Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates

LAY ABSTRACT

Post-traumatic stress disorder is a mental health disorder that may be triggered by the experience of events perceived as terrifying or overwhelming. Examples of such events include being the victim of violence or sexual abuse. Compared with other people, autistic people have increased risk of being exposed to violence or sexual abuse. In addition, autistic people may be more vulnerable to developing post-traumatic stress disorder following such exposure. However, knowledge is limited concerning the prevalence of experiences involving violence and sexual abuse, and post-traumatic stress disorder, in autistic people with co-occurring intellectual disabilities. Detection of these experiences, and identification of post-traumatic stress disorder, may be challenging in these individuals, and previous research indicates that post-traumatic stress disorder symptoms may be overlooked or misinterpreted. In this study, we examined prevalence of post-traumatic stress disorder, violence and sexual abuse in a clinical sample of 88 autistic adults with intellectual disabilities referred for mental health assessment. Only 3.4% were diagnosed with post-traumatic stress disorder, even if experiences involving violence (34.1%) or sexual abuse (17.0%) were common. Anxiety and affective disorders were common diagnoses among participants with these experiences. Controlling for autism characteristics, level of intellectual disability and communication skills, experiences of violence/sexual abuse were found to be associated with a measure of 'challenging' behaviours. These results indicate that potentially traumatic experiences are common in autistic adults with intellectual disabilities referred for mental health assessment, and that post-traumatic stress disorder may be under-recognised. The findings highlight the importance of trauma screening and post-traumatic stress disorder assessment, as well as the importance of trauma-informed care, in this population.

The relationship between patterns of negative life experiences and clinical presentation in a psychiatric sample

BACKGROUND

Attempts have been made to classify the patterns of polytraumatization using a person-centered approach. However, most studies have only focused on maltreatment and interpersonal trauma and have been unable to examine various clinical symptoms.

OBJECTIVES

This study aimed to explore patterns of negative life experiences, including maltreatment, lifetime trauma, and recent stressful life events, and compare diverse dimensions of the clinical manifestations among the subtypes in a clinical sample.

METHOD

We investigated childhood maltreatment, lifetime trauma, and recent stressful events using a self-report method in 1410 psychiatric patients; we classified the patterns of lifelong negative life experiences using latent profile analysis (LPA). We used the rates of psychiatric diagnosis, the Beck Depression Inventory, the Impact of Event Scale-Revised (IES-R-K), and the Multiphasic Minnesota Personality Inventory-2-Restructured Form to compare various symptom dimensions among the derived subtypes.

RESULTS

LPA indicated a four-class solution: mild, recent stress, maltreatment, and multiple adversity group. The multiple adversity group experiencing both lifetime trauma and recent stressful life events, in addition to maltreatment, including sexual abuse, had a high rate of severe mental illness and more symptom dimensions of thought and behavior problems. However, the rates of depressive disorders and emotional/internalizing symptoms were not more than those in the other two groups (recent stress and maltreatment groups) experiencing moderate levels of lifetime trauma. There was no significant difference between the recent stress and maltreatment groups for most symptom dimensions.

CONCLUSIONS

The findings indicate that distinct symptom profiles may be associated with the pattern of negative experiences, suggesting that negative experiences need multidimensional investigation in clinical settings.

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.

Evaluation of an adapted version of the International Trauma Questionnaire for use by people with intellectual disabilities

AIMS

The International Trauma Questionnaire (ITQ) is a novel assessment instrument that is aligned to the ICD-11 diagnoses of post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD). The purpose of this study was to develop and evaluate an adapted version of the ITQ suitable for use by people with intellectual disabilities.

METHODS

The ITQ-ID follows the original ITQ, using wording developed in collaboration with a focus group of people with intellectual disabilities The ITQ-ID was administered to 40 people with intellectual disabilities recruited from learning disability forensic and community settings, alongside a Trauma Information Form and the Impact of Event Scale-Intellectual Disabilities (IES-IDs).

