groups.

CONCLUSIONS

Psychiatric practitioners relied on the diagnostic examination to formulate their diagnosis, whereas the chief complaint reflected the view of caregivers of the subjects with ID. In contrast to previous studies, outpatient providers frequently diagnosed depression, and the prescribing pattern showed increased usage of antidepressants and mood stabilizers.