RESULTS

Most participants reported multiple traumatizing events. Around half of the participants met strict criteria for a diagnosis of PTSD, and around three quarters met looser criteria. Depending on definitions, between 66% and 93% of those who met criteria for PTSD also met criteria for a diagnosis of CPTSD. The ITQ-ID showed a single-component structure, with very good-to-excellent internal consistency, excellent test-retest reliability, and evidence of concurrent, discriminant, and content validity.

SIGNIFICANCE

The results support the potential of the ITQ-ID for assessment of PTSD and CPTSD in people with intellectual disabilities in both clinical and research contexts and highlight the need for further validation work.

Proxy-report in individuals with intellectual disability: A scoping review

BACKGROUND

Views can be collected from individuals (self-report) or others on their behalf (proxy-report).

OBJECTIVE

We aimed to review the literature on methods and statistical approaches used to evaluate observer versus self-report responses from individuals with intellectual disability or Down syndrome.

METHODS

A series of key questions related to statistical approaches and data collection methods were formulated a priori to inform the search strategy and review process. These addressed the topics of self-report in individuals with intellectual disability, including Down syndrome. Using the National Library of Medicine database, PubMed, detailed literature searches were performed. The quality of available evidence was then evaluated, the existing literature was summarised, and knowledge gaps and research needs were identified.

RESULTS

Fifty relevant original articles were identified which addressed at least one key question. Study details, including: research design, internal validity, external validity, and relevant results are presented. Review of studies of individuals with intellectual disability which used a variety of statistical approaches showed mixed agreement between self-report and proxy-report.

CONCLUSION

Few studies identified to-date have used self-report from individuals with Down syndrome, but lessons from the existing intellectual disability literature can guide researchers to incorporate self-report from individuals with Down syndrome in the future.

A Systematic Review of Treatment Interventions for Individuals With Intellectual Disability and Trauma Symptoms: A Review of the Recent Literature

Individuals with intellectual disabilities (IDs) are at increased susceptibility to adverse life experiences and trauma sequelae. There is a disparate range of therapeutic interventions for post-traumatic stress disorder (PTSD) and associated symptoms. This systematic review aimed to appraise the effectiveness of both cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR) for PTSD and associated symptoms for both adults and children with mild, moderate, or severe intellectual delay. A systematic search, in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of the PsychInfo, PubMed, Cochrane Database of Systematic Reviews, and MEDLINE databases were performed, and all relevant articles published between 2010 and March 2020 were included. A total of 11 articles were included, eight that focused on EMDR and three on CBT. The methodological quality of many of these articles was generally weak. Tentative findings suggest that EMDR and CBT are both acceptable and feasible treatment options among adults and children with varying levels of intellectual delay, but no firm conclusions can be drawn regarding effectiveness due to small sample sizes, lack of standardized assessment, and a paucity of methodological rigorous treatment designs. This review highlights the continued use of therapeutic approaches with clients presenting with IDs and PTSD. It adds to the extant literature by providing an expansive and broad overview of the current effectiveness of both EMDR and CBT. Further high-quality research is needed to provide more conclusive findings regarding treatment effectiveness and modifications to treatment needed with this population.

Short report and initial evaluation of the factor structure of the Lancaster and Northgate Trauma Scales (LANTS)

BACKGROUND

Research suggests exposure to adverse life events is elevated in people with intellectual disabilities. We developed the Lancaster and Northgate Trauma Scales (LANTS) to address the limited availability of screening questionnaires for people with intellectual disabilities affected by adverse traumatic experiences.

AIMS

The aims of this study were to (i) evaluate the factor structure of the self-report LANTS and (ii) assess compatibility with the International Classification of Diseases Eleventh Revision (ICD-11) criteria for complex PTSD.

METHODS AND PROCEDURE

Ninety-eight people with mild to moderate intellectual disability (86 % men; mean age 41 years) completed the self-report LANTS. Exploratory factor analysis was undertaken using a polychoric correlation matrix, appropriate for the LANTS ordinal response options.

OUTCOMES AND RESULTS

Seven items including self-harm and anger were non-normal in distribution and excluded from the analysis; a four-factor structure was identified for the 22 remaining items. We make suggestions for correspondence of LANTS items to ICD-11 criteria for complex PTSD.

CONCLUSIONS AND IMPLICATIONS

This is the first exploratory factor analysis of the LANTS. Items pertaining to anger and self-harm may be prone to response bias and development of these items using qualitative methods would be useful. The findings require replication with a larger group of people with intellectual disabilities, including more women.

Trauma experiences of people with an intellectual disability and their implications: A scoping review

BACKGROUND

People with an intellectual disability are more vulnerable to psychological trauma compared with the general population. The aim of this scoping review was to identify the current status of the literature on trauma that is specific to the experiences of adults with an intellectual disability, living in community settings.

METHODS

A scoping review was conducted using the Arksey and O'Malley (International Journal of Social Research Methodology, 2005, 8, 19) framework. Forty-one international papers were reviewed spanning 2000-2020, and their quality assessed using the MMAT.

FINDINGS

(1) Aggressive behaviours can be symptoms of trauma, (2) there are appropriate assessment tools for the impact of trauma, (3) evidence-based interventions for trauma may be effective, and (4) factors associated with disability can be experienced as traumatic.

CONCLUSION

There is a growing body of literature highlighting assessment needs and potential interventions for people with an intellectual disability who have experienced psychological trauma. Further research is needed to develop trauma-informed pathways.

The association between challenging behaviour and symptoms of post-traumatic stress disorder in people with intellectual disabilities: a Bayesian mediation analysis approach

BACKGROUND

A preponderance of behavioural symptoms is assumed to be the main difference in the manifestation of symptoms of post-traumatic stress disorder (PTSD) in people with intellectual disability (ID). However, no study so far has assessed the relationship between challenging behaviour (CB) and PTSD. The present study aims to explore this relationship by exploring whether CB is directly related to trauma exposure or whether this relationship is mediated through core symptoms of PTSD.

METHODS

Trauma exposure and current symptoms of PTSD were assessed in 43 adults with mild to moderate ID. Parallel versions were administered to 43 caregivers, including the Aberrant Behaviour Checklist to measure CB. Bayesian mediation analyses were conducted using self-rated and informant-rated data.

RESULTS

The self-report data showed no associations of CB with trauma exposure or PTSD symptoms. The association between informant-rated trauma exposure and irritability was mediated by severity and frequency of PTSD symptoms. The associations between informant-reported trauma exposure and the Aberrant Behaviour Checklist subscales hyperactivity and inappropriate speech were mediated by PTSD symptom severity.

CONCLUSIONS

The relationship between trauma exposure and CB was mediated by PTSD symptoms. PTSD core symptoms should be considered as underlying causes of CB, highlighting the necessity to explore trauma biography and symptoms of PTSD. The improvement of self-report assessment in people with ID is an important task for future studies.

Applicability of the post-traumatic stress disorder gate criterion in people with mild to moderate intellectual disabilities: Do additional adverse events impact current symptoms of Post Traumatic Stress Disorder in people with intellectual disabilities?

Background

Diagnostic manuals provide a strict definition of the PTSD gate criterion. Research on the adequacy of this definition in people with intellectual disabilities is lacking. This study aims to test the adequacy of the gate criterion for this population.

Method

Fourty nine adults with mild to moderate intellectual disabilities and 43 caregivers were questioned. Traumatic events included in the gate criterion definition and adverse events going beyond it were assessed. It was tested whether adverse events affect symptoms of PTSD additionally to traumatic events.

Results

The current data showed ambiguous findings in self‐ and informant report. Informant data suggested an additional impact of adverse events on PTSD symptoms. Self‐report data suggested the contrary.

Conclusion

Adverse events seem to have an impact on externalizing behavioural symptoms, such as hyperarousal. Self‐report assessment of more specific, intrapsychic PTSD symptoms, such as intrusions and avoidance, should be addressed in future studies.

"If we do not look for it, we do not see it": Clinicians' experiences and understanding of identifying post-traumatic stress disorder in adults with autism and intellectual disability

BACKGROUND

Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) are at increased risk of potentially traumatic events and may be at increased risk of post-traumatic stress disorder (PTSD). However, knowledge regarding identification of PTSD in this population is limited. The aim of this study was to investigate clinical experience regarding PTSD and trauma assessment in individuals with co-occurring ASD and ID.

METHOD

Interpretative phenomenological analysis was used to explore experiences of identifying PTSD in this population among 18 mental health clinicians working with ASD and ID.

RESULTS

Informants viewed PTSD in individuals with ASD and ID as equivalent to PTSD in the general population, but with causes and expressions potentially differing. Several factors were described to contribute to challenges in identification.

CONCLUSIONS

Trauma may have severe impact in individuals with ASD and ID. Multidimensional, individualized assessment strategies seem necessary to recognize PTSD or trauma-related symptoms in this population.

Not recognized enough: The effects and associations of trauma and intellectual disability in severely mentally ill outpatients

Background:

Little is known about the association between trauma and intellectual disability in SMI patients.

Aim:

To establish the prevalence of trauma and its association with intellectual functioning in SMI outpatients.

Methods:

A cross-sectional study was conducted in two mental health trusts in the Netherlands. We used the Trauma Screening Questionnaire (TSQ) to screen for trauma and PTSD, and the Screener for Intelligence and Learning disabilities (SCIL) for suspected MID/BIF. Chi-square and t-tests were used to test differences in outcome over patient characteristics. Post-hoc analysis was used to investigate gender differences between patients with and without MID/BIF on trauma and sexual trauma.

Results:

Any trauma was found in 86% of 570 patients and 42% were suspected for PTSD. The SCIL suggested that 40% had Borderline Intellectual Functioning (BIF), half of whom were suspected of having Mild Intellectual Disability (MID). These patients had more traumatic experiences (1.89 in BIF, 1.75 in MID, against 1.41 in SCIL-negative patients). Female MID/BIF patients (61%) had experienced significantly more sexual abuse than male MID/BIF patients (23%).

Conclusions:

Significantly more SMI outpatients who screened positive for MID/BIF reported having experienced traumatic events than those who screened negative. Rates of all trauma categories were significantly higher in the screen-positive group, who were also more likely to have PTSD. Sexual abuse occurred more in all females but the SCIL positive women are even more often victim. Clinical practice has to pay more attention to all of these issues, especially when they occur together in a single patient.

A systematic review of cognitive behavioural therapy for anxiety in adults with intellectual disabilities

BACKGROUND

Anxiety disorders have high prevalence in people with intellectual disabilities. In populations without intellectual disabilities, cognitive behavioural therapy is a first line psychological therapy for these presentations. There is no existing review of the range of methods and outcomes from intervention studies in this area.

METHOD

A systematic review was carried out following guidance in the Cochrane handbook for systematic reviews of interventions.

RESULTS

Nineteen studies were identified. The majority of reports were descriptive case studies; the most frequently described presentations were non-specific anxiety disorders and post-traumatic stress disorder; the most frequently described cognitive techniques were psycho-education and interventions directly aimed at thoughts and beliefs and most studies reported positive outcomes, although the better controlled studies tended to report less comprehensive impacts.

CONCLUSIONS

A range of presentations have been described although the area is still at a primarily descriptive stage. We discuss intervention structures and approaches that require further research.

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study)

PURPOSE

The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives.

METHODS

This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff.

RESULTS

We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group.

CONCLUSIONS

Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01818895.

Complicated grief after death of a relative in the intensive care unit

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements.